Above 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 Inn At Sarasota Bay Club during CMS and state inspections, most recent first.
The facility failed to provide care according to professional standards for three residents. A resident with malnutrition did not have weekly weights documented as ordered. Another resident's Lidoderm Patch was not removed as scheduled, contrary to physician's orders. Additionally, a resident under Hospice care lacked a coordinated care plan, leading to potential duplication of services. These deficiencies highlight lapses in following physician orders and coordinating care with external services.
The facility failed to inform residents about their rights regarding the binding arbitration agreement. Residents were given a stack of documents to sign upon admission without explanation, leading them to sign the arbitration agreement without understanding it was voluntary and not a condition for admission. Interviews revealed that staff did not explain the agreement or inform residents of their rights to rescind it within 30 days.
The facility did not inform residents of their rights to select a neutral arbitrator and venue in its binding arbitration agreement. The Community Liaison admitted to not explaining the agreement, leaving it for residents to sign without proper guidance. The Administrator confirmed the omission of these rights in the agreement.
A resident's room in the facility was observed to have a persistent foul odor of urine due to the use of a urine collection system. Despite multiple interventions by staff, including daily baths and cleaning, the odor remained. The resident's clinical record lacked documentation of interventions to address the odor, and the Director of Nursing acknowledged the issue but could not provide documentation of attempted solutions.
A facility failed to develop a comprehensive care plan for a resident with a cardiac pacemaker. Despite the resident's admission records and physician's order summary noting the pacemaker, the MDS assessment did not document it, and the care plan lacked goals, interventions, and follow-up. The MDS coordinator admitted to missing this in the care plan, and the DON confirmed that a care plan should have been in place.
The facility exceeded the acceptable medication error rate with two errors identified. An RN administered an incorrect dosage of Vitamin B12 to a resident, while an LPN prepared an incorrect dosage of Vitamin D for another resident. These errors resulted in a medication error rate of 8%.
Deficiencies in Resident Care and Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure that Resident #21 received care in accordance with professional standards of practice. The physician's orders required weekly weight monitoring for the resident due to a diagnosis of malnutrition. However, the clinical record showed that the resident's weight was only documented once on 8/2/24, and there was no documentation explaining the absence of subsequent weekly weights. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the order for weekly weights was not followed, and the staff did not document any reasons for this oversight. Resident #25 did not receive care as per the physician's orders regarding the application and removal of a Lidoderm Patch for pain management. The patch was to be applied daily at 9:00 a.m. and removed at 9:00 p.m. However, on 8/13/24, it was observed that the patch applied on 8/12/24 was not removed as scheduled. LPN Staff C acknowledged the oversight, and the DON confirmed that the nurse did not follow the physician's orders, as the patch was not removed at the designated time. For Resident #180, the facility did not coordinate care effectively with Hospice services. The resident was admitted with a diagnosis of failure to thrive and was under Hospice care. However, the Baseline Care Plan did not include the Hospice services to be provided, and the Hospice Plan of Care was missing from the resident's medical record. Interviews with the Hospice Aid, the resident's nurse, and the MDS Coordinator confirmed the absence of the Hospice Plan of Care, which is essential for coordinating care between the facility and Hospice staff. This lack of documentation led to potential duplication of care and inadequate coordination of services for the resident.
Failure to Inform Residents About Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that its binding arbitration agreement explicitly informed residents of their rights, leading to a deficiency. The agreement did not clearly state that it could be rescinded within 30 days of signing, that signing was not a condition for admission or continued care, or that residents could communicate with federal, state, or local officials. Interviews with the administrator and community liaison staff revealed that residents were presented with a packet of documents to sign upon admission, which included the arbitration agreement. However, the staff did not explain the agreement or inform residents that signing was voluntary and not a requirement for admission. Three residents, identified as cognitively intact based on their Brief Interview for Mental Status (BIMS) scores, reported that they were not informed about the arbitration agreement. They recalled receiving a stack of papers with highlighted lines to sign but did not understand the nature of the arbitration agreement. The residents assumed the documents were standard admission paperwork and signed them without any explanation from the staff. This lack of communication and clarity in the arbitration agreement process led to the deficiency identified by the surveyors.
Failure to Inform Residents of Arbitration Rights
Penalty
Summary
The facility failed to ensure that its binding arbitration agreement explicitly informed residents of their rights to select a neutral arbitrator and participate in the selection of a venue for dispute resolution. This deficiency was identified during a review of the clinical records for three residents who had signed the facility's binding arbitration agreement upon admission. The agreement did not indicate that residents had the right to be included in selecting a neutral arbitrator agreed upon by both parties or in choosing a convenient venue for the arbitration. During interviews, the Community Liaison admitted to not explaining the arbitration agreement to residents or their representatives, instead leaving the paperwork on the bedside table with highlighted lines for signatures. The Administrator confirmed that the agreement did not inform residents of their rights regarding the selection of an arbitrator or venue.
Failure to Maintain Sanitary Environment Due to Urine Odor
Penalty
Summary
The facility failed to maintain a sanitary environment for a resident's room, which was observed to have a strong foul odor of urine. The resident, who was frequently incontinent of urine, used a non-invasive urine collection system. Despite the facility's policy requiring regular cleaning of resident rooms and bathrooms, the odor persisted. The resident's room was observed multiple times with the odor, and staff interviews confirmed awareness of the issue since the resident's admission. The resident's clinical record did not document any interventions to address the urine odor, nor did it show that the facility provided information to the resident about the use of the urine collection system. Interviews with staff revealed that multiple interventions had been attempted, such as daily baths, testing for urinary tract infections, and cleaning with vinegar, but none were effective in eliminating the odor. The resident's daughter also noted the persistent odor and expressed concerns about the proper use of the urine collection system. The Director of Nursing acknowledged the ongoing issue with the urine odor and stated that the facility had begun paying for the supplies for the urine collection system to replace them more frequently. However, there was no documentation of the interventions attempted to address the odor. The interdisciplinary team had discussed the issue, but the problem persisted, and the room continued to have a strong foul smell of urine.
Failure to Develop Comprehensive Care Plan for Resident with Pacemaker
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident with a cardiac pacemaker. The resident was admitted with a cardiac pacemaker, as noted in the physician's order summary and nursing progress notes. However, the Admission Minimum Data Set (MDS) assessment did not document the presence of the pacemaker in the active diagnoses or cardiopulmonary procedures. The comprehensive care plan initiated later did not address the pacemaker with appropriate goals, interventions, precautions, and follow-up. The MDS coordinator acknowledged the oversight and confirmed that she was responsible for ensuring care plans were in place, but she missed including the pacemaker in the care plan. The Director of Nursing stated that the normal process is to have a care plan for the pacemaker with interventions.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by two medication errors identified during a survey. The first error involved a Registered Nurse (RN) administering an incorrect dosage of Vitamin B12 to a resident. On August 13, 2024, the RN gave one tablet of Vitamin B12 (500 mcg) instead of the prescribed two tablets. The RN later acknowledged the mistake, having misunderstood the physician's order, which was confirmed upon review of the Medication Administration Record (MAR) and the physician's order summary. The second error involved a Licensed Practical Nurse (LPN) who prepared and attempted to administer an incorrect dosage of Vitamin D to another resident. The LPN placed three tablets of Vitamin D (400 units each) into a medication cup, totaling 1200 units, instead of the prescribed two tablets (800 units). The error was identified before administration when the LPN was asked to verify the dosage, confirming the discrepancy with the physician's order. These errors contributed to a medication error rate of 8%, exceeding the acceptable threshold.
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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) |
|---|---|---|---|---|
| Pines Of Sarasota | 0.5 mi | ★★★★★ | 2 | 0 |
| Indian Beach Nursing And Rehab Center | 0.8 mi | ★★★★★ | 5 | 0 |
| Siesta Key Health And Rehabilitation Center | 2 mi | ★★★★★ | 1 | 0 |
| Sarasota Health And Rehabilitation Center | 2.3 mi | ★★★★★ | 2 | 0 |
| Sarasota Point Rehabilitation Center | 2.4 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.