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 Crescent Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to maintain an adequate supply of clean washcloths and towels, impacting resident care. CNAs and residents reported frequent shortages, with the Director of Housekeeping admitting to not conducting linen inventories. The Administrator was unaware of the linen needs for the resident census, and an inventory revealed a significant shortfall, attributed to staffing and inventory issues.
The facility failed to ensure proper disinfection of shared glucometers, placing residents at risk of exposure to blood-borne pathogens. Observations revealed that nurses did not follow the manufacturer's disinfection instructions, using alcohol wipes inadequately and failing to maintain the required contact time. The Infection Preventionist and DON were aware of the issue, but the facility lacked a specific disinfection policy, contributing to the deficiency.
The facility failed to ensure proper disinfection of shared glucometers between resident uses, as observed over two days. Multiple nurses used glucometers on several residents without following the manufacturer's disinfection instructions, placing residents at risk of exposure to blood-borne diseases. The facility lacked a clear policy for glucometer disinfection, contributing to the improper practices.
The facility was found to have multiple deficiencies in maintaining a clean and sanitary environment, including stained carpets, peeling wallpaper, gouged drywall, and stained privacy curtains in several rooms. The Maintenance Director confirmed the need for significant carpet replacement and acknowledged previous roof leaks, while the Director of Housekeeping verified the buildup of debris behind handrails.
A resident at high risk for pressure ulcers did not receive a physician-ordered low air loss mattress, leading to skin breakdown. Despite the absence of the mattress, nursing staff inaccurately documented its presence and function. The resident's skin condition was not reported to the physician, contributing to a deficiency in care.
A resident with left hemiplegia, dependent on staff for transfers, was transferred by a CNA using a mechanical lift without the required second staff member, due to staffing shortages. The CNA acknowledged the safety protocol breach, and the LPN supervising did not document the supervision.
The facility's medication error rate was found to be 12%, exceeding the acceptable threshold of 5%. Errors included an LPN failing to administer prescribed medications and an RN not instructing a resident to rinse their mouth after using an inhaler, as required by the manufacturer's guidelines.
Inadequate Linen Supply in Facility
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment by not ensuring an adequate supply of clean washcloths and towels for residents. Observations and interviews revealed that during the 7 a.m. to 3 p.m. shift, there were no clean linens available on the floor. Certified Nursing Assistants (CNAs) and residents reported a consistent shortage of towels and washcloths, with some residents having to wait for these items. The Director of Housekeeping admitted to not conducting inventories of linens and was observed delivering a limited number of washcloths to the floors. The Administrator was unaware of the exact number of linens needed for the current resident census and had not conducted an inventory until prompted. The inventory revealed only 81 towels available for 108 residents, indicating a significant shortfall. The Administrator acknowledged that the lack of linens was due to both staffing issues and insufficient inventory. The Director of Housekeeping was new to the position, having been moved from the activities department, which may have contributed to the oversight in linen management.
Improper Disinfection of Shared Glucometers
Penalty
Summary
The facility failed to ensure that licensed nurses were knowledgeable and competent in the disinfection of multi-resident shared glucometers according to the manufacturer's specifications. Observations from 9/10/24 to 9/11/24 revealed that four licensed nurses across different shifts and units did not disinfect glucometers between resident uses. This failure placed 17 residents requiring blood glucose testing at risk of exposure to blood-borne pathogens, which could result in serious illness or death. On 9/10/24, RN Staff A was observed using a glucometer on multiple residents without proper disinfection between uses. She did not wear gloves or sanitize her hands during the procedure and used an alcohol wipe incorrectly, allowing the glucometer to dry in six seconds instead of the required one minute. Similarly, RN Staff C and LPN Staff B were observed using glucometers without following proper disinfection protocols, either by not disinfecting at all or using alcohol wipes inadequately. These actions were contrary to the facility's infection control policies and the manufacturer's instructions. The facility's Infection Preventionist and Director of Nursing were informed of these observations. Despite the Infection Preventionist's awareness of the improper disinfection, she did not intervene effectively. The Director of Nursing acknowledged the issue and stated that the nurses had been recently educated on proper disinfection procedures. However, the facility lacked a specific policy for glucometer disinfection, and the competency checklists used did not adequately describe the disinfection process, contributing to the deficiency.
Removal Plan
- Residents #46, #34, and #82 were assessed by a licensed nurse to ensure no adverse effects were noted from the alleged deficient practice.
- RN Staff A, LPN Staff B, and RN Staff D were re-educated by the Director of Nursing/Designee on proper disinfecting of the glucometer machine and provided a return demonstration on proper disinfecting of glucometer machine.
- Proof the glucometer disinfection competencies for the four licensed nurses (RN Staff A, LPN Staff B, RN Staff C and RN Staff D).
- Current residents who received blood glucose monitoring were assessed by a licensed nurse to ensure no adverse effects were noted from the alleged deficient practice.
- Current licensed nurses were re-educated in person or via phone by the Assistant Director of Nursing/Designee on the process for glucometer disinfection and 100% completion was achieved.
- The facility initiated training with current licensed nurses on disinfecting glucometers and have completed competencies with return demonstration, on disinfection of glucometer machines.
- All four nurses on duty were interviewed and were able to verbalize the process for disinfecting the glucometers using the selected EPA approved disinfecting wipes.
- The Infection Preventionist was re-educated on proper disinfection of glucometer machine by the Director of Nursing and provided return demonstration on proper disinfection of glucometer machines.
- The facility implemented a new process where each resident requiring blood glucose monitoring will be provided with their own individual glucometer machines which will be stored in plastic containers with lids and their names to identify individual glucometer machine.
- All current medication carts are equipped with a plastic basket to hold EPA approved disinfection wipes, timers to ensure timeliness of disinfection, instructions on how to disinfect glucometer machines and contact time listed on the container of the disinfectant wipes.
- The Medical Director was contacted to review the recommendations for monitoring of the current residents potentially affected by the alleged deficient practice; new orders received for monitoring CBC (Complete Blood Count) with Diff (Differential) once in the morning and then again in 7 days; also monitor vital signs every day for duration of 7 days.
- Newly hired nurses will be educated on proper disinfection of glucometers by the Assistant Director of Nursing/Designee and provide return demonstration as part of orientation.
- Currently the facility is not utilizing agency licensed nurses; in the event that the facility would need to utilize licensed agency staff, those licensed agency nurses would be educated on proper disinfection of glucometers and provide return demonstration.
- DON/Designee will conduct audits on five nurses to ensure proper disinfection of blood glucose machines is maintained. Findings of the audits will be reviewed in the Quality Assurance Meetings.
Improper Disinfection of Shared Glucometers
Penalty
Summary
The facility failed to maintain an ongoing infection prevention and control program by not ensuring that shared glucometers were properly disinfected between each resident use. This deficiency was observed over two days, where multiple licensed nurses on different shifts and units used shared glucometers without disinfecting them between uses. The nurses did not follow the manufacturer's specifications for disinfection, which placed residents at risk of exposure to blood-borne diseases. During observations, several nurses were seen using glucometers on multiple residents without proper disinfection. For instance, a registered nurse used a glucometer on five residents without disinfecting it between uses and did not follow standard precautions such as wearing gloves. Another nurse was observed cleaning the glucometer with an alcohol pad for only 15 seconds, which was insufficient according to the manufacturer's instructions. Additionally, a licensed practical nurse admitted to not disinfecting the glucometer between resident uses, stating it had slipped her mind. The facility did not have a policy for disinfecting glucometers, and the Director of Nursing was unable to provide one when requested. The lack of a clear policy and proper training contributed to the improper disinfection practices observed. The Medical Director acknowledged the risk of cross-contamination and the need for proper disinfection procedures, highlighting the potential for transmission of blood-borne pathogens such as HIV and HBV.
Removal Plan
- Residents #46, #34, and #82 were assessed by a licensed nurse to ensure no adverse effects were noted from the alleged deficient practice.
- RN Staff A, LPN Staff B, and RN Staff D were re-educated by the Director of Nursing/Designee on proper disinfecting of the glucometer machine and provided a return demonstration on proper disinfecting of glucometer machine.
- An Ad Hoc Quality Assurance Meeting was held with the facility Medical Director and other team members to approve recommendations and develop a Performance Improvement Plan based on Root Cause Analysis.
- All current licensed nurses received prior education and completed return demonstration competencies on disinfection of glucometers during orientation or skills fair training.
- Current residents who received blood glucose monitoring were assessed by a licensed nurse to ensure no adverse effects were noted for the alleged deficient practice.
- Current licensed nurses were re-educated in person or via phone by the Assistant Director of Nursing/Designee on the process for glucometer disinfection.
- The facility initiated training with current licensed nurses on disinfecting glucometers and completed competencies with return demonstration.
- The facility implemented a new process where each resident requiring blood glucose monitoring will be provided with their own individual glucometer machines stored in plastic containers with lids and their names.
- The facility reviewed the new process changes of individualized glucometers and the implementation of baskets on the nurses med carts to hold the sanitizer, timer, instructions for disinfections and contact time marked on the disinfectant wipe.
- Each cart had a timer to ensure the wet contact time per manufacturer's specification for the disinfecting wipes.
- The Medical Director was contacted to review the recommendations for monitoring of the current residents potentially affected by the alleged deficient practice; new orders received for monitoring CBC with Diff once in the morning and then again in 7 days; also monitor vital signs every day for duration of 7 days.
- The Infection Preventionist was re-educated on proper disinfection of glucometer machine by the Director of Nursing and provided return demonstration on proper disinfection of glucometer machines.
- Newly hired nurses will be educated on proper disinfection of glucometers by the Assistant Director of Nursing/Designee and provide return demonstration as part of orientation.
- In the event that the facility would need to utilize licensed agency staff, those licensed agency nurses would be educated on proper disinfection of glucometers and provide return demonstration.
- DON/Designee will conduct audits on five nurses to ensure proper disinfection of blood glucose machines is maintained. Findings of the audits will be reviewed in the Quality Assurance Meetings.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as evidenced by multiple observations of stained carpets in the hallways and rooms, peeling wallpaper, and gouged drywall in several rooms. Specific rooms, including 616, 614, 610, and 609, were noted to have walls in disrepair, with peeling wallpaper and scuffed drywall. Privacy curtains in rooms were observed to have brown stains, and the ceiling in one room showed signs of a roof leak. Additionally, handrails throughout the facility were scuffed, with dirt and debris accumulated behind them. Interviews with the Maintenance Director and the Director of Housekeeping confirmed these observations. The Maintenance Director acknowledged the presence of carpet stains throughout the building and stated that significant carpet replacement would be necessary. He also confirmed the disrepair of walls in specific rooms and acknowledged a previous roof leak that had been patched. The Director of Housekeeping verified the stained privacy curtains and the buildup of debris behind the handrails, indicating a need for more frequent cleaning in certain areas.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement physician-ordered interventions to prevent the development of avoidable pressure ulcers for a resident identified at high risk. The resident, who was admitted with left hemiplegia and was dependent on staff for mobility, was assessed using the Braden Scale and scored an 8, indicating a very high risk for pressure ulcers. Despite this, the physician's order for a low air loss mattress, intended to prevent pressure ulcers, was not followed. Observations on multiple occasions revealed the absence of the low air loss mattress, although the Treatment Administration Record (TAR) was signed by licensed nurses across all shifts, falsely indicating that the mattress was in place and functioning. The resident developed redness and skin breakdown on the coccyx, which was noted in nursing progress notes but not reported to the physician. The Director of Nursing confirmed the absence of the mattress and the inaccurate documentation by the nursing staff. The failure to implement the prescribed intervention and the lack of communication regarding the resident's skin condition contributed to the deficiency in care, as the resident was at a very high risk for developing pressure ulcers.
Failure to Follow Safety Protocols During Resident Transfer
Penalty
Summary
The facility failed to ensure staff followed safety precautions to prevent avoidable falls and accidents for a resident who was dependent on staff for transfers. The resident, who had left hemiplegia and was totally dependent on staff for chair to bed transfers, required the assistance of two staff members and the use of a full body mechanical lift. However, during an observation, a Certified Nursing Assistant (CNA) was seen transferring the resident alone using the mechanical lift, contrary to the care plan and safety protocols. The CNA admitted to operating the lift alone due to staffing shortages, acknowledging that two people should be present for safety reasons. The CNA had previously completed training that specified the need for two caregivers to operate the lift. Despite this, the CNA chose to proceed alone, citing the time it would take to get assistance. The Licensed Practical Nurse (LPN) supervising the CNAs did not maintain documentation of supervision, and the Director of Nursing was aware of the incident.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 12% based on observations, record reviews, and staff interviews. During the survey, three medication errors were identified among five nurses, seven residents, and 25 opportunities. One incident involved an LPN who did not administer MiraLax and Fexofenadine to a resident as per the physician's orders but incorrectly documented that the medications were given. The LPN later confirmed in an interview that she did not administer the medications but had signed the Medication Administration Record (MAR) as if she had. Another incident involved an RN who administered an inhaler to a resident with chronic obstructive pulmonary disease but failed to instruct the resident to rinse their mouth after use, as specified by the medication's manufacturer. This omission was confirmed by the RN during an interview, who admitted forgetting to provide the necessary instruction. The manufacturer's insert highlighted the importance of rinsing the mouth to reduce the risk of thrush. These errors were discussed with the Director of Nursing, who was informed of the facility's medication error rate.
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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) |
|---|---|---|---|---|
| Creekside Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 3 | 0 |
| Sarasota Memorial Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Brookdale Palmer Ranch Snf | 2.4 mi | ★★★★★ | 0 | 0 |
| Springs At Lake Pointe Woods | 2.4 mi | ★★★★★ | 8 | 0 |
| Glenridge On Palmer Ranch Inc. | 2.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.