Inspection visit
Inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, resident and staff interview, the facility failed to ensure they provided an
ongoing program to support residents in their choice of activities which are designed to meet the resident's
interests and support the resident physical, mental and psychosocial well-being for 1 (Residents #38) of 2
residents reviewed for involvement in the activity program. The lack of an ongoing activity program could
lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being.
Residents Affected - Few
The findings included:
On 2/28/22 at 10:28 a.m. Resident #38 was observed in her room lying in bed wearing a hospital gown. Via
observation noted the television or the radio were not on, and Resident #38 was not participating in a
facility activity.
On 3/1/22 at 11:22 a.m., Resident #38 was observed in her wheelchair in the day room next to the nursing
station. Via observation noted the television or the radio were not on, and Resident #38 was not
participating in a facility activity.
On 3/3/22 review of Resident #38's medical record revealed she was admitted to the facility on [DATE] with
diagnoses including dementia without behaviors, hypertension, insomnia, heart failure and neuropathy.
The quarterly MDS (Minimum Data Set) assessment dated [DATE], a tool used for clinical assessment of a
resident assessed Resident #38 a cognitive BIMS (Brief Interview for Mental Status) of 3 out of 15. A BIMS
score between 0 to 7 means severe cognitive impairment.
The Activity Quarterly Participation Review dated 1/12/22 stated Resident #38 was alert and able to make
her own decisions pertaining to her leisure activities. Resident #38 enjoyed watching television, card
games, going outside, keeping up with the news, and reading the newspaper daily.
Resident #38's activity plan of care dated 7/22/20 and revised 7/4/21 listed a goal for Resident #38 to
attend at least three weekly activity programs.
On 3/3/22 at 9:08 a.m., in an interview the Activity Director said she was the only person in the activity
department until early this year. She said when a resident attends a facility activity, she would put their
name on the attendance sheet for that activity, and that is how she keeps track of what activities the
residents' attend.
(continued on next page)
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 5
Event ID:
105567
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
105567
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Lake Pointe Woods
3280 Lake Pointe Blvd
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 0679
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
The Activity Director reviewed Resident #38's medical record and confirmed Resident #38 enjoys watching
television, card games, going outside, keeping up with the news, and reading the newspaper daily as noted
in the Activity Quarterly Participation Review dated 1/12/22. She also said Resident #38 has dementia but
enjoys going to bingo activity which are held 3 times a week.
The Activity Director reviewed the activity sign-in sheets for January 2022 and February 2022 and was only
able to find documentation Resident #38 attended morning resident social on 1/23/22 and did an outside
activity for fresh air on 2/20/22. She said over the past two months from 1/1/22 to 3/3/22 she was only able
to find documentation of Resident #38 attended two facility activities.
The Activity Director said she was unable to find documentation the facility had provided an ongoing activity
program for January and February 2022 which supported Resident #38's activity choices, as documented
in the activity quarterly assessment dated [DATE] which are designed to meet the resident's interests and
maintain Resident #38's physical, mental, and psychosocial well-being.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 2 of 5
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
105567
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Lake Pointe Woods
3280 Lake Pointe Blvd
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 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, staff and resident interviews, the facility failed to ensure 1 resident (Resident
#35) of 4 residents who entered the facility with an indwelling catheter was assessed for appropriate
diagnosis and removal of the catheter.
The findings included:
On 2/28/22 at 10:55 a.m., Resident# 35 was observed with an indwelling urinary catheter (a tube inserted
in the bladder that allows urine to drain from the bladder into a bag). Resident #35 said prior to going to the
hospital she did not have a Foley catheter and did not ask why she still ha the urinary catheter because the
nurses know better than I do.
Clinical record for Resident #35 was reviewed on 2/28/22 at 11:50 a.m. An admission MDS (Minimum Data
Set) dated 12/17/21 showed that resident admitted on [DATE] with an indwelling urinary catheter. There
was no physician's order for the use of indwelling urinary catheter and no assessment conducted for the
possible discontinue of the urinary catheter.
On 3/2/22 at 08:37 a.m., in an interview Licensed Practical Nurse (LPN) Staff F said Resident #35's clinical
condition did not support the use of an indwelling urinary catheter.
On 3/2/22 9:15 a.m., LPN Staff B was unable to provide the clinical indication for use for the catheter, and
the record did not contain documentation for the use of the catheter.
On 3/2/22 at 2:20 p.m., in an interview the Director of Nursing (DON) stated that although their policy did
not state so the Urinary Catheter should be discontinued within 24 hours of admission to avoid
complications such as UTIs [Urinary Tract Infections]. A Bowel and Bladder pattern is initiated, and resident
is assessed for toileting plan. The DON said there was no documentation in the Resident's clinical record
indicating the need for an indwelling urinary catheter and the nursing staff failed to assess Resident#35 for
removal of the indwelling urinary catheter.
On 3/2/2022 at 2:56 p.m., Resident #35's attending physician gave an order for the indwelling urinary
catheter be removed. Documentation after removal of urinary catheter showed Resident#35 was able to
void without difficulty and complaints.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 3 of 5
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
105567
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Lake Pointe Woods
3280 Lake Pointe Blvd
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review and interview, the facility the facility failed to maintain an effective
water management program to minimize the risk of outbreak of water borne pathogens.
Residents Affected - Many
The findings included:
The Center for Clinical Standards and Quality/Survey and Certification group (Ref S&C 17-30) revised on
6/9/17 directs facilities to, implement a water management program that considers the ASHRAE [American
Society of Heating, Refrigerating, and Air Conditioning Engineers] industry standards and the CDC [Center
for Disease Control] toolkit, and includes control measures such as physical controls, temperature
management, disinfectant level control, visual inspection, and environmental testing for pathogens.
Specify testing protocols and acceptable range for control measures and document the result of testing and
corrective actions taken when control limits are not maintained .
The Centers for Disease Control and Prevention (CDC) at
https://www.cdc.gov/safewater/chlorine-residual-testing.html notes,
The presence of free chlorine (also known as chlorine residual, free chlorine residual, residual chlorine) in
drinking water indicates that: 1) a sufficient amount of chlorine was added initially to the water to inactivate
the bacteria and some viruses that cause diarrhea disease; and 2) the water is protected from
recontamination during storage. The presence of free chlorine in drinking water is correlated with the
absence of most disease-causing organisms, and thus is a measure of the potability of water.
The facility's policy titled Legionella Water Management Program, (MED-PASS, Inc. (Revised July 2017)
read, Our facility is committed to the prevention, detection, and control of water-borne contaminants,
including Legionella .
The water management team will consist of at least the following personnel: The infection preventionist; the
administrator; the medical director (or designee), the director of maintenance; and the director of
environmental services .
The water management program includes the following elements:
The identification of areas in the water system that could encourage the growth and spread of Legionella or
other waterborne bacteria, including: storage tanks, water heaters, filters, aerators, showerheads and
hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains, and medical devices .
The identification of situations that can lead to Legionella growth, such as: . construction; .water main
breaks; . changes in municipal water quality; . the presence of biofilm, scale, or sediment; .water
temperature fluctuations; .water pressure changes; . water stagnation; and . inadequate disinfection.
Specific measures used to control the introduction and/or spread of Legionella (e.g., temperature,
disinfectants);
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 4 of 5
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
105567
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/03/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Lake Pointe Woods
3280 Lake Pointe Blvd
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 0880
The Control limits or parameters that are acceptable and that are monitored .
Level of Harm - Minimal harm
or potential for actual harm
A system to monitor control limits and the effectiveness of control measures .
Documentation of the program .
Residents Affected - Many
On 3/3/22 at 9:03 a.m., the administrator said he was responsible for the water management program since
the previous maintenance director left. The administrator said each month the chemical services company
comes to the facility and tests the water in the cooling tower. He said the cooling tower supplies the water to
the heating, ventilation, and air conditioning (HVAC) system. He said the company does the testing monthly.
The administrator submitted the Service Report dated 2/8/22, as an example.
Review of the chemical services company service report dated 2/8/22, which included water testing for
facility's HVAC system. The report did not contain testing of any other water in the facility.
On 3/3/22 at 9:15 a.m., during observation of the outdoor cooling tower, the administrator said the water in
the cooling tower does not supply drinking water to the facility. He said the facility's water is supplied by the
county and the facility does not test the municipal water supply for chlorine or bacteria.
On 3/3/22 at 9:20 a.m., during observation of the pond and fountain in the facility's courtyard, the
administrator said residents and/or family members like to sit around the fountain. The administrator said
chlorine tablets from the home improvement store are added to the pond (and fountain). He said here is no
documentation of how much or when the chlorine tablets are added. He said the water in the pond and
fountain is not tested for chlorine amount or content. The administrator said there is no routine testing for
chlorine levels of water inside the facility used for such things as drinking, showering, eye wash station or
ice machines.
On 03/3/22 at 9:58 a.m., the Infection Preventionist said she is not involved in the Water Management
Program.
On 03/3/22 at 10:05 a.m., the Environmental Services Director said she does not know anything about
Legionella.
On 3/3/22 at 10:21 a.m., the administrator submitted the facility's Water Management Program book, which
included Centers for Disease Control (CDC) guidelines, Facility Risk Assessment for Legionella, facility
H2O (water) flow chart, and additional monthly Service Reports from the chemical services company for
the HVAC system. He said the Maintenance Director is new and did not know he was supposed to test the
water for chlorine or bacteria.
On 3/3/22 at 10:48 a.m. during a telephone interview, the sales representative from the contracted chemical
services company verified testing and treating of the cooling tower only. He said there was no testing of
facility water supplying drinking, showering, eye wash station, ice machines, or fountains.
On 3/3/22 at 11:14 a.m., the administrator again verified they were not monitoring or testing facility water for
chlorine levels or Legionella.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 5 of 5
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F679 - Activities
Provide activities to meet all resident's needs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
FAQ · About this visit
Common questions about this visit
What happened during the March 3, 2022 survey of SPRINGS AT LAKE POINTE WOODS?
This was a inspection survey of SPRINGS AT LAKE POINTE WOODS on March 3, 2022. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SPRINGS AT LAKE POINTE WOODS on March 3, 2022?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide activities to meet all resident's needs."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.