Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookdale Palmer Ranch Snf during CMS and state inspections, most recent first.
An LPN administered Melatonin and Benadryl without provider orders to multiple residents, resulting in observed changes such as increased confusion, drowsiness, and behavioral alterations. Staff and resident interviews, along with medication records, confirmed the unauthorized use of these medications, which violated facility policy and residents' rights to be free from abuse.
A nurse administered Melatonin and Benadryl to several residents without physician orders, using these medications to induce sleep during the night shift. This led to changes in resident behavior, including increased confusion and drowsiness, and was reported by staff and residents. The facility's investigation confirmed that the medications were not ordered for the affected residents and that the actions violated residents' rights to be free from chemical restraints and abuse.
Two residents with cognitive impairments were inadequately supervised, leading to one elopement and another being at risk. One resident, initially not deemed an elopement risk, eloped after becoming ambulatory. Another resident was identified as an elopement risk but was not provided with a wanderguard or updated care plan. Clerical errors and lack of timely reassessment contributed to these deficiencies.
The facility failed to provide timely physician-ordered medications for two newly admitted residents, leading to significant care deficiencies. A resident did not receive Tramadol for pain management post-surgery due to procedural lapses, resulting in severe pain and hospital transfer. Another resident with COPD missed doses of Cefepime IV due to unavailability in the facility's stock, causing a delay in treatment. Staff interviews revealed a lack of clarity in medication access procedures during off-hours.
A resident admitted after knee replacement surgery did not receive prescribed Tramadol for pain management due to the facility's failure to reconcile hospital discharge orders and notify the pharmacy. The MAR lacked documentation of the medication, leading to severe pain and a transfer to the emergency room. Staff interviews revealed issues with medication access and order processing.
A facility failed to maintain accurate medical records and ensure proper medication administration for two residents. One resident, admitted for post-surgery care, was discharged with uncontrolled pain due to incomplete documentation and lack of access to medication machines. Another resident, admitted with severe respiratory conditions, did not receive timely IV antibiotics, with records lacking verification of administration. Staff interviews revealed systemic issues with documentation and access to necessary resources, contributing to these deficiencies.
Unauthorized Administration of Sleep Aids and Antihistamines by LPN
Penalty
Summary
A deficiency was identified when a facility failed to protect residents' rights to be free from abuse by allowing an LPN to willfully administer unauthorized over-the-counter medications, specifically Melatonin and Benadryl, to multiple residents during the night shift. The facility's policy prohibits the use of chemical restraints or medications for staff convenience or discipline without a provider order. Despite this, the LPN was found to have given these medications to residents without physician orders, as confirmed by medication counts, staff statements, and resident interviews. Several residents exhibited changes in behavior and cognition that coincided with the nights the LPN worked. For example, one resident became significantly more confused, another was excessively drowsy and unable to walk, and others displayed increased aggression or changes in activity participation. Staff and residents reported these changes, and documentation confirmed that the medications administered were not ordered for these individuals. The facility's investigation substantiated the allegations, with multiple staff overhearing the LPN discuss giving these medications and observing the resulting behavioral changes in residents. The affected residents had various diagnoses, including dementia, anxiety, insomnia, and a history of falls. Some were cognitively intact, while others had severe cognitive impairment. The unauthorized administration of medications was not isolated to a single resident but involved at least five individuals, with the exact number undetermined. The DON confirmed that both Melatonin and Benadryl were stock medications and that the LPN administered them without proper orders, violating residents' rights and facility policy.
Plan Of Correction
I have enclosed the Plan of Correction for the above-referenced facility in response to the Statement of Deficiencies. While this document is being submitted as confirmation of the facility's ongoing efforts to comply with all statutory and regulatory requirements, it should not be construed as an admission or agreement with the findings and conclusions in the Statement of Deficiencies. F: 600 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? On 7/9/25, Nurse A was suspended pending investigation related to the administration of Melatonin and Benadryl. Nurse A resigned on 7/15/25. Resident 999 was evaluated by a licensed nurse on 7/11/25, and notified the Healthcare Provider (HCP), and the resident's representative of the medication error. No new orders were obtained. Resident 900 was reviewed on 7/11/25 by the Director of Clinical Services (DCS) and/or Assistant Director of Clinical Services (ADCS) for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the med error. No new orders were obtained. Resident 850 was reviewed on 7/11/25 by the Director of Clinical Services and/or Assistant Director of Clinical Services for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the Director of Clinical Services and/or Assistant Director of Clinical Services for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the Director of Clinical Services and/or Assistant Director of Clinical Services for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. On 7/15/25, current residents with a BIMS of 12 or higher were interviewed by Social Services or designee regarding medications and if they were offered sleep medications. No further residents were identified. Between 7/10/25 and 7/15/25, eight (8) family members were interviewed by the Executive Director or designee for any concerns in care, medications, or changes in their loved one. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? On 7/18/25, the Assistant Director of Clinical Services provided re-education to licensed nurses on Melatonin and Benadryl administration, 7 rights of medication administration, physician notification on missed/refused medication, PRN medication administration, abuse, and neglect. On 7/8/25, Melatonin was counted by the DCS or designee. Upon further staff interviews, on 7/9/25, daily Melatonin counts expanded to all nurse carts, and daily Benadryl counts were added. On 7/28/25, the DCS or designee changed the Melatonin and Benadryl from stock bottles to individual bubble cards filled through the pharmacy. Social Services and/or designee will review the Behavior Report in Daily Stand Up to assist with identification of new changes in residents' behaviors that may require an additional review. How will the facility monitor its performance to make sure that solutions are sustained? To assist with compliance, the DCS or designee has audited the count for melatonin, daily beginning on 7/8/25. The DCS or designee has audited daily the count for Benadryl beginning on 7/9/25. Daily audits continued through 7/27/25 with no discrepancies noted. Audits will be conducted twice a week for two weeks, then weekly for a combined total of 12 weeks. Social Services or designee will conduct two resident interviews weekly with residents BIMS 12 or higher for 12 weeks. The Assistant Director of Clinical Services or designee will conduct one medication pass observation per week for 12 weeks. The DCS or designee will review findings of the audits monthly in the Quality Assurance Performance Improvement (QAPI) Meeting for 3 months. Discipline Responsible: The Director of Clinical Services or designee will be responsible for compliance.
Unauthorized Administration of Chemical Restraints
Penalty
Summary
A deficiency occurred when a nurse administered over-the-counter medications, specifically Melatonin and Benadryl, to multiple residents without physician orders and for non-medical reasons, such as to induce sleep during the night shift. The facility's policy clearly states that residents have the right to be free from chemical restraints imposed for discipline or staff convenience, and that any use of such medications must be authorized in writing by a physician for a specific and limited period or in an emergency, with proper documentation and immediate physician consultation for chemical restraints. However, the investigation revealed that the nurse gave these medications to residents without proper authorization, and the medications were not ordered for those residents at the time of administration. The incident was brought to light when staff members reported unusual resident behaviors, such as increased confusion, excessive drowsiness, decreased participation in activities, and changes in mood or behavior that correlated with the nights the nurse in question worked. Statements from staff and residents indicated that some residents received medications they were not supposed to get, and in some cases, residents could recall being given something to help them sleep. The facility's investigation found that bottles of Melatonin were placed in medication carts and that a significant number of pills were unaccounted for. The nurse involved denied giving sleep aids but later admitted to administering Melatonin and Benadryl to residents without current orders. Clinical record reviews confirmed that the affected residents did not have active orders for the medications administered. Several residents experienced notable changes in their cognitive and physical status, such as increased confusion, inability to walk, and behavioral changes. The Director of Nursing verified that the allegations of abuse were substantiated, and it was unclear how many residents received unauthorized medications. The facility's failure to ensure that medications were only administered as ordered by a physician and not for staff convenience resulted in a violation of residents' rights to be free from chemical restraints and abuse.
Plan Of Correction
N: 0204 How will the corrective action be accomplished for those residents found to have been affected by the deficient practice? On 7/9/25, Nurse A was suspended pending investigation related to the administration of Melatonin and Benadryl. Nurse A resigned on 7/15/25. Resident 999 was evaluated by a licensed nurse on 7/11/25, and notified the Healthcare Provider (HCP), and the resident's representative of the medication error. No new orders were obtained. Resident 900 was reviewed on 7/11/25 by the Director of Clinical Services (DCS) and/or Assistant Director of Clinical Services (ADCS) for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the med error. No new orders were obtained. Resident 850 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. Resident 850 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 825 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. Resident 800 was reviewed on 7/11/25 by the DCS and/or ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. The HCP and resident representative were notified of the medication error. No new orders were obtained. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 7/9/25, the DCS or designee reviewed current resident records to determine if they had physician orders for Melatonin and Benadryl. Between 7/10/25 and 7/15/25, current residents' records and associate interviews were reviewed by the DCS and ADCS for changes in sleep patterns, drowsiness, decreased participation in activities, sudden incontinence at night, shower refusals, decrease in appetite especially at breakfast and lunch, falls, significant changes, and other indicators. On 7/15/25, current residents with a BIMS of 12 or higher were interviewed by Social Services regarding medications and if they were offered sleep medications. No further residents were identified. Between 7/10/25 and 7/15/25, eight (8) family members were interviewed by the Executive Director or designee for any concerns in care, medications, or changes in their loved ones. What measures will be put into place or systematic changes made to ensure that the deficient practice will not recur? On 7/18/25, the Assistant Director of Clinical Services provided re-education to licensed nurses on Melatonin and Benadryl administration, 7 rights of medication administration, physician notification on missed/refused medication, PRN medication administration, abuse, and neglect. On 7/8/25, Melatonin was counted by the DCS or designee. Upon further staff interviews, on 7/9/25, daily Melatonin counts expanded to all nurse carts, and daily Benadryl counts were added. On 7/28/25, the DCS or designee changed the Melatonin and Benadryl from stock bottles to individual bubble cards filled through the pharmacy. Social Services and/or designee will review the Behavior Report in Daily Stand Up to assist with identification of new changes in residents' behaviors that may require an additional review. How will the facility monitor its performance to make sure that solutions are sustained? To assist with compliance, the DCS or designee has audited the count for Melatonin, daily beginning on 7/8/25. The DCS or designee has audited daily the count for Benadryl beginning on 7/9/25. Daily audits continued through 7/27/25 with no discrepancies noted. Audits are conducted twice a week for two weeks, then weekly for a total of 12 weeks. Social Services or designee will conduct two resident interviews weekly with residents BIMS 12 or higher for 12 weeks. The Assistant Director of Clinical Services or designee will conduct one medication pass observation per week for 12 weeks. The DCS or designee will review findings of the audits monthly in the Quality Assurance Performance Improvement (QAPI) Meeting for 3 months. Discipline Responsible: The Director of Clinical Services or designee will be responsible for compliance.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Assessment
Penalty
Summary
The facility failed to prevent neglect through inadequate assessments and supervision, leading to the elopement of two residents. Resident #5, who was admitted with severe cognitive impairment and multiple health conditions, was not initially deemed an elopement risk due to his inability to ambulate. However, his condition improved, and he became ambulatory, which was not reassessed in a timely manner. Consequently, Resident #5 eloped from the facility and was found outside, confused and with an abrasion, after passerby's reported his presence. Resident #6, admitted with severe cognitive impairment and a history of repeated falls, was identified as an elopement risk in a quarterly assessment. Despite this, no care plan was updated, and no wanderguard was provided to mitigate the risk. The resident was observed moving independently in a wheelchair, yet the necessary precautions were not implemented. The ADON admitted to a clerical error in the elopement risk assessment, which contributed to the oversight. The facility's failure to reassess and implement appropriate elopement prevention measures for both residents highlights a significant deficiency in their supervision and risk management processes. The lack of timely updates to care plans and the failure to equip residents with necessary safety devices contributed to the potential risk of harm.
Medication Management Deficiencies for Newly Admitted Residents
Penalty
Summary
The facility failed to ensure timely acquisition of physician-ordered medications for newly admitted residents, leading to significant deficiencies in care. Resident #1, admitted after knee replacement surgery, did not receive the prescribed Tramadol for pain management due to a lack of reconciliation of discharge orders with the attending physician and failure to notify the designated pharmacy. The resident experienced severe pain, rated 10/10, and was transferred back to the hospital for uncontrolled pain. The facility's emergency medication kit contained Tramadol, but the medication was not accessed due to procedural lapses, including the absence of a hard script and electronic prior authorization. Resident #2, admitted with a diagnosis of COPD and an acute lower respiratory infection, was prescribed Cefepime IV, which was not administered as scheduled. The medication was not available in the facility's Omnicell, and the first dose was delayed until the afternoon of the following day. The facility did not stock Cefepime, and the resident had to wait for the medication to be delivered, resulting in missed doses. The DON confirmed the delay in receiving the medication but did not comment on the missed doses due to not being employed at the time. Interviews with staff revealed a lack of clarity and training regarding the process for obtaining medications during off-hours. Staff members were unsure of how to access the medication machine or contact the pharmacy for unavailable medications. The consulting pharmacist and regional clinical services director confirmed the absence of necessary orders in the EHR, which contributed to the failure to administer the prescribed medications. These deficiencies highlight significant gaps in the facility's medication management processes, impacting resident care.
Failure in Pain Management for Post-Surgery Resident
Penalty
Summary
The facility failed to provide appropriate pain management services for a resident who was admitted following joint replacement surgery. The resident, who had a right knee replacement and was diagnosed with heart failure, cardiomyopathy, and type 2 diabetes, was discharged from the hospital with orders for Tramadol to manage pain. However, the facility did not reconcile the hospital discharge orders with the attending physician, nor did they notify the designated pharmacy of the new admission. As a result, the resident's Medication Administration Record (MAR) did not include the prescribed Tramadol, leading to the resident experiencing severe pain and requesting to be transferred to the emergency room. Interviews with staff revealed a lack of understanding and access to the medication dispensing process. A Licensed Practical Nurse (LPN) working the overnight shift stated she did not have access to the medication machine and was unaware of the process for contacting the pharmacy if medication was unavailable. The Director of Nursing (DON) could not confirm what medication was offered to the resident, and the consulting pharmacist indicated that no order was placed in the Electronic Health Record (EHR) for the Tramadol. Additionally, another staff member confirmed that if a medication order is not reflected on the MAR, it would not be administered, especially narcotics.
Deficiencies in Medical Record Maintenance and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in care. For the first resident, who was admitted for aftercare following joint replacement surgery, the facility did not file a nursing admission data collection, which should have included admission details, cognition, communication preferences, skin issues, systems review, falls assessment, elopement risk assessment, and patient medication orders. The resident was discharged with uncontrolled pain, and the facility lacked a physical chart or paperwork, relying solely on the Electronic Health Record (EHR), which only contained vitals and a pain score. Interviews with staff revealed issues with access to medication machines and computers, hindering proper documentation and medication administration. The second resident, admitted with pneumonia due to pseudomonas, lung cancer, chronic obstructive pulmonary disease, and acute respiratory failure with hypoxia, did not receive intravenous (IV) antibiotics on the day of admission. The clinical record lacked documentation to verify whether the antibiotics were administered, and there was no admission time recorded. The nurse's progress notes did not include notification of the physician for medication verification. The consulting pharmacist confirmed that the orders for IV Cefepime were received late and sent to the facility with a delay. Interviews with various staff members, including the Medical Records Director, Regional Nurse, and Director of Operations, highlighted systemic issues with documentation and access to necessary resources. The facility's policy required the nursing department to record specific clinical data upon admission, but this was not consistently followed. The lack of proper documentation and medication administration verification contributed to the deficiencies observed in the care of both residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sarasota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glenridge On Palmer Ranch Inc. | 0.3 mi | ★★★★★ | 0 | 0 |
| Sarasota Memorial Nursing & Rehabilitation Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Springs At Lake Pointe Woods | 2 mi | ★★★★★ | 8 | 0 |
| Bay Village Of Sarasota | 2.3 mi | ★★★★★ | 0 | 0 |
| Crescent Health And Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
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