F 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review and interview, the facility failed to protect the resident's right to be free from
misappropriation of property for 1 (Resident #1) of 3 residents reviewed.The findings included:Review of
the facility policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown
Origin (ANEMMI), revision date 3/2025 revealed Misappropriation of resident property means the deliberate
misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money
without the resident's consent.On 2/3/26 at 10:30 a.m., the Regional Director of Operations provided
incident investigations for November 2025 which included an investigation into an allegation of
misappropriation of resident's property. Review of the facility provided investigations revealed that on
11/13/25, the facility initiated an investigation into an allegation of unauthorized transfer of money from
Resident #1's bank account to Certified Nursing Assistant (CNA) Staff A's money transfer application. The
facility's investigation included documentation from local law enforcement indicating that the bank statement
from 10/6/25 to 10/31/25 showed transactions totaling $13,250.00 went from Resident #1's bank account to
CNA Staff A's (brand name) money transfer application. On 2/6/26 at 10:42 a.m., in an interview the
Business Office Manager (BOM) said she wrote a statement that on 11/13/25 she was doing her rounds
and entered Resident #1's room. She said after asking Resident #1 a few questions, he asked why he was
being charged $14,000 per month for his stay at the facility. The BOM said she explained to the resident
that the Veterans Administration paid for his stay and the facility did not receive any funds from him.
Resident #1 asked her to look at his bank account statements and explain the charges to him. The BOM
said she noted transfers made to CNA Staff A through (brand name), a mobile application that allows users
to send and receive money instantly. She said Resident #1 asked her to help him and call the police. BOM
said she told Resident #1 that she would notify the Administrator and an investigation ensued.On 2/5/26 at
12:12 p.m., in an interview the Director of Nursing (DON) confirmed he wrote a statement which indicated
that on 11/13/25 he interviewed Resident #1. The DON said Resident #1 gave him permission to look at his
cell phone and bedside computer with his assistance. The DON said Resident #1 and himself validated that
he did not have the (brand name) application used to transfer the money from his bank account linked to
his phone or computer. When asked, Resident #1 said he kept his debit card in his room in his bedside
dresser. Resident #1 said he did not give anyone permission to use his debit card. He said he could have
given his debit card to CNA Staff A once to purchase items for him, but he could not remember for sure.
Resident #1 stated that he had called his bank and cancelled the debit card. Review of Resident #1's bank
statements provided by the facility from October 2025 showed multiple transfers made to CNA Staff A
through (brand name) application.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105454
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105454
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/05/2026
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Creekside Health and Rehabilitation Center
5511 Swift Road
Sarasota, FL 34231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0603
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review and interview, the facility failed to protect the right to be free from
involuntary seclusion for 1 (Resident #2) or 4 residents reviewed.The findings included:Review of the facility
policy titled Abuse, Neglect, Exploitation, Misappropriation, Mistreatment and Injury of Unknown Origin
(ANEMMI), revision date 3/2025 indicated the resident has the right to be free from abuse, neglect,
exploitation, misappropriation of resident property, mistreatment and exploitation as defined in this subpart.
This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical symptoms. Abuse is defined at
483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in
physical harm, pain or mental anguish.On 2/4/26 at 11:39 a.m., Resident #2 was observed in the secured
memory care unit. Resident #2 said, They moved me back here against my will. He said they taped the door
up saying do not enter and he was locked in his room for 3 days.Clinical Record review for Resident #2
revealed Power of Attorney paperwork allowing his children to make decisions about his healthcare if he
could not decide for himself anymore. The clinical record lacked documentation of a physician's incapacity
statement that Resident #2 was not able to make his own health care decisions. Record review also
indicated Resident #2 had a BIMS score (Brief Interview for Mental Status) of 15 indicating he was
cognitively intact.On 2/4/26 at 12:04 p.m., in an interview the Director of Regional Operations said for the
safety of female residents Resident #2 was moved to the secured memory care unit as he had made
inappropriate statements and behaviors. She said Resident #2 had confusion, but he made that decision
himself. She said it was documented throughout the progress notes that the resident made the decision to
move to the secured unit. The Director of Regional Operations said there was nothing signed by the
resident that he agreed to move to the secured unit. She verified that Resident #2 did not have a lacks
capacity statement from a physician. She said Resident #2 was concerned about people coming in his
room. They had placed a stop sign across the door as an intervention so no one would enter his
room.Review of a psychology progress note dated 1/22/26 revealed that Resident #2 reported making
statements related to self-harm following distress about being moved to a different room within the facility.
He did not articulate a specific plan or intent and stated that his comments were directly related to feeling
upset about the room change. Resident #2 reported that if he were moved back to his previous room, he
would not engage in self-harm statements. Social Service Administration was advised of Resident #2's
behavior.On 2/5/26 at 1:04 p.m., in an interview the Social Services Director (SSD) said Resident #2 had
reached out to the VA (Veterans Administration) suicide hotline and they in turn notified her. She said she
notified the psychiatry provider. She said Resident #2 did not make any attempts and when interviewed he
denied wanting to harm himself. On 2/5/26 at 1:10 p.m., in an interview the Regional Nuse said they had
just completed an audit on 2/2/26 on what residents have as far as advanced directives, including
incapacity statements. The audit didn't indicate if they need it, just if they currently have one. He said the
next step would be to review whether they need one.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105454
If continuation sheet
Page 2 of 2