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 Indian Beach Nursing And Rehab Center during CMS and state inspections, most recent first.
Six residents experienced unauthorized withdrawals from their personal funds managed by the facility, with no supporting receipts or documentation for large sums spent on personal needs, tobacco, and other items. Some residents were charged for items they did not use or after discharge, and interviews revealed distress and lack of understanding about their finances. Facility staff confirmed missing receipts and could not explain the discrepancies, indicating a failure to protect resident property.
Facility administration failed to prevent the misappropriation of resident funds by not ensuring proper oversight and documentation. A staff member responsible for managing resident accounts could not account for missing funds, and required receipts and signatures were not obtained for multiple withdrawals, including those made after residents were discharged or deceased. Residents were not adequately informed about their financial statements, and leadership did not fully investigate the discrepancies when they were discovered.
A facility failed to report an allegation of misappropriation of resident property within the required timeframe. Despite policy requiring immediate reporting, an incident involving missing funds from the resident cash box was not reported to authorities until several days after the initial discovery, resulting in a deficiency for delayed reporting.
The facility failed to conduct a thorough investigation into the misappropriation of resident funds after discovering a significant cash shortage. Multiple residents reported missing money and unauthorized withdrawals, with no receipts to support the transactions. Staff interviews confirmed that no comprehensive review or audit was performed to determine the full extent of the loss, and residents were not properly informed or guided to check their financial statements for accuracy.
The facility did not ensure safe and comfortable room temperatures when central air conditioning units failed in multiple halls. Despite installing window units in some rooms, staff did not monitor temperatures or implement timely interventions, resulting in room and common area temperatures exceeding 81°F. Multiple residents reported discomfort and difficulty sleeping due to excessive heat, and ongoing concerns about temperature regulation were documented in Resident Council meetings. The deficiency was determined to be Immediate Jeopardy due to the risk of heat-related harm.
The facility did not take timely or adequate action to maintain safe and comfortable temperatures after multiple central air conditioning units failed, resulting in excessively high room temperatures and resident complaints of discomfort. Despite installing window AC units in some rooms, staff did not consistently monitor or document room temperatures, and concerns about heat were repeatedly raised by residents over several months without effective resolution.
Facility administration did not take immediate and effective action to maintain safe and comfortable temperatures for residents when multiple central air conditioning units failed. Despite ongoing complaints from residents about excessive heat, temperatures in resident rooms and common areas were repeatedly recorded above recommended levels, and interventions to address heat exposure were delayed. The administration's monitoring practices were insufficient, and residents' concerns were not adequately addressed, resulting in Immediate Jeopardy.
A resident with multiple diagnoses, including COPD and Dysphagia, experienced a 9.41% weight loss over six months and developed an unstageable pressure ulcer. Despite these significant changes, the facility failed to complete a required significant change in status MDS assessment. The resident's care plan noted risks for pressure ulcer development, but the necessary assessment was not conducted.
The facility failed to maintain a safe and comfortable environment for residents in the 300 hallway due to a malfunctioning air conditioning system. Despite awareness of the issue, necessary repairs were not completed, and temporary measures were insufficient. Residents experienced significant discomfort, with temperatures reaching 83.4 degrees Fahrenheit, and staff confirmed the administration's knowledge of the problem without effective resolution.
The facility failed to address grievances related to room temperature, pest control, and staff treatment. Residents reported unresolved issues with high room temperatures, persistent pest problems, and slow staff response times. Despite complaints, the facility did not document or resolve these grievances, as confirmed by the DON.
The facility failed to effectively control a roach infestation, as evidenced by multiple sightings and resident complaints. Observations on a specific day revealed live roaches in various areas, and interviews with residents and staff highlighted persistent issues. The pest control technician identified unsealed entry points as the main problem, which had not been addressed despite recommendations. Service inspection reports noted regular pest control visits, but the issue remained unresolved due to unsealed doors in the 800 hallway.
Failure to Safeguard Resident Funds and Prevent Misappropriation
Penalty
Summary
The facility failed to protect the rights of six residents whose personal funds were managed by the facility, resulting in misappropriation of resident property. Facility policy clearly prohibits the misplacement, exploitation, or wrongful use of resident belongings or money without consent, and requires receipts for all petty cash disbursements. However, for multiple residents, there were significant withdrawals from their accounts for personal needs items, tobacco, clothing, and telephone charges, with no supporting receipts or documentation. In several cases, residents were charged for items they did not use or request, such as tobacco for a non-smoker and personal care items after discharge or death. Interviews with the affected residents revealed that they were only allowed to withdraw small amounts of money at a time, typically $40, and were not provided with clear explanations of their financial statements. Some residents expressed distress and anger upon discovering unexplained or unauthorized withdrawals from their accounts. One resident reported being manipulated by a former Business Office Manager (BOM) into giving money under false pretenses, while others denied ever making or authorizing the large withdrawals documented in their records. The lack of receipts and inconsistent withdrawal practices were confirmed by both residents and facility staff. The facility's own staff, including the Nursing Home Administrator and current BOM, acknowledged the absence of required receipts and could not explain the discrepancies in resident accounts. The former BOM was terminated after a significant amount of petty cash was found missing, but there was no evidence that the facility reviewed prior transactions for additional losses. The President of Revenue Cycle also confirmed that the residents had unsupported charges and that receipts could not be located, indicating a systemic failure in the management and safeguarding of resident funds.
Failure to Safeguard Resident Funds Due to Lack of Oversight and Documentation
Penalty
Summary
The facility administration failed to utilize its resources effectively and provide necessary oversight to prevent the misappropriation of residents' personal funds. The Business Office Manager (BOM) was responsible for maintaining accurate financial records and ensuring compliance with state and federal regulations. However, an investigation revealed that the BOM could not account for $905.00 missing from the Resident Fund Management Service (RFMS) petty cash account, and was unable to provide receipts or explanations for the missing funds. The facility's own policies required withdrawal receipts with resident or representative signatures for all transactions, but these procedures were not followed. A review of records for six residents whose funds were managed by the facility showed multiple unauthorized withdrawals and missing receipts for significant amounts of money, including withdrawals made after residents were discharged or deceased. Interviews with residents indicated that they were not aware of the details of their financial statements, did not receive explanations about their accounts, and in some cases, were charged for items they did not use or receive. Some residents expressed distress and anger over missing funds and lack of transparency regarding their finances. Despite being made aware of missing receipts and discrepancies, facility leadership did not conduct a thorough investigation into all transactions during the former BOM's tenure. Quarterly statements were distributed to residents without instructions to review them for accuracy, and there was no oversight or audit of the BOM's activities during the relevant period. The lack of proper documentation, oversight, and adherence to policy resulted in the misappropriation of resident funds and failure to safeguard residents' property.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property within the required timeframe for one of three incidents reviewed. According to the facility's policy, any employee or contracted service provider who witnesses or has knowledge of an act of abuse, neglect, exploitation, or misappropriation of resident property is obligated to report such information immediately, but no later than two hours after the allegation is made. In this case, on 10/22/25, the President of Finance was informed that the former Business Office Manager (BOM) had called off work and that there was only $125.00 in the Resident Fund Management System cash box, despite a recent petty cash check being cashed. The Nursing Home Administrator (NHA) was notified the same day and began investigating the missing funds, which amounted to $905.00. Despite the facility's policy requiring immediate reporting, the allegation of misappropriation was not reported to law enforcement until 10/24/25, to the Agency for Healthcare Administration later that day, and to the Abuse Registry on 10/28/25. The delay in reporting exceeded the facility's required two-hour timeframe. The investigation confirmed that the previous BOM was terminated, and the missing funds were not accounted for with receipts. The deficiency centers on the facility's failure to adhere to its own policy for timely reporting of suspected misappropriation of resident property.
Failure to Investigate Misappropriation of Resident Funds
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of residents' personal funds, as required by its own policy and procedure. The incident began when the Nursing Home Administrator (NHA) was made aware that the cash box for resident funds contained only $125.00, when it should have contained $1,030.00. The investigation identified the former Business Office Manager (BOM) as the alleged perpetrator, and the NHA reported the missing $905.00 to the appropriate authorities. However, the facility did not conduct a comprehensive review of all resident fund transactions during the former BOM's tenure, nor did it investigate whether additional funds were missing beyond the initial amount discovered. A review of resident fund statements for six residents who authorized the facility to manage their personal funds revealed multiple withdrawals for personal needs, clothing, tobacco, and telephone charges, with no supporting receipts for these transactions. Several residents reported that they did not receive the amounts indicated on their statements, did not smoke or purchase the items listed, or were only allowed to withdraw small amounts at a time. One resident expressed distress over missing funds and stated that she was charged for items she never received, while another resident was visibly angry about unauthorized withdrawals. Withdrawals were also documented for residents after their discharge or death, with no receipts to substantiate these transactions. Interviews with facility staff confirmed that after the initial discovery of missing funds, no further investigation was conducted to determine if other residents were affected. The NHA and the President of Revenue Cycle both acknowledged that there was no audit or oversight of the former BOM, and residents were not instructed to review their financial statements for accuracy. The Social Worker was only directed to deliver statements to residents without further explanation or guidance, and the facility did not follow up on missing receipts or discrepancies in resident accounts.
Failure to Maintain Safe Room Temperatures During Air Conditioning Outages
Penalty
Summary
The facility failed to maintain a safe and comfortable air temperature range for residents when the central air conditioning units in multiple halls broke down. Specifically, the central air conditioning unit for the 500 hall failed on 4/28/25, and although window air conditioning units were installed in residents' rooms, the facility did not monitor the room temperatures to ensure they remained within a safe and comfortable range. Subsequently, on 5/19/25, the central air conditioning unit for the 400 hall also broke, and the facility did not implement immediate or appropriate actions to maintain safe temperatures in residents' rooms and common areas. On 5/20/25, temperatures in various resident rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended range and creating a likelihood of serious harm or death from prolonged heat exposure. Temperature monitoring logs from January through May 2025 showed that temperatures were only documented twice a month in common areas and hallways, not in individual resident rooms. The logs indicated temperature ranges up to 80°F, but did not capture the elevated temperatures that occurred in resident rooms during the air conditioning failures. Resident interviews revealed ongoing discomfort due to excessive heat, with multiple residents reporting difficulty sleeping, sweating, and feeling unwell over several days. Resident Council minutes from January through April 2025 documented repeated concerns about temperature regulation, with residents consistently reporting that temperatures were either too hot or too cold and that the issue was not being resolved. Staff interviews confirmed that the facility attempted to repair the air conditioning units and installed window units as a temporary measure, but did not implement a comprehensive safety plan or monitor room temperatures until after the elevated temperatures were identified by surveyors. The DON acknowledged that interventions to address the heat were not implemented until 5/20/25 at 3:30 p.m., after the high temperatures had already been present. The failure to monitor and control room temperatures, despite ongoing resident complaints and known equipment failures, resulted in the determination of Immediate Jeopardy due to the risk of heat-related complications for residents.
Removal Plan
- Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
- Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
- Temperatures were taken throughout the facility and verified to be within the temperature range of between 71 and 81 degrees.
- Maintenance staff were educated on maintaining the facility temperatures between 71 degrees and 81 degrees.
- Air conditioners will be maintained in working condition.
- If an air conditioner unit fails, maintenance staff along with administration will activate the emergency plan to maintain facility temperatures between 71 and 81 degrees.
- Clinical staff education on abuse/neglect related to assessment and care of residents when the temperatures are above 81 degrees, verified by posttest results and interview.
Failure to Maintain Safe and Comfortable Temperatures Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect residents from neglect by not taking immediate and appropriate actions to maintain safe and comfortable temperature levels when multiple central air conditioning units broke down in several halls and common areas. Despite the breakdown of the central air conditioning units in the 400, 500, and 700 halls, the facility did not implement its Emergency Preparedness Plan in a timely manner to ensure residents' comfort and minimize the risk of hyperthermia. Window air conditioning units were installed in some resident rooms, but there was no consistent monitoring of room temperatures to ensure they remained within a safe range. Residents repeatedly reported discomfort due to excessive heat, with room temperatures documented between 81.3°F and 84.3°F. Multiple residents complained of being excessively hot and uncomfortable for several days, with some describing difficulty sleeping and feeling as if they were overheating. Resident Council meeting minutes over several months also documented ongoing concerns about temperature regulation, indicating that the issue was persistent and not adequately addressed by facility leadership. Temperature monitoring logs provided by the facility only included common areas and did not document temperatures in individual resident rooms. The logs showed that temperatures were only checked twice a month, rather than more frequently, and did not reflect the elevated temperatures experienced by residents. The facility's own policies defined neglect as the failure to provide necessary goods and services to avoid physical harm or distress, yet there was no evidence that the facility consistently monitored or responded to unsafe room temperatures until after the deficiency was identified by surveyors.
Removal Plan
- Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
- Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
- Took temperatures throughout the facility and verified to be within the temperature range of between 71 and 81 degrees.
- Will continue to maintain hourly temperature logs until all air conditioner units are repaired.
- Provided facility-wide staff abuse/neglect education, verified through staff interview and record review of post-test results.
- Ensured no staff will be permitted to work until they are reeducated on Abuse and Neglect policies.
- Education included a written competency test to include who and when to notify when a resident room is at or above 81 degrees.
- Education included information on where the cool zones are located, and that failure to report is considered neglect.
Failure to Maintain Safe Temperatures During Air Conditioning Outage
Penalty
Summary
Facility administration failed to utilize its resources effectively and efficiently to maintain a safe and comfortable temperature for residents when multiple central air conditioning units broke down in several halls and common areas. Despite being aware of ongoing issues with the air conditioning units, as documented in resident council meeting minutes from January through April, administration did not implement immediate and effective measures to address the excessive heat. Residents repeatedly raised concerns about uncomfortable temperatures, and the administration acknowledged the problems but only noted that the concerns were being addressed, without evidence of timely or sufficient action. On multiple occasions, temperatures in residents' rooms and common areas were measured between 81.3°F and 84.3°F, exceeding the recommended comfort range. Several residents reported ongoing discomfort, difficulty sleeping, and feeling overheated for weeks, with some stating that the issue had persisted for months. The facility's temperature monitoring logs did not include resident rooms and were only conducted twice a month in common areas, failing to capture the actual conditions experienced by residents. The Director of Nursing confirmed that interventions to mitigate heat exposure, such as providing ice, water, and monitoring vital signs, were not implemented until after temperatures had already reached excessive levels. Interviews with residents and staff further revealed that the excessive heat was a persistent problem, with residents expressing that their complaints were not adequately addressed. The administration's approach relied on hallway temperature checks to trigger room checks, which proved insufficient. The lack of timely and comprehensive action to ensure a safe and comfortable environment for all residents created a likelihood of serious harm or death due to prolonged exposure to excessive heat, resulting in the determination of Immediate Jeopardy.
Removal Plan
- Placed portable air conditioners and chillers throughout the facility to maintain temperatures between 71 and 81 degrees.
- Verified through resident interviews that the residents feel the temperature is now comfortable throughout the facility including in the resident rooms.
- Took temperatures throughout the facility at multiple times and verified they were within the range of 71 to 81 degrees.
- Facility will continue to maintain hourly temperature logs until all air conditioner units are repaired.
- Completed education with the Administrator and Director of Nursing (DON) by the President of Clinical Operations regarding their responsibility to implement the facility excessive heat emergency plan related to broken air conditioning units.
- Education included the monitoring process and notification procedure to the Chief Executive Officer/Chief Nursing Officer and to ensure residents are provided with a clean, comfortable environment.
- Chief Nursing Officer educated the Administrator and DON on their job descriptions, emphasizing responsibility to ensure proper temperatures and a safe, comfortable environment.
- Reviewed the agenda and staff sign-in page for the Quality Assurance and Performance Improvement (QAPI) meeting, which included a review of the affected regulations and implementation of the facility's Excessive Heat Emergency Plan.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to complete a significant change in status assessment for a resident who experienced a 9.41% weight loss over a six-month period and developed an unstageable pressure ulcer. The resident, who was admitted with diagnoses including COPD, Hypertension, Dysphagia, Depression, Anxiety, and Bipolar Disorder, was noted to have moderately impaired cognition and required substantial assistance for mobility. The Quarterly MDS assessment indicated the resident was not on a physician-prescribed weight-loss regimen but had experienced significant weight loss and was at risk for pressure ulcers, although none were documented at that time. Subsequent records revealed the resident lost 9.5 lbs. from June to December and developed a left buttock wound, which was later documented as an unstageable pressure ulcer by a Wound Care Specialist. Despite these changes, a significant change in status MDS assessment was not completed, as verified by the MDS coordinator. The care plan had noted the resident's potential for pressure ulcer development due to factors such as malnutrition, fragile skin, decreased mobility, and incontinence, but the necessary assessment to address these changes was not conducted.
Failure to Maintain Safe and Comfortable Environment Due to A/C Malfunction
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for residents in the 300 hallway, as evidenced by the non-functioning air conditioning system. Observations and interviews revealed that the temperature in the affected rooms was significantly higher than the acceptable range, with readings as high as 83.4 degrees Fahrenheit. Residents expressed discomfort and distress due to the heat, with some unable to sleep or perform daily activities comfortably. The issue persisted despite the facility's awareness, as indicated by staff and resident interviews. The Director of Nursing and maintenance staff confirmed the malfunctioning air conditioning system, which had been an issue for at least 20 days. Despite receiving estimates for repairs from an outside company, the necessary repairs had not been completed. Temporary measures, such as installing window A/C units, were only partially implemented, leaving several rooms without adequate cooling. The facility's temperature monitoring logs were incomplete, failing to document room temperatures to ensure compliance with the required range. Staff interviews highlighted a lack of effective communication and action from the administration to address the problem. Maintenance staff reported that the facility's administration was aware of the issue, yet no comprehensive solution was implemented. The failure to provide a consistent and comfortable environment for residents in the 300 hallway reflects a significant deficiency in the facility's maintenance and operational procedures.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances related to comfortable temperature, pest control, and staff treatment of residents. Multiple residents, including ten sampled individuals, reported unresolved grievances. The facility's policy required prompt efforts to resolve grievances, but the facility did not adhere to this policy. Residents complained about high room temperatures, with some rooms reaching over 82 degrees Fahrenheit. Despite complaints, the air conditioning issues were not resolved, and temporary measures like installing window units were not implemented in all affected rooms. Residents also reported ongoing pest control issues, specifically the presence of roaches. Despite complaints and routine spraying, the pest problem persisted. The facility was aware of the issue and was attempting to secure a new pest control contract, but no effective action had been taken to resolve the residents' grievances. Additionally, residents expressed concerns about staff treatment, including slow response times to call lights and inadequate care. These grievances were not documented or addressed by the facility, as confirmed by the Director of Nursing. The facility's grievance log did not reflect the complaints made by the residents, indicating a lack of proper documentation and follow-up. Resident council meeting minutes showed discussions about similar issues, but the specific grievances of the sampled residents were not addressed. The facility conducted an inservice for staff on responding to call lights, but there was no evidence of follow-up with the residents to ensure their grievances were resolved. The Director of Nursing acknowledged the lack of documentation and follow-up on the grievances voiced by the residents.
Ineffective Pest Control Measures Lead to Ongoing Roach Infestation
Penalty
Summary
The facility failed to implement effective pest control measures to address ongoing sightings of roaches, as evidenced by multiple observations and interviews. On the morning of September 25, 2024, a live roach was observed on the medication cart in the secured unit, and another was seen crawling out of a dresser in a resident's room. Interviews with residents revealed persistent complaints about roaches, with one resident noting that despite multiple complaints, the issue had not improved. Staff interviews indicated uncertainty about the frequency of pest control measures, and the Director of Nursing (DON) acknowledged awareness of the ongoing pest control issues. The pest sighting log from November 2023 to September 2024 documented recurrent sightings of roaches in various rooms and common areas throughout the facility. The pest control technician, who had not visited the facility for over a year, noted that the problem was due to unsealed entry points, particularly the doors of the 800 hallway, which allowed roaches to enter. Despite recommendations to seal these entry points, the facility had not addressed the issue, rendering pest control efforts ineffective. Service inspection reports from the pest control company indicated regular visits, but the persistent issue of unsealed cracks and crevices was noted as early as May 2023. During a tour of the facility, the DON confirmed that the doors in the 800 hallway did not seal properly, leaving gaps for insects to enter. Resident interviews further highlighted the ongoing problem, with several residents reporting frequent sightings of roaches in their rooms and expressing dissatisfaction with the facility's pest control efforts.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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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) |
|---|---|---|---|---|
| Pines Of Sarasota | 0.3 mi | ★★★★★ | 2 | 0 |
| Inn At Sarasota Bay Club | 0.8 mi | ★★★★★ | 0 | 0 |
| Siesta Key Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 1 | 0 |
| Birchwood Health And Rehabilitation Center | 1.9 mi | ★★★★★ | 8 | 0 |
| Sarasota Point Rehabilitation Center | 2.1 mi | ★★★★★ | 0 | 0 |
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