Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Harborview Sarasota during CMS and state inspections, most recent first.
Failure to provide required ADL assistance affected multiple residents whose care plans called for help with grooming, oral hygiene, nail care, shaving, eating, and positioning support. A resident with amputations and chronic infection, a resident with dementia, a resident with stroke-related paralysis and aphasia, and a resident with stroke-related hemiplegia were observed with long nails, debris under the nails, poor grooming, inadequate oral care, and unmet eating or hand-support needs. Staff interviews and record review showed the residents’ assessed needs and care plan interventions were not consistently carried out, despite documentation that they required substantial assistance or total care.
Uncertified LPNs administered IV Meropenem to two residents with serious infections and orthopedic complications. Facility policy and the DON and ADON stated that only an RN or IV-certified LPN could give IV meds, but the facility could not produce IV certification documentation for the LPNs who gave the doses.
Missing documentation for ordered IV antibiotic administration. Two residents with serious infections had MARs that did not show multiple scheduled Meropenem doses were given, and the progress notes did not explain the omissions or show physician notification. Staff interviews confirmed that missed doses should be documented and reported, and the DON verified the missing MAR entries.
Failure to document and administer flu and pneumococcal vaccines for 5 reviewed residents. The facility policy required residents to be offered influenza and CDC-recommended pneumococcal vaccines, but record review showed two residents consented to pneumococcal vaccination without documentation that it was given, and three residents had incomplete consent forms that did not show acceptance, refusal, or contraindication. The ICP confirmed the missing documentation and had no explanation for the missed vaccines or incomplete forms.
Incomplete COVID-19 vaccination documentation was found for five residents. Records showed that some residents or their legal reps consented to the vaccine, but the chart lacked proof that the vaccine was administered or that it was medically contraindicated. For other residents, the consent forms were left blank and did not show whether they accepted or declined the vaccine. An ICP confirmed the missing documentation during record review.
Unsafe and Unkempt Resident Areas: Surveyors found multiple shared bathrooms with unlabeled or uncovered wash basins, bedpans, toiletries, and other personal items stored on counters and floors, along with trash, a corroded tube feeding pole, and call lights clipped out of residents’ reach. They also observed stained, peeling walls with black bio growth, and several rooms on the 400 hall lacked chairs, leaving visitors to stand or sit on beds.
A resident with dementia and a history of multiple falls did not consistently receive care planned fall prevention interventions, such as a low bed, perimeter mattress, and enabler bars, despite documentation indicating otherwise. The facility also failed to conduct and document thorough investigations after several unwitnessed falls, including one resulting in a femur fracture and hospitalization. Staff interviews revealed a lack of awareness and oversight regarding required interventions and incident follow-up.
The facility did not maintain an effective pest control program, resulting in ongoing cockroach and ant infestations in resident rooms, bathrooms, and common areas. Multiple residents and staff reported and observed live pests, pest droppings, and black bio growth in personal spaces and on belongings. Pest control services were inconsistent due to unprepared rooms and unresolved structural and sanitation issues, leading to persistent pest problems and resident distress.
A resident with multiple health conditions and cognitive impairment did not receive adequate assistance with personal hygiene and activities of daily living. The individual was observed unkempt, unshaven, with matted hair, soiled bedding, and poor oral hygiene. Documentation showed missed scheduled showers, and staff interviews confirmed that grooming was not consistently provided as required by facility policy.
A resident with acute respiratory failure and pulmonary fibrosis did not receive physician-ordered continuous oxygen therapy, as there was no documentation of administration over several days. Staff and DON interviews confirmed the lack of implementation and documentation of the order, and there was also no admission or transfer assessment or investigation into the resident's change in condition.
Surveyors found that the facility did not maintain required records for monthly and weekly maintenance and testing of its emergency generator, including battery testing, load testing, and visual inspections, as required by NFPA standards. The last documented load test was several months prior to the review, and the Maintenance Director confirmed the lack of documentation.
A deficiency was identified in a facility where residents experienced neglect and mental abuse by CNAs. A resident reported rough handling and verbal threats during care, while another resident corroborated the account, describing the CNA as intimidating. Two other residents raised concerns about a different CNA's aggressive behavior, leading to feelings of fear and discomfort. The facility's investigation resulted in the termination of both CNAs due to violations of resident rights and customer service standards.
A resident at moderate risk for pressure injuries did not receive necessary preventive interventions, leading to the development of a pressure injury. The care plan failed to address the risk, and there was no documentation of preventive measures. A darkened area was later identified on the resident's heel, but the prescribed treatment was not documented as applied. The facility was undergoing changes with new management and procedures.
A resident at moderate risk for pressure injuries developed a pressure injury due to the facility's failure to implement an effective care plan. The resident's care plan did not address their skin condition or risk for pressure injuries, and a treatment plan for a darkened area on the heel was not documented or applied. The facility was in the process of implementing new procedures for skin assessments, but these were not in place at the time of the incident.
The facility failed to protect residents from abuse and neglect, as evidenced by incidents involving CNAs who were verbally and physically rough with residents. A resident reported being handled roughly during a shower by a CNA, who also used inappropriate language. Another incident involved two residents who felt intimidated by a CNA's aggressive behavior. Despite reports and witness accounts, the facility's investigation was inconclusive, and the CNA's employment was terminated based on customer service concerns. The facility did not adequately communicate with residents about the outcomes, leaving them in fear.
Failure to Provide Required ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, including grooming, oral hygiene, nail care, shaving, eating assistance, and positioning/support devices, for multiple residents whose care plans and assessments identified those needs. The report states that 4 of 7 residents reviewed for ADLs did not receive assistance as outlined in their care plans and according to their preferences. Facility policy required that residents who are unable to perform ADLs receive services to maintain good nutrition, grooming, and personal and oral hygiene, and that care plans be maintained and reviewed. Resident #1 was observed in bed with long fingernails containing a brown substance underneath and with approximately one week of facial hair growth. The resident stated he needed his nails trimmed and his facial hair shaved and said he did not usually have a beard or mustache. His record showed diagnoses including chronic osteomyelitis and a traumatic amputation of toes and part of the foot, and his care plan called for assistance with grooming, bathing, personal hygiene, and nail care as needed. Later observations again showed him unshaven with long nails and visible debris under the nails. Staff interviews indicated shaving and nail care were expected on a routine basis, and the DON stated male residents should be shaved daily if needed. Resident #55 was observed with several days of facial hair growth, long fingernails with a black substance under them, and dry, scaly feet. The resident said he could not cut his own nails and that staff did not always come to help him, stating he lay in bed waiting. His record showed dementia and other chronic conditions, and his MDS indicated substantial to maximum assistance was needed for personal hygiene, bathing, and toileting. Although CNA documentation reflected daily personal hygiene assistance including shaving, observations on multiple days showed the resident remained unshaven and with untrimmed nails. The Administrator acknowledged awareness of care concerns for another resident and stated nails had been done but could use cleaning. Resident #90, who had hemiplegia/hemiparesis following stroke, dementia, and aphasia, was dependent for all ADLs and required total care. The resident was observed with long fingernails and black/brown debris under the nails, curled fingers in the right hand, no palm guard in place, and a foul odor from the hand. The care plan required a palm guard to the right hand and assistance with grooming, bathing, and personal hygiene. On a later observation, the resident’s lips were coated with a thick, dry, brown substance, and the DON directed CNA staff to provide oral care. Resident #2, who had hemiplegia and intact cognition, reported she could not clip her fingernails and had asked staff to do so without success, and said staff did not help her brush her teeth. Observations showed her fingernails extended beyond the fingertips, white substance remained at the gumline of her lower front teeth, and an untouched meal tray was present even though she stated she could not manage the sandwich with one hand. Her care plan required assistance with grooming, personal hygiene, and eating, but staff interviews reflected disagreement about her needs, and the DON stated her teeth should be brushed at least twice a day and nail care should occur with showers or baths.
Uncertified LPNs Administered IV Antibiotics
Penalty
Summary
The facility failed to ensure that 5 of 5 reviewed LPNs had the appropriate competencies and certifications to administer IV antibiotic therapy for 2 of 3 residents reviewed for IV therapy. Facility policy stated that continuous infusion, IV push, and intermittent medication infusion procedures were to be completed by an RN or certified LPN, and the DON and ADON both stated that LPNs had to be IV certified to administer IV medications. The facility was unable to provide documentation of IV therapy certification for the IV antibiotic doses administered by LPN Staff H, Staff N, Staff O, Staff P, and Staff Q. Resident #73 was admitted with chronic osteomyelitis of the right foot and ankle, peripheral vascular disease, type 2 diabetes mellitus, and a history of osteomyelitis of the left foot and ankle with below-the-knee amputation. The resident’s record showed an order for Meropenem 1 gram IV every 8 hours for wound infection, and the MAR documented multiple IV doses given by the five LPNs. Resident #66 was admitted with a periprosthetic fracture around an internal prosthetic, a left artificial knee joint, infection and inflammatory reaction due to the left knee prosthesis, osteoporosis, and chronic pain. The resident also had an order for Meropenem 1 gram IV every 8 hours, and the MAR documented IV doses given by LPN Staff N, O, P, and Q. The facility could not provide certification documentation for the LPNs who administered these IV medications.
Missing Documentation for Ordered IV Antibiotic Administration
Penalty
Summary
The facility failed to document administration of ordered IV antibiotics for 2 residents reviewed, Resident #73 and Resident #66. Resident #73 was admitted with chronic osteomyelitis of the right foot and ankle, and had an order dated 3/2/26 for Meropenem 1 gram IV every 8 hours for a wound infection until 4/2/26. The MAR for March 2026 did not show documentation that multiple scheduled doses were administered, including doses on 3/3, 3/4, 3/6, 3/12, 3/13, 3/14, 3/22, 3/24, 3/25, and 3/26. The progress notes did not explain the missed documentation or show physician notification of the missed doses. Resident #66 was admitted with infection and inflammatory reaction due to an internal left knee prosthesis and chronic pain, and had an order dated 2/16/26 for Meropenem 1 gram IV every 8 hours until 3/19/26. The MAR for March 2026 failed to show documentation that doses were administered on 3/3, 3/12, and 3/13. The progress notes did not provide an explanation for the undocumented doses or show physician notification. During interviews, staff stated that missed or refused medication doses should be documented and reported to the physician, and the DON verified that the MAR lacked documentation for multiple IV antibiotic doses for both residents.
Failure to Document and Administer Flu and Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer and/or administer influenza and pneumococcal vaccinations for 5 of 5 residents reviewed for vaccinations. The facility policy titled Infection Prevention and Control Program stated that residents are to be offered the influenza vaccine each year between October 1 and March 31 unless contraindicated or received elsewhere, and that residents are to be offered pneumococcal vaccines recommended by the CDC upon admission unless contraindicated or received elsewhere. Record review showed that Resident #8 and Resident #49 had consented to receive the pneumococcal vaccine, but the clinical record lacked documentation that the vaccine was administered and there was no documentation of contraindication. Resident #2, Resident #92, and Resident #66 each had a pneumococcal consent form dated 10/3/25, but the forms were left blank and did not indicate whether the residents accepted or refused the vaccine, and there was no documentation that the vaccine was contraindicated. During interview, the Infection Control Preventionist stated that residents are offered influenza, pneumococcal, and COVID vaccines on admission, that consent forms are included in the admission packet, and that vaccine receipt or refusal is documented on the immunizations tab; he verified the missing administrations and incomplete consent forms and had no explanation for the missed vaccines or incomplete forms.
Incomplete COVID-19 Vaccination Documentation
Penalty
Summary
The facility failed to ensure that five residents reviewed for COVID-19 vaccination were offered and either administered the vaccine or documented as medically contraindicated. Clinical record review showed that one resident’s legal representative consented to the COVID-19 vaccine, but the record did not document that the vaccine was given or that it was contraindicated. For three other residents, the COVID-19 consent forms were incomplete because the sections indicating whether the resident wanted to receive or declined the vaccine were left blank, and the records did not show acceptance, refusal, or a contraindication. Another resident had consented to the COVID-19 vaccination, but the record lacked documentation that the vaccine was administered or medically contraindicated. During interview, the Infection Control Preventionist stated that the COVID-19 vaccine consent form is included in the admission packet and that residents are offered the vaccine on admission and annually. He explained that alert and oriented residents sign the form to indicate whether they want or decline the vaccine, while legal representatives make that decision for residents who are not alert and oriented. After reviewing the records, he verified that two residents had consented to the vaccine but there was no documentation that they received it, and he verified that three residents had incomplete consent forms that did not show whether they accepted or declined the vaccine or whether the vaccine was contraindicated.
Unsafe and Unkempt Resident Areas
Penalty
Summary
The facility failed to ensure a safe, clean, sanitary, and homelike environment that emphasized and enhanced resident comfort in the 100, 200, and 400 halls. During an initial tour, surveyors observed multiple shared bathrooms with personal care items and equipment stored in an unorganized manner, including disinfecting wipes on a bathroom counter, unlabeled wash basins stacked on counters and floors, unlabeled and uncovered bedpans, unlabeled bottles of soap, lotion, and cleansing foam, an uncapped razor, wheelchair footrests and a wheelchair cushion stored on the floor, and trash on the bathroom floor. In one room, a corroded tube feeding pole with multiple yellow, dried stains was also observed. The call lights for two residents were clipped to the privacy curtain and were not within reach while the residents were in bed, and a resident’s catheter drainage bag was attached to the bedframe and touching the floor. Surveyors also observed environmental concerns in resident rooms, including stained walls near air conditioning units, peeling and cracking paint, discolored baseboards pulling away from the wall, and black bio growth on a wall where paint had peeled. In addition, one resident stated that chairs had been removed from the room about a month earlier and not returned, leaving visitors to sit on the bed or stand and causing them to leave sooner. Survey findings showed that 6 of 11 rooms on the 400 hall did not have a chair, and one shared room had only one chair for two residents. The DON verified the call light observations, and staff interviews confirmed the facility was aware of concerns about personal items in shared bathrooms not being labeled or stored properly.
Failure to Implement and Document Fall Prevention Interventions and Investigations
Penalty
Summary
The facility failed to ensure that a resident at high risk for falls was adequately protected from accident hazards and that appropriate supervision and interventions were consistently implemented. Despite the resident's documented history of dementia, gait abnormalities, impulsivity, and multiple falls, the facility did not maintain required fall prevention interventions as outlined in the care plan. Observations revealed that the resident's bed was not in the lowest position, the perimeter mattress was not in place, and bilateral enabler bars were missing, even though nursing documentation indicated these interventions were present. The facility also failed to conduct and document thorough investigations following several unwitnessed falls, including a significant incident that resulted in a right femur fracture and subsequent hospitalization for surgical repair. Progress notes and care plan reviews did not include root cause analyses for the falls or specify whether all prescribed interventions were in place at the time of each incident. Additionally, there was no documentation provided for the investigation of the fall that led to the femur fracture, despite requests from the survey team and concerns raised by the resident's responsible party. Staff interviews confirmed a lack of awareness and oversight regarding the implementation of fall prevention measures. The DON was unaware that certain interventions, such as the perimeter mattress, were part of the resident's care plan, and acknowledged that documentation in the Medication Administration Record did not reflect the actual status of interventions. The Administrator also confirmed the absence of investigation documentation for the critical fall event and did not address the incident in a subsequent abuse/neglect investigation, citing a change in facility administration.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program as required by its own policies, resulting in ongoing infestations of cockroaches and ants throughout resident rooms, bathrooms, and common areas. Multiple residents reported seeing cockroaches in their bathrooms, bedrooms, dresser drawers, and even on their bodies and personal items. Observations confirmed the presence of live cockroaches and ants in various locations, including behind soap dispensers, in dresser drawers, and on floors and walls. Photographic evidence was obtained of live insects, pest droppings, and black bio growth in resident areas and on personal belongings. Staff interviews revealed that pest sightings were being logged, but the problem persisted and was not fully addressed. Several staff members, including LPNs and the Housekeeping Supervisor, acknowledged the ongoing issue with roaches and described their own actions to kill or report pests. The pest control company’s logs indicated that treatments were not consistently performed because rooms were not prepared for service, and the technician eventually stopped weekly visits due to unresolved structural and sanitation issues. Documentation showed gaps in pest control services and incomplete follow-through on pest control recommendations. Residents expressed embarrassment and distress over the pest infestations, with some avoiding showers or having family members assist in killing insects during visits. The pest control company’s records and statements from facility leadership confirmed that pest control visits were inconsistent and that recommendations for structural and sanitation improvements were not implemented in a timely manner. The deficiency was further evidenced by direct observations of live pests and pest droppings in resident living spaces and common areas, as well as by resident council minutes and pest sighting logs.
Failure to Provide Necessary Personal Hygiene and ADL Assistance
Penalty
Summary
The facility failed to provide necessary care and services to maintain personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, who had diagnoses including a displaced intertrochanteric fracture of the right femur, type 2 diabetes mellitus, dementia, and anxiety, required partial to maximum assistance with oral hygiene and bathing according to the clinical record and care plan. Observations revealed the resident was unkempt, unshaven with a long beard and mustache, had matted and greasy hair, and was lying in bed with soiled sheets and a strong foul odor of urine in the room. The resident's teeth had black spots and a thick white coating, and his mouth was dry with foul breath. The resident reported not having been shaved or had a haircut in a long time and expressed a desire to be shaved. Review of CNA documentation showed missed scheduled showers on multiple dates, with no documentation that the resident received showers as planned. The facility's policy required staff to provide grooming and personal hygiene services for residents unable to perform these tasks. Interviews with staff confirmed that shaving typically occurred during showers or upon request, and that assistance was provided with oral care. However, the lack of documented and observed care indicated a failure to follow the care plan and facility policy, resulting in the resident not receiving adequate assistance with personal hygiene.
Failure to Provide Ordered Respiratory Care and Documentation
Penalty
Summary
A deficiency occurred when the facility failed to provide respiratory care as ordered for a resident with acute respiratory failure with hypoxia and idiopathic pulmonary fibrosis. The physician's order specified that oxygen should be administered continuously at 2 liters per minute via nasal cannula. However, review of the Medication Administration Record (MAR) for the relevant period showed no documentation that the oxygen was administered as ordered from 11/22/25 through 11/24/25. Nursing progress notes also did not specify whether the resident was receiving oxygen at the time of a noted change in condition. Interviews with staff and the Director of Nursing confirmed the lack of documentation and implementation of the oxygen order. The resident was described as cognitively intact and was able to answer questions appropriately earlier in the day. On the day of the incident, the resident became lethargic, and family members requested transfer to the hospital. The DON verified the absence of an admission assessment, a transfer out assessment, and any documented investigation into the resident's change in condition.
Failure to Maintain and Test Emergency Generator per NFPA Standards
Penalty
Summary
The facility failed to provide evidence of proper maintenance and testing of its 135 KW diesel-powered generator in accordance with National Fire Protection Association (NFPA) standards. During a record review with the Maintenance Director, surveyors found that the facility did not have documentation for monthly specific gravity or conductance testing of the generator's maintenance-free battery, weekly voltage testing of the battery, monthly load testing of the life safety generator, or weekly visual inspections of the generator. The last documented monthly load test was dated several months prior to the review. These deficiencies were confirmed during an interview with the Maintenance Director, who acknowledged the lack of required records. The absence of these maintenance and testing records indicates that the facility did not adhere to the required schedules and procedures outlined in NFPA 99, NFPA 110, and NFPA 101 for ensuring the reliability of the essential electrical system, specifically the emergency generator and its components.
Neglect and Mental Abuse in Resident Care
Penalty
Summary
The deficiency involves the failure of a facility to protect residents from neglect and mental abuse, as evidenced by the experiences of four residents. Resident #699 reported that a CNA was verbally abusive and rough during care, failing to follow proper hygiene procedures and threatening to leave the resident unattended. The resident expressed fear and anxiety due to the CNA's behavior and was not informed promptly about the CNA's termination, which prolonged the resident's distress. Resident #700 corroborated the account of Resident #699, describing the CNA as intimidating and rough during care. The resident witnessed the CNA's inappropriate handling of Resident #699 and reported the incident to the facility. Despite the facility's investigation, the CNA's behavior was deemed inconsistent with facility standards, leading to her termination. Additionally, Residents #800 and #850 raised concerns about another CNA, Staff B, who displayed aggressive behavior and was rough during care. Resident #850 reported being left uncovered and in a soiled state for an extended period, feeling demeaned and hurt by the CNA's actions. The facility's investigation into these allegations was inconclusive, but due to concerns about customer service, CNA Staff B's employment was terminated.
Plan Of Correction
Tag Cited: F-600 Free from and Neglect CFR(s): 483.12(a)(1) 1. Immediate action(s) taken for the resident(s) found to have been affected include: CNA Staff A and CNA Staff B were immediately removed from the schedule and terminated from employment and reported to board. Affected residents (R699, R700, R800, R850) received assessments from Social Services and were offered ongoing emotional support. The facility formally notified residents R699, R700, R800, and R850 (and/or their representatives) that CNA Staff A and B were no longer employed. 2. The Identification of other residents having the potential to be affected was accomplished by: Starting a facility-wide audit of grievance reports and residents with of 12 or higher was conducted by Social Services to identify any other concerns related to or neglect and was completed by . 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On Human Resources re-conducted Prevention Training and Customer Service education for all staff to be completed by . Any staff who are unable to meet the compliance date will be educated prior to their next working shift. All new hires must complete Prevention and Customer Service modules in Relias during orientation. The facility doesn't currently utilize agency staffing at this time. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will complete 10 resident interviews weekly for 2 weeks, and then 5 residents weekly for 4 weeks to monitor any concerns about staff behavior or . With any allegation of neglect a licensed psychologist/social Worker will conduct an initial interview and determine plan for resident(s) emotional or needs. Customer service satisfaction rounds will be completed 5x weekly by the Department Heads for a total of 80 residents by the end of the week and submitted to the Administrator and/or Designee for review by the end of each day 5 x weekly for 6 weeks. The Administrator will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25.
Failure to Prevent Pressure Injuries in Resident
Penalty
Summary
The facility failed to provide necessary interventions to prevent the development of avoidable pressure injuries for a resident identified as at risk. The resident, who was dependent for bed mobility, transfers, toileting, and bathing, was admitted without any pressure injuries and was initially assessed as not at risk. However, a subsequent assessment indicated a moderate risk for pressure injuries, yet the care plan did not address this risk. There was no documentation of preventive measures being implemented to decrease the risk of pressure injuries for the resident. A darkened area was later identified on the resident's left heel, and a treatment plan was developed, but there was no documentation that the prescribed skin preparation was ordered or applied. The resident was transferred to the hospital at the family's request, and the facility's investigation noted that a pressure injury developed during the resident's stay, which was documented and treated according to facility protocol. The facility was undergoing changes with a new company and new Director of Nursing, and they were in the process of implementing new procedures for skin assessments.
Plan Of Correction
Tag Cited: F686 Treatment/Svcs to Prevent/Heal CFR(s): 483.25(b)(1)(1)(ii) 1. Immediate action(s) taken for the resident(s) found to have been affected include: The facility failed to implement skin integrity interventions for Resident R799. Resident R799 was transferred to hospital and didn't return to the facility. 2. Identification of other residents having the potential to be affected was accomplished by: On the Director of Nursing, Assistant Director of Nursing, and Unit Manager conducted a 100% skin sweep audit for current residents to establish a baseline skin assessment by completed by. On a 100% audit for Braden Assessments was completed for current residents to address moderate to high-risk Braden Scores. This audit was conducted by the Director of Nursing. Assistant Director of Nursing, and Unit Manager completed by. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On the Director of Nursing conducted an audit of all current residents to review and identify those with and/or Braden scores of moderate to high risk by and completed by. Any resident with or Braden Scores of moderate to high had care plans initiated or revised care plan focusing on skin integrity and prevention needs. All new admissions are ordered skin prep to heels for the first 14 days of admission and then reassessed by nurse for further skin integrity needs. A designated treatment nurse was hired on. Starting, the Assistance Director of Nursing began re-education for Licensed Nursing staff (RN and LPN) on Care Best Practices including timely documentation. All licensed nursing staff will be educated by anyone not in compliance with this date will be educated prior to the next working shift. All newly hired licensed nursing staff (RN and LPN) will complete this education during orientation. The facility is not currently utilizing agency staffing. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: Starting the Care Nurse or designee will audit new admissions five times a week for 2 weeks, and 5 new admission records weekly for 4 weeks, to ensure residents with high-risk Braden Scores have appropriate interventions in place for skin integrity. The Care Nurse will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25
Failure to Prevent Pressure Injury in Resident
Penalty
Summary
The facility failed to provide necessary care and services to prevent the development of avoidable pressure injuries for a resident identified as at risk. The facility's policy on 'Pressure Injury Prevention and Management' was not effectively implemented, as evidenced by the lack of a care plan addressing the resident's skin condition and potential risk for pressure injuries. The resident, who was dependent for bed mobility, transfers, toileting, and bathing, was initially assessed as not at risk for pressure injuries upon admission. However, a subsequent assessment indicated a moderate risk, which was not reflected in the care plan. A darkened area on the resident's left heel was identified, but the treatment plan, which included skin preparation, was not documented as ordered or applied. The resident was transferred to the hospital at the family's request and did not return to the facility. Interviews with the facility's new administration and nursing staff revealed that they were in the process of implementing new procedures for skin assessments and care, but these were not in place at the time of the incident. The facility's investigation confirmed the development of a pressure injury during the resident's stay, which was documented and treated according to protocol.
Plan Of Correction
Tag Cited: F686 Treatment/Svcs to Prevent/Heal CFR(s): 483.25(b)(1)(i)(ii) 1. Immediate action(s) taken for the resident(s) found to have been affected include: The facility failed to implement skin integrity interventions for Resident R799. Resident R799 was transferred to hospital and didn't return to the facility. 2. Identification of other residents having the potential to be affected was accomplished by: On the Director of Nursing, Assistant Director of Nursing, and Unit Manager conducted a 100% skin sweep audit for current residents to establish a baseline skin assessment by completed by. On a 100% audit for Braden Assessments was completed for current residents to address moderate to high-risk Braden Scores. This audit was conducted by the Director of Nursing, Assistant Director of Nursing, and Unit Manager completed by. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On the Director of Nursing conducted an audit of all current residents to review and identify those with and/or Braden scores of moderate to high risk by and completed by. Any resident with or Braden Scores of moderate to high had care plans initiated or revised care plan focusing on skin integrity and prevention needs. All new admissions are ordered skin prep to heels for the first 14 days of admission and then reassessed by nurse for further skin integrity needs. A designated treatment nurse was hired on. Starting the Assistance Director of Nursing began re-education for Licensed Nursing staff (RN and LPN) on Care Best Practices including timely documentation. All licensed nursing staff will be educated by, anyone not in compliance with this date will be educated prior to the next working shift. All newly hired licensed nursing staff (RN and LPN) will complete this education during orientation. The facility is not currently utilizing agency staffing. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: Starting the Care Nurse or designee will audit new admissions five times a week for 2 weeks, and 5 new admission records weekly for 4 weeks, to ensure residents with high-risk Braden Scores have appropriate interventions in place for skin integrity. The Care Nurse will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents' rights to be free from abuse and neglect, as evidenced by multiple incidents involving inappropriate and rough handling by certified nursing assistants (CNAs). Resident #699 reported that CNA Staff A was verbally abusive and physically rough during a shower, failing to follow proper hygiene procedures and leaving the resident feeling afraid and intimidated. The resident was not informed of the CNA's termination, leaving her in fear of potential retaliation. Resident #700 corroborated the account, describing the CNA's aggressive demeanor and improper care practices. In another incident, Residents #800 and #850 raised concerns about CNA Staff B's aggressive behavior. Resident #850 reported feeling intimidated and uncomfortable due to the CNA's rough handling and verbal aggression. Central Supply Staff D witnessed the CNA's inappropriate behavior and reported it to the nurse on duty. Despite these reports, the facility's investigation was inconclusive, and the CNA's employment was terminated based on customer service concerns rather than confirmed abuse. The facility's response to these allegations was inadequate, as there was no documentation of increased monitoring or protective measures for the affected residents. The Administrator acknowledged the need for improved customer service and staff education but did not provide evidence of effective measures to prevent future incidents. The lack of communication with residents about the outcomes of investigations contributed to their ongoing fear and discomfort.
Plan Of Correction
Tag Cited: F-600 Free from and Neglect CFR(s): 483.12(a)(1) 1. Immediate action(s) taken for the resident(s) found to have been affected include: CNA Staff A and CNA Staff B were immediately removed from the schedule and terminated from employment and reported to board. Affected residents (R899, R700, R800, R850) received assessments from Social Services and were offered ongoing emotional support. The facility formally notified residents R699, R700, R800, and R850 (and/or their representatives) that CNA Staff A and B were no longer employed. 2. The Identification of other residents having the potential to be affected was accomplished by: Starting a facility-wide audit of grievance reports and residents with of 12 or higher was conducted by Social Services to identify any other concerns related to or neglect and was completed by. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: On Human Resources re-conducted Prevention Training and Customer Service education for all staff to be completed. by Any staff who are unable to meet the compliance date will be educated prior to their next working shift. All new hires must complete Prevention and Customer Service modules in Rellas during orientation. The facility doesn't currently utilize agency staffing at this time. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The Administrator or designee will complete 10 resident interviews weekly for 2 weeks, and then 5 residents weekly for 4 weeks to monitor any concerns about staff behavior or. With any allegation of or neglect a licensed psychologist/social Worker will conduct an initial interview and determine plan for resident(s) emotional or needs. Customer service satisfaction rounds will be completed 5x weekly by the Department Heads for a total of 80 residents by the end of the week and submitted to the Administrator and/or Designee for review by the end of each day 5 x weekly for 6 weeks. The Administrator will bring the findings to the QAPI meeting monthly starting to evaluate effectiveness and recommend changes. 5. Corrective action completion date: 6/3/25.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 118 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sarasota
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benderson Family Skilled Nursing And Rehab Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Sunnyside Nursing Home | 1.1 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare Meadows | 1.3 mi | ★★★★★ | 2 | 0 |
| Aviata At Beneva | 1.6 mi | ★★★★★ | 16 | 4 |
| Birchwood Health And Rehabilitation Center | 2.1 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.