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 Sarasota Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was readmitted after hospital treatment for scabies, but the facility did not document required skin assessments for the resident, close contacts, or staff, nor did it clean or launder clothing, bedding, or the room as per policy. No staff in-services on scabies were conducted, resulting in noncompliance with infection control protocols.
A resident with severe cognitive impairment and physical dependency was found with a significant bruise and later diagnosed with a femoral neck fracture. The facility did not document a thorough investigation, as required by policy, with missing staff statements and unwitnessed accounts of the incident. Interviews revealed that the DON and other staff could not provide written documentation or clear details about how the injury occurred.
The facility did not have effective supervision processes for cognitively impaired residents with aggressive behaviors, resulting in multiple incidents where residents physically assaulted each other, causing injuries such as scratches and skin tears. Staff were not present or did not intervene during these altercations, and existing monitoring programs were insufficient to prevent these events.
Multiple residents with cognitive impairment and aggressive behaviors were involved in repeated physical altercations, including hitting and scratching, resulting in injuries. These incidents occurred in various areas of the secured dementia unit without adequate staff supervision or individualized care plan interventions. Staff were often unaware of residents' whereabouts, and behavioral monitoring was insufficient, leading to a pattern of harm and risk among residents.
A facility failed to ensure a dietary aide was screened for a history of abuse, neglect, or exploitation before employment. Despite a policy requiring background checks, the aide was not entered into the Florida Agency For Healthcare Administration's Care Provider Background Screening Clearinghouse, and a new screening was not obtained after a break in employment. The aide worked several days without the required screening, violating state regulations and facility policies.
A resident with severe cognitive impairment was administered psychotropic medications without informed consent from the appointed health care surrogate (HCS). The facility failed to inform the HCS about the risks, benefits, side effects, and alternatives of the medications. Interviews and record reviews confirmed the absence of signed consent forms and documentation of discussions with the HCS.
A resident with severe cognitive impairment and multiple medical conditions experienced an injury of unknown origin. The facility failed to thoroughly investigate the incident, as the investigation did not consider the possibility that the right arm fracture occurred when a left arm injury was documented. The investigation lacked staff statements and an interview with the LPN who noted the initial injury. The facility's failure to conduct a thorough investigation was acknowledged by the current Administrator and Interim DON.
A facility failed to provide adequate social services for a resident with toxic encephalopathy and dementia, who wished to relocate closer to family. Despite the family's request for assistance, the social worker did not actively help in finding a suitable facility, leaving the family to independently search for a specialized dementia care unit. The Nursing Home Administrator acknowledged that the social services director should assist in such situations.
A facility failed to maintain proper communication and documentation for a resident receiving dialysis. The required Dialysis Communication Tool forms were missing or incomplete for several dates, lacking necessary information, signatures, and timestamps. This deficiency was confirmed by staff, highlighting a failure to adhere to the facility's policy, which could impact the resident's care and safety.
The facility failed to provide necessary dental services for four residents, resulting in unmet dental needs. A resident was edentulous and had not received dentures or seen a dentist since admission. Another resident had multiple missing and broken teeth but did not receive dental care. A third resident had broken teeth, and their care plan did not address the issue. Lastly, a resident with loose dentures experienced weight loss, and the facility staff were unaware of the problem.
A facility licensed for 169 beds failed to ensure their full-time social worker met the required qualifications. The current social worker, who started in March 2024, only held a bachelor's degree in social work and lacked the necessary one year of supervised experience in a healthcare setting. Additionally, there was no signed job description on file. The Regional Consultant confirmed the absence of a qualified regional social worker to fill in until a qualified hire is made.
A facility failed to obtain a valid Do Not Resuscitate Order (DNRO) for a resident with severe cognitive impairment. The resident's sister signed a DNR form, but it was not signed by a physician and not available in the clinical record. Staff interviews revealed confusion about the DNR's validity without the signed form, leading to potential CPR administration despite DNR orders.
A resident with multiple missing and broken teeth was inaccurately assessed in the MDS as having intact natural teeth. Despite informing staff of her dental issues and desire for dentures, the MDS and Nursing Admission Data Collection forms were incorrectly coded, failing to reflect her true dental status. This discrepancy was confirmed by the SSD and MDS Coordinator after reviewing the resident's medical record and conducting interviews.
Two residents with cognitive impairments and functional limitations did not receive necessary grooming and nail care assistance as per their care plans. Despite being dependent on staff for personal hygiene, both residents were observed with long fingernails and facial hair growth. Staff acknowledged the need for grooming but failed to provide consistent care, revealing a deficiency in meeting the personal care needs of these residents.
The facility failed to ensure that two residents participated in activities of their choice, impacting their psychosocial well-being. Observations showed the residents were often in their rooms without engaging in activities, despite care plans indicating preferences for afternoon activities. The DOA assumed staff would facilitate activities without verifying participation, leading to a deficiency in activity provision.
A resident with impaired vision due to glaucoma was not provided timely assistance in replacing lost prescription glasses. Despite multiple observations of the resident without glasses and her reports of the loss, the facility's Social Services department did not take action to address the issue. The resident's care plan included interventions for glasses maintenance, but there was no documented follow-up or grievance filed. The Social Service Director was unaware of the missing glasses, highlighting a communication lapse within the facility.
A resident with impaired cognition and range of motion did not receive proper care to prevent contractures. Despite a care plan requiring splints, the resident was often observed without them, and staff failed to document any refusal. Interviews revealed confusion about responsibilities, and therapy records did not address the resident's needs. The DON could not provide relevant documentation.
The facility did not post the required daily nurse staffing information, as observed over three days. The Administrator admitted that the facility had not posted this information since late February, acknowledging the requirement to display it prominently.
Failure to Implement and Document Infection Control Measures for Scabies
Penalty
Summary
The facility failed to follow its infection prevention and control procedures to prevent the potential spread of scabies in the Memory Care Unit. According to the facility's policy, early identification and management of scabies, including treatment of close contacts, laundering of clothing and bedding, and thorough cleaning of the resident's environment, are required. However, after a resident was diagnosed and treated for scabies at the hospital and subsequently readmitted, the Infection Preventionist (IP) did not document the skin assessments performed on the resident, the roommate, or other close contacts. Additionally, the IP did not document inquiries made to staff regarding rashes or skin issues. The facility did not clean or launder the resident's or roommate's clothing, bedding, or room prior to the resident's return from the hospital, as required by policy. The resident involved had severe cognitive impairment and was dependent on staff for all activities of daily living. The IP acknowledged that no in-services were conducted for staff regarding scabies management, as it was deemed unnecessary. The lack of documentation and failure to implement required infection control measures, including environmental cleaning and staff education, contributed to the facility's noncompliance with its own infection prevention and control program.
Failure to Document Thorough Investigation of Injury of Unknown Origin
Penalty
Summary
The facility failed to document a thorough investigation into an injury of unknown origin for one resident with significant cognitive impairment and physical dependency. The resident, who had diagnoses including a displaced femoral neck fracture, dementia, and anxiety disorder, was found with a bruise on the right medial knee/shin. The initial nursing note indicated the bruise was noticed in the dining room, but the event was unwitnessed, and the resident was unable to describe what happened. The facility's incident investigation form noted the injury was not witnessed, and immediate actions included ordering an X-ray and considering changes to table height. However, there was no documentation of staff or resident statements, and the investigation lacked written accounts from those involved or present at the time. Interviews with the DON and staff revealed inconsistencies and gaps in the investigation process. The DON stated that no one witnessed the incident and that he could not locate statements from the nurse or CNA, with the Unit Manager only verbally asking staff about the event without documentation. A CNA reported discovering the bruise during rounds and notifying the nurse, but did not witness the resident hitting her leg. The LPN recalled being informed of the bruise and assessing it, but also did not witness the event and stated that assumptions could not be made. The lack of documented interviews, statements, and a comprehensive investigation process led to the deficiency cited in the report.
Failure to Prevent Resident-to-Resident Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect residents' right to be free from abuse by not having effective processes in place to supervise cognitively impaired residents with known aggressive behaviors. Multiple incidents occurred in which residents with histories of aggression, wandering, or agitation were not adequately supervised, resulting in avoidable resident-to-resident altercations. These altercations led to physical injuries, including scratches and skin tears, among several residents. Specific events included residents hitting, scratching, or otherwise physically assaulting each other in various locations such as hallways, activity rooms, and dining areas. In several instances, residents with dementia or behavioral disturbances wandered unsupervised into other residents' rooms, leading to confrontations and injuries. Staff were observed not supervising residents at critical times, and altercations occurred without immediate staff intervention. The facility's monitoring program, which involved staff rounding every 15 minutes, was not sufficient to prevent these incidents. The facility's own records and staff interviews confirmed that incidents of resident-to-resident aggression continued to occur despite the implementation of monitoring programs. The Director of Nursing acknowledged the high frequency of such altercations, and the Administrator verified multiple incidents of physical abuse between residents. The lack of adequate supervision and ineffective monitoring processes directly resulted in physical harm to several residents and led to a determination of Immediate Jeopardy.
Removal Plan
- The Risk Consultant educated the Administrator and Director of Nursing on abuse, neglect, and exploitation as well as the reporting requirements to the Facility Risk Manager, Nursing Home Administrator, or direct supervisor as they relate to ensuring adequate supervision to ensure the safety of cognitively impaired residents on the secured dementia unit to prevent further incidents of resident-to-resident physical altercations and abuse.
- Administrator educated staff on abuse, neglect, and exploitation as well as the reporting requirements to the Facility Risk Manager, Nursing Home Administrator, or direct supervisor. 147 out of 147 staff members were educated.
- Administrator educated staff on abuse, neglect, and exploitation as they relate to ensuring adequate supervision to ensure the safety of cognitively impaired residents on the secured dementia unit to prevent further incidents of resident-to-resident physical altercations and abuse. 147 out of 147 staff members were trained.
- A Quality Assurance and Assessment meeting was held. Psychiatric services attended with the facility interdisciplinary team and reviewed high risk residents with behaviors. Medications and care planned interventions for behaviors were reviewed.
- Psychiatric service visits were increased for high-risk residents.
- Facility leadership along with the interdisciplinary team planned for enhanced oversight of the secured unit to monitor hallways and common areas for negative behaviors that could lead to a resident-to-resident altercation. Enhanced oversight was initiated.
- Two staff were assigned per shift to conduct enhanced oversight.
- The Administrator or designee is responsible for ensuring that enhanced oversight of the secured unit is in place.
- A qualified activity staff member was assigned to activities in the secured unit.
- A Quality Assurance meeting was conducted to review the effectiveness of the implemented interventions.
Failure to Prevent Resident-to-Resident Altercations Due to Inadequate Supervision
Penalty
Summary
The facility failed to implement adequate supervision and processes on the secured dementia unit to prevent multiple avoidable incidents of resident-to-resident physical altercations among cognitively impaired residents with aggressive behaviors. Over a period of several weeks, numerous residents with severe to moderate cognitive impairment and behavioral disturbances were involved in repeated physical altercations, including hitting, scratching, and grabbing, resulting in injuries such as skin tears, scratches, and emotional distress. These incidents occurred in various locations within the secured unit, including hallways, resident rooms, the dining room, and the activity room, often without staff present to intervene or prevent escalation. Care plans for residents with known aggressive behaviors and wandering tendencies were found to be insufficiently individualized and did not consistently include interventions to ensure adequate supervision or to protect other residents from harm. In several cases, residents with a history of aggression or wandering were not monitored closely enough, leading to altercations when they entered other residents' rooms or were in close proximity to others. Documentation revealed that staff were sometimes unaware of residents' whereabouts or did not witness the altercations, and in some cases, staff only became aware of incidents after hearing raised voices or residents calling for help. Behavioral monitoring and documentation of target behaviors for psychotropic medication use were also lacking or incomplete. The facility's failure to provide necessary structures and supervision resulted in physical injuries to several residents and created a likelihood of serious harm to others. The pattern of incidents demonstrated a lack of effective oversight and intervention for residents at high risk for aggressive behaviors, despite their known diagnoses of dementia, mood disorders, and behavioral disturbances. The deficiency was determined to be at the Immediate Jeopardy level due to the ongoing risk and actual harm experienced by residents on the secured dementia unit.
Removal Plan
- Educate the Administrator and Director of Nursing on ensuring that residents on the secured dementia unit are provided with adequate supervision to prevent incidents of resident-to-resident physical altercations and ensure resident safety.
- Educate staff on ensuring that residents on the secured dementia unit are provided with adequate supervision to prevent incidents of resident-to-resident physical altercations and ensure resident safety.
- Give specific examples of behavioral patterns that potentially lead to resident-to-resident altercations such as wandering patterns and behaviors, proximity of residents, verbal queues, and physical queues.
- Initiate enhanced monitoring and oversight by facility leadership over the secured unit to monitor patient care areas and resident rooms for resident behaviors that could lead to resident-to-resident altercations.
- Ensure that enhanced oversight of the secured unit is in place.
Failure to Screen Employee for Abuse History
Penalty
Summary
The facility failed to protect the health, welfare, and rights of its residents by not ensuring that a dietary aide, referred to as Staff A, was properly screened for a history of abuse, neglect, exploitation, or misappropriation of resident property before beginning employment. The facility's Abuse Prevention Program, which was last updated in November 2024, mandates that potential employees undergo criminal background checks as part of the hiring process to identify any history of abuse or mistreatment. However, Staff A, who was hired on January 14, 2025, was not entered into the Florida Agency For Healthcare Administration's Care Provider Background Screening Clearinghouse, and a new background screening was not obtained despite a break in employment greater than 90 days. The Human Resources Director confirmed that Staff A's employment was not recorded in the background screening clearinghouse, and the last eligibility determination for employment at a Medicaid/Medicare Participating Provider was dated March 23, 2023. Despite this oversight, Staff A worked multiple days in February 2025 without the required screening, which is a violation of the facility's policies and state regulations. This failure to conduct the necessary background checks before employment poses a risk to the residents' safety and well-being.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to honor the right of a resident's health care surrogate (HCS) to be informed about the risks, benefits, side effects, and alternatives of psychotropic medications administered to the resident. The resident, who had severe cognitive impairment and was diagnosed with non-Alzheimer's dementia, was deemed incapable of making informed medical decisions. Consequently, the resident's son was appointed as the HCS. Despite this, the facility administered several psychotropic medications, including Buspirone, Seroquel, Trazodone, and Depakote, without obtaining informed consent from the HCS. Interviews and record reviews revealed that the facility did not have signed consent forms for these medications, and the HCS was not informed about the medications' risks, benefits, side effects, or alternatives. The HCS explicitly stated that he did not consent to the use of antipsychotics and was not informed by the facility staff, who primarily communicated with the business office manager. The psychiatric specialist assumed that the facility obtained the necessary consents but could not recall discussing the medications with the HCS. The medical records lacked documentation of any informed consent discussions with the HCS.
Inadequate Investigation of Resident's Injury
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple medical conditions, including dementia and hemiplegia. The resident was dependent on staff for personal care and mobility. On June 20, 2024, staff noted the resident favoring her left arm and screaming when it was touched, leading to an X-ray that showed no fracture. However, on June 23, 2024, the resident complained of pain in her right forearm, which was swollen and discolored. The resident was sent to the emergency room, where a fracture of the right ulna was identified, and the physician noted the bruising appeared old. The facility's investigation into the injury was inadequate, as it did not consider the possibility that the right arm injury occurred on June 20, 2024, when the left arm injury was documented. The investigation lacked documentation of any trauma to the left arm after June 20, 2024, and did not include written statements from staff or an interview with the LPN who initially documented the left arm injury. The facility's failure to conduct a thorough investigation was acknowledged by the current Administrator and Interim Director of Nursing.
Failure to Assist in Resident Relocation
Penalty
Summary
The facility failed to provide adequate social services for the discharge and transfer of a resident diagnosed with toxic encephalopathy and dementia. The resident and their family expressed a desire to relocate the resident to a skilled nursing facility closer to family. The social worker's care plan included assisting with referrals to facilities in the desired area and facilitating a safe discharge. However, the social worker did not actively assist the family in finding a suitable facility, despite the family's request for help and the resident's need for a specialized dementia care unit. The Health Care Surrogate (HCS) for the resident reported that the facility instructed them to find a suitable facility independently, with the facility only offering to fax referrals once a location was identified. The Nursing Home Administrator, who had recently started at the facility, stated that the social services director should assist families in such situations. Despite this, the social worker did not provide the necessary support, resulting in the resident remaining in the facility without the desired relocation closer to family.
Failure in Dialysis Communication and Documentation
Penalty
Summary
The facility failed to ensure proper communication and documentation between the nursing facility and the dialysis center for a resident receiving dialysis. The facility's policy required the completion of a Dialysis Communication Tool before and after each dialysis session to maintain communication and ensure the resident's stability. However, the review of the resident's records revealed missing forms for several dates and incomplete forms lacking required information, signatures, dates, and times. This deficiency was confirmed by both a registered nurse and a unit manager, who acknowledged the missing and incomplete documentation. The resident involved had multiple diagnoses, including anemia, end-stage renal disease, and heart failure, and was scheduled for dialysis three times a week. Despite the critical nature of the resident's condition, the facility did not adhere to its policy, resulting in a lack of documented communication and assessment of the resident's condition before and after dialysis treatments. This oversight in documentation and communication could potentially impact the resident's care and safety.
Failure to Provide Dental Services for Residents
Penalty
Summary
The facility failed to provide or obtain necessary dental services for four residents, leading to unmet dental needs. Resident #45, who was edentulous, had not received dentures or seen a dentist since admission, despite expressing a desire for dentures. The facility's staff, including nurses and social services, did not follow up on the initial referral for dental services, and there was no documentation of any dental appointments or evaluations in the resident's clinical record. Resident #25 had multiple missing and broken teeth upon admission and expressed a desire to have her remaining teeth extracted for dentures. However, the facility did not arrange for dental services, and the nursing assessment failed to document her dental issues. The resident's requests for dental care were not addressed, and no appointments were scheduled to evaluate or treat her dental concerns. Resident #94 was observed with broken front upper teeth, but her care plan did not reflect her dental status or provide interventions for her dental issues. Similarly, Resident #44 had loose upper dentures that were not addressed by the facility, contributing to his weight loss and insufficient food intake. The facility's staff, including the Registered Dietitian and Social Service Director, were unaware of the resident's dental problems, and no actions were taken to address the loose dentures.
Unqualified Social Worker in Facility
Penalty
Summary
The facility, licensed for 169 beds, failed to ensure that the full-time social worker met the required qualifications. The facility's policy and procedure, effective February 2021, stated that social services staff should have qualifications in line with state and federal regulations, job responsibilities, and applicable licensure laws. However, the current full-time social worker, who assumed the role in March 2024, only held a bachelor's degree in social work and lacked the required one year of supervised social work experience in a healthcare setting. Additionally, there was no signed job description on file for the current social worker. The Regional Consultant confirmed that the previous social worker left in March and that there was no qualified regional social worker available to fill in until a qualified social worker was hired.
Failure to Obtain Valid DNR Order
Penalty
Summary
The facility failed to obtain a Do Not Resuscitate Order (DNRO) in accordance with the advanced directives for a resident with severe cognitive impairment. The resident, who had been diagnosed with anxiety disorder and Parkinson's disease, had a designated durable power of attorney, which did not include health care decisions. Despite the physician issuing a DNR order, the clinical record lacked documentation that the resident had verbalized the wish not to receive CPR in the event of cardiac or respiratory arrest. Additionally, there was no incapacity statement authorizing the resident's sister to make health care decisions on his behalf. The facility's policy required that if a resident or their representative verbalizes the wish not to receive CPR, two staff members must witness and document this request, and the conversation should be printed and placed as the first document in the medical record. However, the yellow Florida DNR form signed by the resident's sister was not signed by the physician and was not available in the clinical record for staff reference. Interviews with staff revealed confusion about the validity of the DNR order without the signed yellow form, indicating that CPR would be performed if the form was not present, even if the computer and orders indicated a DNR status.
Inaccurate MDS Assessment of Resident's Dental Status
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected the dental status of a resident, leading to a deficiency in the assessment process. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, was admitted with multiple missing and broken teeth. Despite informing multiple nursing staff about her dental condition and her desire to have her teeth extracted for dentures, the MDS assessment inaccurately recorded her as having natural teeth that were not broken, cracked, unclean, or loose. The Social Service Director (SSD) and the MDS Coordinator confirmed that the MDS and Nursing Admission Data Collection forms were incorrectly coded, failing to reflect the resident's actual dental status. The SSD and MDS Coordinator both acknowledged the discrepancy after reviewing the resident's medical record and conducting interviews with the resident, who demonstrated her dental issues. This inaccuracy in the MDS assessment could potentially delay or prevent the resident from receiving appropriate dental care.
Deficiency in Grooming and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with grooming and nail care for two residents who were dependent on staff for activities of daily living. Resident #29, with severe cognitive impairment and functional limitations, was observed multiple times with long fingernails and beard growth, despite being dependent on staff for personal hygiene. The resident's care plan indicated that nail care should be provided on bathing days, yet documentation showed nail care was only provided once in a month. Staff acknowledged the resident's nails were long and needed trimming, but this was not consistently done. Resident #44, who had moderate cognitive impairment and required maximal assistance for personal hygiene, was also observed with long fingernails and facial hair growth. The resident expressed a need for assistance with showering and grooming. The care plan for Resident #44 did not specifically address nail care, and there was no documentation of nail care being provided over a month. Staff confirmed the resident's nails were long and needed trimming, and the resident was unable to perform these tasks independently. Interviews with staff, including the CNA and DON, revealed that the expectation was for residents to receive nail care on shower days. However, there was no specific policy for ADL and nail care, and it was included in the CNA's job description. The lack of consistent nail care and grooming for these residents indicates a deficiency in meeting the personal care needs of dependent residents, as outlined in their care plans.
Failure to Ensure Resident Participation in Activities
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #24 and Resident #106, participated in activities of their choice, which is essential for maintaining and improving their psychosocial well-being and independence. Observations on multiple days revealed that both residents were consistently found in their rooms, in bed, without engaging in any in-room or out-of-room activities. The television or radio was not on, and there was no evidence of participation in any facility activity programs during the observed times. Resident #24 was admitted with several diagnoses, including anemia, end-stage renal disease, and heart failure, and had a care plan that required staff assistance for activity involvement. The care plan specified that the resident preferred afternoon activities, such as watching television, movies, and participating in group activities. However, documentation showed that the resident's activities were recorded as watching television early in the morning, without confirmation that these activities occurred. The Director of Activities (DOA) admitted to assuming that staff would turn on the television for the resident, without verifying or documenting the actual participation in activities. Similarly, Resident #106, who had a history of anxiety, aphasia, and cognitive communication deficits, was observed in her room without engaging in any activities. The resident's care plan indicated a preference for afternoon activities, including watching television, movies, and socializing outdoors. However, the activity records showed early morning documentation of activities that were not confirmed to have occurred. The DOA acknowledged not observing or confirming these activities, assuming that staff would facilitate them. This lack of oversight and documentation led to the deficiency in providing appropriate activities for the residents.
Failure to Assist Resident with Replacement of Lost Glasses
Penalty
Summary
The facility failed to provide timely assistance to a resident in obtaining replacement prescription glasses, which were lost. The resident, who had a history of impaired vision due to glaucoma, was observed multiple times without her glasses and reported that she had been without them for a while. Despite the resident's impaired cognition and her reliance on glasses to read and enjoy activities like artwork, there was no documented follow-up or action taken by the Social Services department to address the missing glasses. The facility's policy required prompt referrals for vision services, but this was not adhered to in the case of the resident. The resident's care plan initially included interventions to assist with cleaning and placing glasses, and to report any damage to the nurse or social service. However, the Social Services progress notes showed no issues reported since February, and the grievance log did not document any grievance or steps taken to replace the glasses. Interviews with the Social Service Director revealed a lack of awareness about the missing glasses, indicating a communication breakdown within the facility. The resident's need for glasses was documented by the eye doctor, but no appointment was arranged to replace them until the issue was brought to the attention of the Clinical Reimbursement Director.
Failure to Prevent Decline in Range of Motion
Penalty
Summary
The facility failed to provide adequate care and services to prevent a decline in range of motion for a resident with limited range of motion. The resident, who had severely impaired cognition and functional range of motion in both upper extremities, required substantial assistance for daily activities. Despite having a care plan that included the application of orthotic devices (splints) to prevent contractures, the resident was observed multiple times without the splints, and there was no documentation of refusal by the resident. The Treatment Administration Record indicated inconsistencies in the application of the splints, with staff failing to apply them as per the care plan. Interviews with staff revealed a lack of clarity and responsibility regarding the application of the splints. The Licensed Practical Nurse acknowledged that the splints were not always applied, and the Restorative CNAs were not working with the resident due to the assumption that the resident was receiving occupational therapy. However, the therapy records did not address the resident's hand contractures or the use of splints, and the therapy Program Manager confirmed that the resident was not receiving therapy for the contractures. The Director of Nursing was unable to provide notes related to the resident's condition, indicating a lack of oversight and documentation.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with federal regulations requiring the daily posting of nursing staff information. During observations on three consecutive days, the required staffing information was not posted or made available to residents and visitors. An interview with the Administrator revealed that the facility had not posted the required daily staffing information since February 29, 2024. The Administrator acknowledged the requirement to post this information daily in a prominent location within the facility.
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Illustrative
What surveyors actually found near you
We read the 131 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
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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) |
|---|---|---|---|---|
| Sarasota Point Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Aviata At Sarasota | 0.9 mi | ★★★★★ | 4 | 0 |
| Pines Of Sarasota | 2.3 mi | ★★★★★ | 2 | 0 |
| Inn At Sarasota Bay Club | 2.3 mi | ★★★★★ | 0 | 0 |
| Indian Beach Nursing And Rehab Center | 2.3 mi | ★★★★★ | 5 | 0 |
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