Inspection visit
Inspection
12 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 12 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation interview and record review the facility failed to maintain a comfortable safe temperature within
the facility.
The findings included:
On 12/11/23 at 9:30 a.m., air temperatures were obtained from the conference room at the entrance of the
building, the 200 hall nursing station, and in the halls and rooms of the 200 hall. The temperatures obtained
in theses areas ranged from 69.4 to 69.8 degrees Fahrenheit.
On 12/11/23 at 1:52 p.m., Resident #1 said the thermostat in his room was not working and it was either to
hot or too cold. Most of the time it is too cold. The resident said the heat had not been working in his room
for more than a month.
On 12/12/23 at 1:52 p.m., Resident #19 said the thermostat in her room was not working. She said the
facility staff keep telling her they are working on the heat. Resident #19 said she had problems with the
temperature almost since she was admitted to the facility. Resident #19 said she had no heat in her room,
and she had to use three blankets to stay warm.
On 12/13/23 at 9:38 a.m., Resident #82's husband said it was very cold in his wife's room. The staff had to
get an extra blanket for his wife.
On 12/14/23 at 10:44 a.m., the Maintence Director said the main issue with the heat not functioning
properly was the thermostats in the resident's rooms. There was not enough pressure in the lines. The
Maintenance Director said the heat in the building had not been working properly for about three months. A
subcontractor had been in the building working on the problem for about a month. The Maintenance
Director said the rooms are below 71 degrees first thing in the morning in the morning when he takes the
temperatures. If I know it's cool he tries to leave the air handlers off to quit blowing the air in the building. He
said it had been very difficult to maintain appropriate temperatures in the building over the last three
months due to the colder weather.
The Maintence Director provided documentation of temperatures being obtained once a day in 66 rooms in
the facility from 10/2/23 through 12/12/23. There were 13 days in which temperatures were documented in
October of 2023. There were no days where all of the rooms were documented as being 71 degrees or
higher. On 10/27/23 there were 28 of the 66 rooms documented with temperatures below 71 degrees.
There were documented temperatures as low as 64 degrees noted on some of the days in some of the
rooms.
(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 13
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
12/14/2023
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
There were 7 days documented in November where temperatures were obtained. There were no days
where all of the rooms were 71 degrees or above. On 11/13/23 there were 36 rooms documented as being
below 71 degrees. room [ROOM NUMBER] was documented at 65 degrees. room [ROOM NUMBER] was
63 degrees, room [ROOM NUMBER] was 64 degrees, and room [ROOM NUMBER] was 65 degrees. There
was no documentation of follow up temperatures or documentation the heaters in the rooms were not
working.
There were 5 days documented in December of 2023 were temperatures were documented. None of the
days documented showed all 66 rooms with temperatures at 71 degrees or greater. On 12/12/23 there were
48 of the 66 rooms documented as being below 71 degrees. 25 of the rooms were documented at 69
degrees or lower. Two rooms were documented as being 66 degrees. There was no documentation found of
any follow-up temperatures or any actions the facility took to maintain comfortable temperatures in the
residents rooms.
On 12/14/23 at 11:30 a.m., the Administrator said they had given residents extra blankets and in-serviced
staff members who were instructed to call maintenance with any issues with the room temperatures. The
Administrator verified there was only one temperature being obtained and many of the temperatures were
below an exceptable temperature, and no documented follow-up as to what interventions were in place to
ensure patient comfort and safety.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 2 of 13
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
12/14/2023
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 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
Based on record review, staff interviews, and review of facility policy the facility failed to ensure the
accuracy of a Pre-admission Screening and Resident Review (PASARR), and make the necessary
corrections for 1(Resident #73) of 2 residents reviewed for PASARR.
The findings included:
The facility policy Pre-admission Screening and Resident Review (PASRR) with no date of implementation
stated: The purpose of PASRR is to ensure individuals who are being considered for placement in a
Nursing Facility are evaluated for serious mental illness and/or intellectual disability and are offered the
most integrated setting appropriate for their long term care needs including determining whether a Nursing
Facility is appropriate.
All persons, regardless of payer or age, needing admission to a Nursing Facility must first be screened for
possible mental illness or the presence of an intellectual disability or both (Level 1). If a mental illness or
intellectual disability appears to exist, the person must be referred for further evaluation (Level II) before
Nursing Facility admission.
Review of the clinical record for Resident #73 revealed an admission date of 8/18/22. The documented
medical history at the time of admission included a primary diagnosis of Dementia, and Depression and
Anxiety.
Resident #73 was confused and unable to state her medical history. Her Brief Interview for Mental Status
(BIMS) score was documented as a 3 on her Minimum Data Set (MDS). BIMS is a tool used to screen and
identify the cognitive condition of residents upon admission into a long-term care facility. A score of 3 out of
15 indicates severe cognitive impact.
On 12/14/2023 at 12:00 p.m. in an interview with the Director of Nursing, (DON), she verified that the
PASARR form dated 8/14/2022 was inaccurate and did not list the Diagnoses of Dementia, Anxiety, or
Depression. There was no documentation that the facility completed an accurate Level 1 PASARR. The
DON said that all new admissions are to get PASARR's reassessed for accuracy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 3 of 13
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
12/14/2023
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interviews, and record review, the facility failed to provide adequate supervision prevent falls
for 2 residents (#9 and #18) of 3 residents reviewed for falls.
The findings included:
1. Review of the Policy Fall Risk Reduction Program: Residents at risk for falls will be identified and the
interdisciplinary team will work with the residents, caregivers, and family to reduce the risk of falls while
maximizing dignity and independence. Components of the fall risk reduction program include but are not
limited to:
Addressing underlying medical issues that may contribute to fall risk and resident/responsible party/family
education.
Reducing the risk of falls included placing in Rising Star Program to promote communication of high risk to
all staff.
Providing assistance whenever the resident ambulates.
Moving the resident to a room closer to a nurse's station or in a higher traffic hallway.
Requesting family or friends to stay with resident at all times or use of sitters, and supervised activities
when up out of bed.
Review of the Rising Star Program revealed it includes assisting with ambulation as needed, anticipate
needs of resident, and check on regularly/frequently.
1. Review of the hospital records dated 4/20/23, revealed Resident #9 had 2 unwitnessed falls at home,
sustaining a nasal fracture. One fall was in the bathroom. The resident was noted to be alert and oriented,
but not a great historian.
Review of the admission record face sheet revealed Resident #9 was elderly, aged in the 9th decade,
admitted to the facility on [DATE] with diagnoses of repeated falls, fracture, pacemaker, age related
osteoporosis, and need for assistance with personal care.
Review of the admission Minimum Data Set (MDS) dated [DATE] section GG revealed Resident #9 required
partial to moderate assistance for toileting, required supervision or touching assistance for transfers, sitting
to standing, and walking 50 feet with 2 turns. Review of section I revealed diagnoses of seizure disorder
and pacemaker.
Review of the incident reports revealed Resident #9 had multiple falls after being admitted to the facility
including falls on 5/6/23; 7/9/23; 7/10/23; 8/16/23; 9/24/23; 10/2/23; 10/26/23; and 11/13/23.
Review of the Activities of Daily Living (ADLs) care plan initiated on 4/28/23 revealed the resident required
touching or supervision assistance for transfers.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 4 of 13
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
12/14/2023
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Review of the fall care plan initiated on 4/28/23 revealed Resident #9 was at risk for further falls due to fall
history, weakness, advanced age, and history of seizures. The interventions put in place on 4/28/23
included anticipate needs; be sure call light in reach and remind resident to use it; resident needs prompt
response to all request for assistance; educate the resident family/care givers about safety reminders and
what to do if a fall occurs; encourage activities that promote strength and improved mobility.
Residents Affected - Few
Review of the incident report dated 5/6/23 at 2:48 a.m. revealed Resident #9 had an unwitnessed fall in the
bathroom. The resident stated, I was getting into my wheelchair and didn't lock the brakes and slipped in
these socks. The facility identified poor safety awareness and using wheeled walker as predisposing
factors.
The care plan was updated on 5/6/23 to include non-skid socks at bedtime.
A Restorative Therapy care plan was initiated on 6/5/23 to maintain ambulation and mobility.
Review of the incident report dated 7/9/23 at 1:45 p.m. revealed Resident #9 had a witnessed fall in the
bathroom reaching for a towel and lost his balance. The facility predisposing factors were weakness/fainted,
ambulating without assistance, recent c/o sore throat and general malaise.
Review of the incident report dated 7/10/23 at 2:50 p.m. revealed Resident #9 had an unwitnessed fall in
the bathroom. The resident took himself to the bathroom and lost balance when he stood up. The facility's
immediate action was the call, don't fall sign and reeducate the resident to call for assistance. The
pre-disposing factors were poor safety awareness, recent illness, weakness/fainted, confusion.
The care plan was updated on 7/10/23 to increase visual checks and place a call, don't fall sign in the
room. On 7/11/23 the care plan was updated with Rising Star Program.
On 7/24/23 the facility updated the fall care plan to include antiseizure medications as ordered and if
seizure activity noted provide safety and notify MD.
Review of the incident report dated 8/16/23 at 11:16 p.m. revealed Resident #9 had an unwitnessed fall
next to the bathroom door. Resident said he got up to use the bathroom. The facility instructed the resident
to call for assistance before getting up. Predisposing factors identified were gait imbalance, impaired
memory, weakness/fainted, improper footwear, and ambulating without assistance.
Resident #9's fall care plan was updated on 8/17/23 to include prompted toileting upon rising before or after
meals/activities, before bed, upon request, and as needed.
Review of the incident report dated 9/24/23 at 9:45 a.m. revealed Resident #9 had an unwitnessed fall in
the bathroom. He said he spit in the toilet and slipped. The predisposing factors were confused, impaired
memory, poor safety awareness.
The care plan was updated on 9/25/23 for medication review.
Review of the incident report dated 10/2/23 at 8:10 a.m. revealed Resident #9 had an unwitnessed fall in
the bathroom but was unable to give a description. The predisposing factors were confusion and poor
safety awareness. The nursing to therapy communication form dated 10/5/23 by the therapist
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 5 of 13
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
12/14/2023
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 0689
indicated Physical Therapy evaluated the resident for fall prevention.
Level of Harm - Minimal harm
or potential for actual harm
The care plan was updated on 10/5/23 to include continue current interventions.
Residents Affected - Few
Review of the Rehabilitation and Skilled Nursing Facility Therapy to Nursing Communication form dated
10/19/23 revealed Resident #19 may ambulate in the hallways without walker.
Review of the incident report dated 10/26/23 at 10:40 p.m. revealed Resident #9 had an unwitnessed fall in
the doorway of his room. Predisposing factors included ambulating without assistance.
The care plan was updated on 10/27/23 to re-educate Resident #9 on calling for assistance.
Review of the incident report dated 11/13/23 at 8:30 p.m. revealed Resident #9 had an unwitnessed fall at
the foot of the bed. Predisposing factors included impaired memory, poor safety awareness and ambulating
without assistance. The root cause of the fall was resident was cleared by therapy for self-ambulation with
walker.
On 12/11/23 at 8:03 a.m., observed Resident #9 in his room eating breakfast. The room was located away
from the nurses' station in the middle of the hallway. Resident #9 could not tell me why he had so many falls
at the facility.
On 12/11/23 at 12:27 p.m., Licensed Practical Nurse (LPN) Staff H said Resident #9 has fallen numerous
times, has been cleared by therapy to walk without a walker, and will probably fall again.
On 12/13/23 at 10:01 a.m., Physical Therapist (PT) Staff G said she discharged Resident #9 from therapy
on 10/19/23. She said she completed the Therapy to Nursing Daily Communication form on 10/19/23
indicating Resident #9 may ambulate in hallways without walker. She said short-term and long-term goals
were met on 10/19/23 for gait with safe ambulation on level surfaced unlimited distance using no assistive
device, supervision, or touching assistance.
On 12/13/23 at 3:06 p.m. LPN Staff E said Resident #9 is confused and does not think the resident would
remember if told something. She said he is on the Rising Star Program because he is a fall risk.
On 12/13/23 at 12:08 p.m., the Director of Nursing (DON) said we do not have enough staff to give
Resident #9 one to one supervision. She said every time he falls, he is screened or evaluated by therapy.
She said he is continent and not a candidate for the toileting program. She said we call the family each time
he falls.
On 12/13/23 at 12:21 p.m., LPN Staff D said she was unaware Resident #9 had a pacemaker and did not
know who monitored the pacemaker.
On 12/13/23 at 12:31 p.m. review of the medical chart revealed no interventions for monitoring the
pacemaker.
On 12/13/23 at 12:38 p.m., the DON verified there were no instructions in the medical record to indicate the
pacemaker was being monitored. She said most residents with pacemakers have a machine in the room.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 6 of 13
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
12/14/2023
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 0689
Level of Harm - Minimal harm
or potential for actual harm
On 12/13/23 at 12:53 p.m., during observation of Resident #9's room with the DON, there was no machine
for monitoring the pacemaker.
On 12/13/23 at 12:55 p.m., the DON said Resident #9's stepson has been monitoring the pacemaker. She
said they were not aware of it until now.
Residents Affected - Few
On 12/13/23 at 2:55 p.m., Certified Nursing Assistant (CNA) Staff F said Resident #9 is unstable on his
feet, hard of hearing and confused. She said he falls, but not a lot. She said the Rising Star Program means
you check on them every 30 minutes or so.
On 12/14/23 at 9:16 a.m., Resident #9's son-in-law said the facility called him about the pacemaker on
12/13/23. He said they never asked about the pacemaker before then.
On 12/14/23 at 10:52 a.m., during an interview with the DON and Registered Nurse (RN) Unit Manager
Staff B, they acknowledged repeated falls in the bathroom for Resident #9. They said the interventions for
prompted toileting and increased visual checks did not include specific times to check the resident and did
not prevent Resident #9 from falling. The DON acknowledged reminding resident to call for assistance was
not effective in that the resident had confusion and impaired memory. The DON said the pacemaker was an
underlying medical issue that may contribute to fall risk and the facility was not monitoring it for proper
functioning. The DON said Resident #9 fell two more times after therapy indicated the resident could
ambulate without assistance, and there were no additional evaluations or screenings after those falls.
On 12/14/23 at 11:30 a.m., Therapist Staff G confirmed Resident #9 was not re-evaluated or re-screened
after the the falls on 10/26/23 and 11/13/23.
2. Review of the facility admission face sheet for Resident #18 revealed admission on [DATE] with
diagnoses of dementia and repeated falls.
Review of the admission MDS with ARD of 4/24/23 revealed the resident's BIMS was 3, meaning severe
cognitive impairment. Review of Section GG revealed Resident #18 was dependent on staff for eating and
toileting. Resident #18 used a wheelchair and was dependent on the helper to do all the effort.
Review of the Resident 18's care plan dated 4/25/23 revealed interventions in place to prevent falls were
anticipate needs, call light in reach and encourage resident to use it, resident needs prompt response to all
requests for assistance, educate resident/family/caregivers about safety reminders and what to do if fall
occurs, encourage resident to participate in activities that promote exercise, physical activity for
strengthening and improved mobility, physical therapy evaluate and treat as ordered and as needed.
Review of the incident reports revealed Resident #18 had multiple falls after admission to the facility
including falls on 4/27/23, 6/9/23, 6/23/23, and 11/16/23.
Review of the incident report dated 4/27/23 at 4:40 p.m., revealed Resident #18 had an unwitnessed fall in
her room. Predisposing factors were listed as confusion, impaired memory, and poor safety awareness.
The care plan was updated on 4/28/23 with bilateral fall mats and low bed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 7 of 13
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
12/14/2023
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Review of the incident report dated 6/9/23 at 11:54 a.m., revealed Resident #18 had an unwitnessed fall in
the Sunroom/Avalon Room. The predisposing factors were listed as confusion, gait imbalance, impaired
memory, poor safety awareness, and ambulating without assistance.
The care plan was updated on 6/9/23 with the Rising Star Program.
Residents Affected - Few
Review of the incident report dated 6/23/23 at 6:59 a.m., revealed Resident #18 had a witnessed fall in front
of the nursing station. The resident leaned forward and fell. Confusion, gait imbalance, poor safety
awareness and ambulating without assistance were listed as predisposing factors.
The care plan was updated on 6/23/23 to offer books, magazines, etc. to distract.
Review of the incident report dated 11/16/23 at 2:10 p.m., revealed an unwitnessed fall for Resident #18.
The resident fell out of bed.
The care plan was updated with the call don't fall sign on 11/17/23.
On 12/11/23 at 8:02 a.m., observed Resident #18 in room in bed. The bedside tray with breakfast on it was
located at the end of the bed up against the wall. The resident did not respond to verbal stimulation.
On 12/14/23 at 10:10 a.m., the DON acknowledged Resident #18 had severe cognitive impairment and
some of the interventions to prevent falls were not appropriate. The DON said there was no evaluation to
ensure Resident #18 would know what the call don't fall sign meant, so it was probably ineffective. The
DON acknowledged placing the resident in the Sun/Avalon Room for supervision was ineffective because
the resident had an unwitnessed fall while she was in the Sunroom/Avalon Room. The DON said the Rising
Star Program was ineffective because it did not include specific time frames for checking on the resident
and Resident #18 fell twice after it was added to the care plan. The DON acknowledged the resident's room
was far from the nurses' station and not in a high traffic area where the resident would be seen by more
staff.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 8 of 13
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
12/14/2023
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.
Based on record review, staff interview, and observation the facility failed to maintain an indwelling catheter
in a safe and sanitary manner for 1(Resident #82) of 1 resident sampled with an indwelling catheter. This
has the potential to cause injury and urinary tract infection.
The facility policy Catheter Care, Including Drainage Bag Care /Maintenance documented the purpose of
the policy:
To provide safe and proper care of the resident with an indwelling urinary catheter.
To minimize the risk of bladder infection.
Procedure #8 documented:
Position the drainage bag below the level of the residence bladder. Secure to the bed or wheelchair in such
a manner that neither the bag nor the spigot touches the floor.
Review of Resident #82's clinical record revealed a physician order for an indwelling catheter (tube inserted
into the bladder to drain urine) for comfort at end of life.
On 12/11/23 at 9:41 a.m., during an observation, Resident #82 was in bed and not responsive. The
catheter drainage bag was observed lying on the floor.
Photographic evidence obtained.
On 12/11/23 at 1:56 p.m., during an observation, Resident #82's catheter drainage bag was in the same
position on the floor.
On 12/11/23 at 2:00 p.m., during an observation and interview, Licensed Practical Nurse Staff A confirmed
the catheter drainage bag should not be on the floor.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 9 of 13
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
12/14/2023
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, review of facility policy and procedures, record review, and staff interview, the facility
failed to provide oxygen therapy, in accordance with physician orders, for 1 (Residents #82) of 1 resident
reviewed for oxygen therapy. The facility also failed to have a system to maintain CPAP (continuous positive
airway pressure therapy) and BIPAP (bi-level positive airway pressure therapy) machines in a sanitary
manner for 2 (Resident #27 and #248) of 2 residents who use a CPAP/BIPAP machines (helps you breathe
more easily when you sleep). This has the potential to cause respiratory infection.
Residents Affected - Few
The findings included:
The facility policy Oxygen Administration documented, The purpose of this procedure is to provide
guidelines for oxygen administration. Turn on the oxygen. Start the flow of oxygen at the prescribed rate.
Adjust the delivery device so that it is comfortable to the resident and the proper flow of oxygen is being
administered. Observe the resident to be sure oxygen is being tolerated.
1. Review of Resident #82's clinical record revealed an admission date of 9/28/23 with diagnoses including
dementia, protein calorie malnutrition and hypertensive heart disease.
On 12/11/23 at 9:49 a.m., during an observation Resident #82 was in her bed and was not responsive to
verbal stimuli. The resident had an oxygen concentrator to deliver oxygen through a nasal cannula. The
oxygen concentrator was set at 0.5 L/M.
Photographic evidence obtained.
On 12/11/23 at 1:53 p.m., during an observation Resident #82's oxygen concentrator was turned on and
set at 0.5 L/M.
Review of the physician's admission orders for Resident #82 documented oxygen at 3 liters/minute (L/M)
via nasal cannula continuous.
On 12/11/23 at 2:15 p.m., Licensed Practical Nurse Staff A verified the oxygen concentrator was not set at
3 L/M as ordered by the physician. Staff A attempted to adjust the oxygen concentrator but was not able to
increase the flow rate to 3 L/M. Staff A said the concentrator was broken. Staff A said there was no way of
knowing how long Resident #82 was not receiving the physician ordered flow rate of the oxygen.
The facility policy Nursing-Use of CPAP/BIPAP/APAP documented the purpose of the policy was To provide
guidelines for use of CPAP (continuous positive airway pressure therapy) or BIPAP (bi-level positive airway
pressure therapy) or APAP (auto adjusting positive airway pressure therapy) for the treatment of obstructive
sleep apnea.
Guidelines for use:
Obtain MD order that includes the following:
a. Specifies what type of machine is required (CPAP, BIPAP, APAP)
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 10 of 13
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
12/14/2023
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 0695
b. Contains the specific pressure.
Level of Harm - Minimal harm
or potential for actual harm
c. Diagnosis for use (obstructive sleep apnea).
d. For cleaning mask and tubing instructions.
Residents Affected - Few
Care and maintenance specified keep the area around the machine clean and dusted to improve the air
quality delivered by the machine.
2. Review of the clinical record revealed Resident #248 had an admission date of 11/25/23 with diagnoses
including morbid obesity and obstructive sleep apnea.
On 12/11/23 at 11:00 a.m., during an observation Resident #248 had a CPAP machine on her bedside
table. The CPAP mask was lying on top of the nightstand uncovered and in contact with other items on the
nightstand, including the phone. Resident #248 said the nurse takes care of filling the water reservoir but
she did not know who was responsible for the care of the mask, I suppose I am.
Photographic evidence obtained.
During random observation on 12/12/23 at 9:12 a.m., and 12/13/23 at 8:30 a.m., Resident #248 CPAP
mask was uncovered on top of the nightstand lying on the phone and in contact with other items on the
nightstand. There was debris from an artificial Christmas trees sprayed on snow next to the CPAP machine
and the mask.
On 12/13/23 at 10:32 a.m., Registered Nurse Unit Manager, Staff B and the Director of Nursing (DON)
went to Resident #248's room and confirmed the findings with the storage of the CPAP mask. The DON
confirmed the CPAP mask was not stored properly.
On 12/13/23 at 10:00 a.m., in an interview Staff B said the process for the CPAP machine masks was to
place the mask in a plastic bag when not in use. Staff B said we follow the physician order for the settings,
and we make sure the CPAP is set to that level.
Further review of Resident #248's clinical record found no documentation of a physician order for the use of
the CPAP machine.
3. Medical record review for Resident #27 showed a Physician order dated 1/18/2023 to apply at
pre-programmed settings with heated humidification at bedtime. Remove in the morning.
On 12/11/23 at 12:15 p.m., a BIPAP oxygen mask was observed sitting on Resident #27's bedside table.
Resident #27 said that staff come in every night and put the mask on him, and he takes it off and sets it on
the table when he's done with it.
On 12/12/23 at 12:36 p.m., observed Resident #27 sitting up in his wheelchair sleeping. His BIPAP mask
was lying on the bedside table in his room uncovered.
*Photographic evidence obtained.
On 12/12/23 at 12:36 p.m., observed Resident #27 sitting up in his wheelchair sleeping. His BIPAP mask
was lying on the bedside table in his room uncovered.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 11 of 13
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
12/14/2023
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 0695
Photographic evidence obtained.
Level of Harm - Minimal harm
or potential for actual harm
On 12/13/23 at 11:10 a.m. observed BIPAP mask on bedside table uncovered.
On 12/14/2023 at 10:30 a.m. observed BIPAP still laying on the bedside table uncovered.
Residents Affected - Few
On 12/14/23 at 10:40 a.m., in an interview Staff D, LPN, said the night nurse puts the BIPAP on Resident
#27 when he will let them. She said the BIPAP should be stored in a plastic bag and the tubing dated and
labeled.
On 12/14/2023 at 10:45 a.m., in an interview Staff E, LPN said that BIPAP masks are supposed to be
cleaned and covered and the tubing labeled.
On 12/14/2023 at 12:00 p.m., in an interview, the DON she said CPAP BIPAP masks should be taken off in
the morning by the nurse and placed in a plastic bag.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 12 of 13
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
12/14/2023
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, review of facility policy and procedures and staff interviews, the facility failed to ensure insulin
was properly dated when opened and stored on one (1) of three (3) medication carts observed. Without an
open date on the medications there was no way to know when it would expire. The facility also failed to
ensure expired medications were removed and disposed of in one (1) of two (2) medication rooms
observed.
The findings included:
The facility policy Medication Storage in the Facility documented when the original seal of a manufacturers
container or vial is initially broken, the container or vial will be dated. The nurse shall place a date open
sticker on the medication and enter the date opened and the new date of expiration. The expiration date of
the vial or container will be 30 days unless manufacturer recommends another date or regulations
guidelines require different dating.
The nurse will check the expiration date of each medication before administering it. No expired medication
will be administered to a resident. All expired medications will be removed from the active supply and
destroyed in the facility regardless of amount remaining.
On 12/11/23 at 8:05 a.m., during an observation on the [NAME] Unit, medication cart 1 contained a vial of
Tresiba insulin. The date opened was 9/30/23. The expiration date was 11/25/23.
The findings in medication cart 1 were verified with Licensed Practical Nurse Staff C.
Photographic evidence obtained.
On 12/11/23 at a.m., 8:20 a.m., during an observation of the the locked medication refrigerator on the
[NAME] Unit there were four (4) purified protein derivative (PPD's) single injection skin tests for tuberculosis
with the expiration date 12/10/23 and 1 PPD with the expiration date 12/6/23. Registered Nurse Unit
Manage Staff B confirmed the findings.
Photographic evidence obtained.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105567
If continuation sheet
Page 13 of 13
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Back to topCitations
12 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.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0324GeneralS&S Dpotential for harm
Provide properly protected cooking facilities.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F915 - Buildings must have an outside window or outside door in every
Have proper power supply for life support equipment.
F916 - Have a floor at or above grade level
Have a battery powered remote alarm panel in a location accessible by operating personnel.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the December 14, 2023 survey of SPRINGS AT LAKE POINTE WOODS?
This was a inspection survey of SPRINGS AT LAKE POINTE WOODS on December 14, 2023. The surveyor cited 12 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SPRINGS AT LAKE POINTE WOODS on December 14, 2023?
Yes, 12 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Coordinate assessments with the pre-admission screening and resident review program; and referring for services as neede..."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.