Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies, 3 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
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.
Level of Harm - Immediate
jeopardy to resident health or
safety
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The
immediate actions implemented by the facility and verified by the survey team on 5/24/25 included:
Residents Affected - Some
On 5/24/25 verified through observation that the facility placed portable air conditioners and chillers
throughout the facility to maintain temperatures between 71 and 81 degrees.
On 5/24/25, verified through resident interviews that the residents feel the temperature is now comfortable
throughout the facility including in the resident rooms.
On 5/24/25 at 10:30 a.m., temperatures were taken throughout the facility and verified to be within the
temperature range of between 71 and 81 degrees.
On 5/24/25 at 1:00 p.m., temperatures were taken throughout the facility and verified to be within the
temperature range of between 71 and 81 degrees.
On 5/24/25 at 5:00 p.m., temperatures were taken throughout the facility and verified to be within the
temperature range of between 71 and 81 degrees.
On 5/24/25, verified the maintenance staff were educated on maintaining the facility temperatures between
71 degrees and 81 degrees. Air conditioners will be maintained in working condition. If an air conditioner
unit fails, maintenance staff along with administration will activate the emergency plan to maintain facility
temperatures between 71 and 81 degrees.
On 5/24/25 at 5:00 p.m., clinical staff education on abuse/neglect related to assessment and care of
residents when the temperatures are above 81 degrees verified by posttest results and interview.
Based on observation, record review, residents and staff interviews, the facility failed to take appropriate
actions to maintain a safe and comfortable air temperature range for all residents of the facility when the
central air conditioning unit of the 500 hall, the 400 hall, and the common area of 700 hall broke.
On 4/28/25 the central air conditioning unit for the 500 hall broke. The facility installed window air
conditioning units in residents' rooms in the 500 hall but failed to monitor the rooms' temperature to ensure
it remained at a safe and comfortable range.
On 5/19/25 the central air conditioning unit for the 400 hall broke. The facility failed to implement immediate
and appropriate actions to maintain a safe and comfortable temperature range in
(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 19
Event ID:
105774
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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
residents' rooms and common areas.
Level of Harm - Immediate
jeopardy to resident health or
safety
On 5/20/25 at multiple times throughout the day, the temperature in random residents rooms in the 400 hall,
500 hall (with window air conditioning units), room [ROOM NUMBER] and the common area of the 700 hall
measured between 81.3 degrees to 84.3 degrees Fahrenheit (F).
Residents Affected - Some
The failure to maintain a safe temperature range created a likelihood of serious harm or death of residents
from prolonged heat exposure which can result in heatstroke, dehydration, heat exhaustion, and resulted in
the determination of Immediate Jeopardy.
On 5/23/25 at 9:30 a.m., the Administrator was notified of the determination of Immediate Jeopardy and
provided the Immediate Jeopardy (IJ) templates.
The findings included:
Cross reference F600 and F835.
On 5/20/25 at approximately 9:30 a.m., during an initial tour of the facility, the hallways felt excessively
warm.
A hygrometer (measures temperature and humidity) was used to take the temperature in residents' rooms
and common areas several times throughout the day.
On 5/20/25 at 10:14 a.m., room [ROOM NUMBER]'s temperature was 82.0 F.
On 5/20/25 at 10:25 a.m., in an interview, the Administrator said the central air conditioning unit in the 500
hallway has been down since early April. He said they installed air conditioning window units to the
residents' rooms to keep the temperature between 76.0 degrees F and 77.0 degrees F. He said the central
air conditioning unit of the 400 hallway went down early this morning. He said both units needed either a
new compressor or needed to be replaced. The Administrator said they were putting a big fan in the 400
hallway right now to bring the cool air in. The Administrator said they took temperatures twice a month and
provided a temperature monitoring log for January 2025, February 2025, March 2025, April 2025 and May
1, 2025.
Review of the temperature monitoring logs for January 2025 through May 2025 revealed each log included
a column for temperature in the morning and a column for temperature in the evening. the temperature was
documented twice a day (morning and afternoon), two times a month in the following areas:
The 300, 400, 600, 700, and 800 hallways.
The Main Dining Room, the Therapy gym, the Activities room, the East, and [NAME] Nurses Stations, East
and [NAME] Day Rooms.
For January 2025 the log noted, Date: Jan-2025 1-10.
[DATE]-24 was written above the temperature obtained in the morning from 8:00 a.m. to 8:50 a.m. The
temperature ranged from 72.0 F to 80.0 F.
[DATE]-31 was written above the temperature obtained in the afternoon from 5:00 p.m. to 5:20 p.m.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 2 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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
The temperature ranged from 72.0 F to 80.0 F.
Level of Harm - Immediate
jeopardy to resident health or
safety
For February 2025 the log noted, Date: 2-3-2025.
2-3-25 2-14 was written above the the column for the temperature documented for 8:00 a.m. The
temperature ranged from 71.0 F to 80.0 F.
Residents Affected - Some
2-17 2-28-25 was written above the column for the temperature documented for 8:00 p.m. The temperature
ranged from 71.0 F to 80.0 F.
For March 2025 the log noted, Date: 3/1/2025.
3-2- 3/14/25 was written above the column for the temperature documented at 8:00 a.m. The temperature
ranged from 72.0 F to 80.0 F.
3-16-3-30 was written above the column for the temperature documented for 8:00 p.m. The temperature
ranged from 73.0 F to 80.0 F.
For April 2025 the log noted, Date: 4/1/2025.
4-1-12 was written above the column for the temperature documented for 8:00 a.m. The temperature
ranged from 73.0 F to 80.0 F.
4-13-30 was written above the column for the temperature documented for 8:00 p.m. The temperature
ranged from 71.0 F to 80.0 F.
For May 2025, the log noted, Date: 5-1-2025.
5-1-2025 was written above the column for the temperature documented for 8:00 a.m. the temperature
ranged from 74.0 F to 80.0 F.
No date range or time was documented above the second column for the temperature range of 74.0 F to
80.0 F.
The log did not include the temperature in residents' rooms.
On 5/20/25 at 11:10 a.m., room [ROOM NUMBER]'s temperature was 82.9 F.
On 5/20/25 at 11:15 a.m., Resident #2 was observed in her room on the 400 hallway. In an interview,
Resident #2 said her room was a bit hot. Resident #2 said, Last night was terrible, I was cooking (indication
of body heat), it felt like I showered. It's been hot like this for a few days. The room temperature obtained
during the interview was 82.2 F.
On 5/20/25 at 11:34 a.m., Resident #3 was observed in his room on the 400 hallway. In an interview,
Resident #3 said, It's hot, it's hot, I am sweating. I had to come in the hallway to cool off. I stayed by the fan,
not moving around. I thought the hallway would be cooler but it's not. It was hot yesterday, I sweated my ass
off all day and all night. Resident #3's room felt warm. The temperature obtained during the interview was
82.4 F.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 3 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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
On 5/20/25 at 11:37 a.m., the temperature in the 400 Hallway was 82.2 F.
Level of Harm - Immediate
jeopardy to resident health or
safety
On 5/20/25 at 11:40 a.m., Resident #4's room temperature was 82.0 F.
On 5/20/25 at 11:42 a.m., room [ROOM NUMBER]'s temperature (with a window air conditioning unit) was
81.6 F.
Residents Affected - Some
On 5/20/25 at 3:09 p.m., Resident #4 was observed in his room. In an interview, Resident #4 complained
about the heat. He said, It's too hot. It's been hot for about two weeks. At night it's bad, it's hard to sleep.
The resident's room temperature obtained during the interview was 83.5 F.
On 5/20/25 at 3:14 p.m., Resident #2's room temperature was 84.0 F.
On 5/20/25 at 3:16 p.m., room [ROOM NUMBER]'s temperature was 84.3 F.
On 5/20/25 at 3:18 p.m., the temperature was 83.4 F in the activity area of the Memory Care Unit.
On 5/20/25 at 3:21 p.m., in an interview, the Administrator stated that teh new Maintenance Director had
experience with repairing air-conditioning. They said tried to refurbish the air conditioning units instead of
replacing them. He said they did routine maintenance of the air conditioning units. When they catch an
issue, they address it.
On 5/20/25, the temperature in random residents' rooms revealed:
On 5/20/25 at 3:24 p.m., room [ROOM NUMBER]'s temperature was 84.0 F.
On 5/20/25 at 3:25 p.m., room [ROOM NUMBER]'s temperature was 84.3 F.
On 5/20/25 at 3:28 p.m., Resident #3's room temperature was 83.4 F.
On 5/20/25 at 3:32 p.m., Resident #1's room temperature was 81.3 F. The room had an air conditioning
window unit. Resident #1's roommate was observed in bed and was not able to answer interview questions.
On 5/20/25 at 3:34 p.m., room [ROOM NUMBER]'s temperature was 82.2 F.
On 5/20/25 at 3:37 p.m., the temperature was 82.7 F in television room of the 500 hallway.
On 5/20/25 at approximately 3:45 p.m., in an interview, the Director of Nursing (DON) discussed measures
implemented to ensure residents' comfort and minimize the risk of complications from prolonged heat
exposure.
The DON said she just implemented a safety plan today at 3:30 p.m. as the temperatures were never as
high as they have been today. The DON said she did not have documentation verifying that the
temperatures in the residents' rooms have not been as high as they have been today. She verified the
interventions listed in the facility's Safety Plan Elevated Temperatures-Heat were not implemented until
5/20/25 at 3:30 p.m.
The DON provided a document titled, Safety Plan Elevated Temperatures-Heat which noted:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 4 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 - Immediate
jeopardy to resident health or
safety
1. Dedicated staff member to pass ice/water/cool cloths throughout the day/night. Please be sure staff are
staying hydrated as well.
2. Offer popsicles, ice cream etc.
3. Nursing: Please take VS (Vital Signs) to include temperature every four hours.
Residents Affected - Some
4. Any resident who shows any change in condition or s/s (signs and symptoms) of being overheated send
to the hospital.
5. Record ambient temperatures in various areas of the bld. (building), and resident rooms. Be sure to keep
a record. If resident rooms are above 81 degrees, please move to a cool zone or cooler area of the facility.
6. Keep blinds closed to help keep the area as cool as possible.
On 5/20/25 at 5:05 p.m., in an interview, Resident #5 said she has been the Resident Council President for
the past six months and the temperature has been an issue for the past six months. She said, A gamut of
issues was raised in the meetings. The temperature was always a concern. She said, If it wasn't too hot, it
was too cold. It was never tempered, never. Resident #5 said, Who can sleep when all you want to do is
strip naked and get in ice. The temperature has never been regulated here, ever. It's been coming up every
month in the meetings. They don't really do anything, it's never comfortable.
Resident #5's room temperature was 81.6 F. Resident #5 said the room always feels warm. She said it was
not a comfortable temperature for her, It's hot for a very small space, with the bathroom door closed, the
hallway door opened and the blinds closed at all times. She said, If I open the blinds, it would be worse than
a sauna.
Review of the Resident Council Minutes from January 2025 through April 2025 revealed:
On 1/23/25, Temperature [sic] in [NAME] wing need replacing was documented under Old business.
Heat and temps are not 71 or higher and being addressed today .
On 2/20/25, Heat and temps being addressed was documented under old business, and AC unit being
fixed under New Business.
On 3/20/25, there was no update documented about the AC unit being fixed under old business. 500 hall
needs AC compressor but hallway is comfortable temps. Was documented under New business.
On 4/17/25, Temps: Regulation temps 71-81 degrees. Working on AC units on 500 and [NAME] halls.
On 5/21/25 at 4:20 p.m., in an interview, the Administrator said on 4/10/25 they noticed the air conditioning
unit of the 500 hallway was not working. The Maintenance Director was able to repair it and it worked for
about 2.5 weeks. On 4/28/25, the air conditioning unit of the 500 and 700 hallway went down. The
Maintenance Director was not able to repair either unit. On 4/28/25, they installed window air conditioning
units in the residents' rooms on the 500 hallway. He said the residents' rooms in the 700 hallway stayed
cool since they were on a separate air conditioning unit. He said on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 5 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 - Immediate
jeopardy to resident health or
safety
5/20/25 the central air conditioning unit of the 400 hallway stopped working. The Maintenance Director was
not able to fix it and they installed window air conditioning units in the residents' rooms. He said they have a
quote from an outside vendor to replace and or repair the broken central units with an anticipated start date
of 6/2/25.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 6 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
Residents Affected - Some
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The
immediate actions implemented by the facility and verified by the survey team on 5/24/25 included:
On 5/24/25 verified through observation that the facility placed portable air conditioners and chillers
throughout the facility to maintain temperatures between 71 and 81 degrees.
On 5/24/25, verified through resident interviews that the residents feel the temperature is now comfortable
throughout the facility including in the resident rooms.
On 5/24/25 at 10:30 a.m., temperatures were taken throughout the facility and verified to be within the
temperature range of between 71 and 81 degrees.
On 5/24/25 at 1:00 p.m., temperatures were taken throughout the facility and verified to be within the
temperature range of between 71 and 81 degrees.
On 5/24/25 at 5:00 p.m., temperatures were taken throughout the facility and verified to be within the
temperature range of between 71 and 81 degrees.
The facility is and will continue to maintain hourly temperature logs until all air conditioner units are
repaired.
On 5/24/25, facility wide staff abuse/neglect education verified through staff interview and record review of
post-test results. All staff interviewed were able to explain the education. No staff will be permitted to work
until they are reeducated on Abuse and Neglect policies. The education included not immediately reporting
to the Administrator when a resident's room is at or above 81 degrees is considered Neglect. Education
included a written competency test to include who and when to notify when a resident room is at or above
81 degrees. It also included information on where the cool zones are located, and failure to report is
considered neglect.
Based on observation, record review, residents and staff interviews, the facility failed to protect residents'
right to be free from neglect by failing to take immediate and appropriate actions to maintain comfortable
and safe temperature levels throughout the facility when the central air conditioning units of the 400 hall,
the 500 hall and the 700 hall common area broke.
The facility neglected to implement their Emergency Preparedness Plan by failing to initiate appropriate
measures to ensure residents' comfort and minimize the risk for hyperthermia (abnormally high body
temperature).
On 4/28/25 the central air conditioning unit for the 500 hall broke. The facility installed window air
conditioning units in residents' rooms in the 500 hall but failed to monitor the rooms' temperature to ensure
it remained at a safe and comfortable range.
On 5/19/25 the central air conditioning unit for the 400 hall broke. The facility failed to implement immediate
and appropriate actions to maintain a safe and comfortable temperature range in residents' rooms and
common areas.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 7 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
On 5/20/25 at multiple times throughout the day, the temperature in random residents' rooms in the 400
hall, 500 hall (with window air conditioning units), room [ROOM NUMBER] and the common area of the 700
hall measured between 81.3 degrees to 84.3 degrees Fahrenheit (F).
On 5/20/25 during interviews, Residents #2, #3, #4, and #5 complained the temperature has been
excessively hot and uncomfortable for at least a few days.
Residents Affected - Some
The facility neglect to maintain safe and comfortable temperature levels for residents created a likelihood of
serious harm or death of residents from prolonged heat exposure which can result in heatstroke,
dehydration, heat exhaustion, and resulted in the determination of Immediate Jeopardy.
On 5/23/25 at 9:30 a.m., the Administrator was notified of the Immediate Jeopardy (IJ) concerns and was
provided the IJ templates.
The findings included:
Cross reference F584 and F835.
Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation with a
revision date of 11/28/2017 revealed, Neglect is the failure of the center, its employees or service providers
to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental
anguish or emotional distress. Examples include but are not limited to . Failure to take precautionary
measures to protect the health and safety of the resident .Prevention. The center is committed to the
prevention of . neglect . The following systems have been implemented: Resident Council .
Review of the Resident Council Minutes from January 2025 through April 2025 revealed:
On 1/23/25, Old business.Temperature [sic] in [NAME] wing need replacing was documented.
Heat and temps are not 71 or higher and being addressed today .
On 2/20/25, Old business. Heat and temps being addressed and New Business . AC (Air Conditioning) unit
being fixed.
On 3/20/25, there was no update documented about the AC unit being fixed under old business. New
business. 500 hall needs AC compressor but hallway is comfortable temps.
On 4/17/25, Temps: Regulation temps 71-81 degrees. Working on AC units on 500 and [NAME] halls.
On 5/20/25 at approximately 9:30 a.m., during an initial tour of the facility, the hallways felt excessively
warm.
A hygrometer (measures temperature and humidity) was used to take the temperature in residents' rooms
and common areas several times throughout the day.
On 5/20/25 at 10:14 a.m., room [ROOM NUMBER]'s temperature was 82.0 Fahrenheit (F).
On 5/20/25 at 10:25 a.m., in an interview, the Administrator said the central air conditioning unit
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 8 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
in the 500 hallway has been down since early April. He said they installed air conditioning window units to
the residents' rooms to keep the temperature between 76.0 degrees F and 77.0 degrees F. He said the
central air conditioning unit of the 400 hallway went down early this morning. He said both units needed
either a new compressor or needed to be replaced. The Administrator said they took temperatures twice a
month and provided a temperature monitoring log for January 2025, February 2025, March 2025, April
2025 and May 1, 2025.
Residents Affected - Some
Review of the temperature monitoring logs for January 2025 through May 2025 revealed each log included
a column for temperature in the morning and a column for temperature in the evening. the temperature was
documented twice a day (morning and afternoon), two times a month in the following areas:
The 300, 400, 600, 700, and 800 hallways.
The Main Dining Room, the Therapy gym, the Activities room, the East, and [NAME] Nurses Stations, East
and [NAME] Day Rooms.
For January 2025 the log noted, Date: Jan-2025 1-10.
[DATE]-24 was written above the temperature obtained in the morning from 8:00 a.m. to 8:50 a.m. The
temperature ranged from 72.0 F to 80.0 F.
[DATE]-31 was written above the temperature obtained in the afternoon from 5:00 p.m. to 5:20 p.m. The
temperature ranged from 72.0 F to 80.0 F.
For February 2025 the log noted, Date: 2-3-2025.
2-3-25 2-14 was written above the the column for the temperature documented for 8:00 a.m. The
temperature ranged from 71.0 F to 80.0 F.
2-17 2-28-25 was written above the column for the temperature documented for 8:00 p.m. The temperature
ranged from 71.0 F to 80.0 F.
For March 2025 the log noted, Date: 3/1/2025.
3-2- 3/14/25 was written above the column for the temperature documented at 8:00 a.m. The temperature
ranged from 72.0 F to 80.0 F.
3-16-3-30 was written above the column for the temperature documented for 8:00 p.m. The temperature
ranged from 73.0 F to 80.0 F.
For April 2025 the log noted, Date: 4/1/2025.
4-1-12 was written above the column for the temperature documented for 8:00 a.m. The temperature
ranged from 73.0 F to 80.0 F.
4-13-30 was written above the column for the temperature documented for 8:00 p.m. The temperature
ranged from 71.0 F to 80.0 F.
For May 2025, the log noted, Date: 5-1-2025.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 9 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0600
5-1-2025 was written above the column for the temperature documented for 8:00 a.m. the temperature
ranged from 74.0 F to 80.0 F.
Level of Harm - Immediate
jeopardy to resident health or
safety
No date range or time was documented above the second column for the temperature range of 74.0 F to
80.0 F.
Residents Affected - Some
The log did not include the temperature in residents' rooms.
On 5/20/25 at 11:15 a.m., Resident #2 was observed in her room on the 400 hallway. In an interview,
Resident #2 said her room was a bit hot. Resident #2 said, Last night was terrible, I was cooking (indication
of body heat) , it felt like I showered. It's been hot like this for a few days. The room temperature obtained
during the interview was 82.2 F.
On 5/20/25 at 11:34 a.m., Resident #3 was observed in his room on the 400 hallway. In an interview,
Resident #3 said, It's hot, it's hot, I am sweating. I had to come in the hallway to cool off. I stayed by the fan,
not moving around. I thought the hallway would be cooler but it's not. It was hot yesterday, I sweated my ass
off all day and all night. The temperature obtained during the interview was 82.4 F.
On 5/20/25 at 11:40 a.m., Resident #4's room temperature was 82.0 F.
On 5/20/25 at 11:42 a.m., room [ROOM NUMBER]'s temperature (with a window air conditioning unit) was
81.6 F.
On 5/20/25 at 1:01 p.m., in an interview, the Administrator said it was an old building with 20 different
central units that were all aged, except one that was installed last fall. He said monitoring temperature
levels has been ongoing. He said they had complaints regarding issues with the air conditioning in the 500
hall. They rectified it right away with window units so room temperatures were comfortable.
On 5/20/25 at 3:09 p.m., Resident #4 was observed in his room (with a window air conditioning unit). The
room temperature was 83.5 F. Resident #4 complained about the heat. He said, It's too hot. It's been hot for
about two weeks. At night it's bad, it's hard to sleep.
On 5/20/25 at 3:18 p.m., the temperature was 83.4 F in the activity area of the Memory Care Unit.
On 5/20/25 at 3:21 p.m., in an interview, the Administrator said the new Maintenance Director knows air
conditioning. They try to refurbish the air conditioning units instead of replacing them. He said they did
routine maintenance of the air conditioning units and when they catch an issue, they address it.
Review of the Work Order Tracking Log revealed on 4/28/25 the central Air Conditioning of the 500 central
unit and the 700 Main Hall were Down. Unable to repair was written under repair date.
The log noted on 4/28/25 window units were placed in each resident's room. The facility had no
documentation the residents' room temperature levels were monitored to ensure the window air
conditioning units maintained a safe temperature level between 71.0 F to 81.0 F.
The Administrator provided estimates from an outside heating and cooling company dated April 28,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 10 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0600
2025, and May 16, 2025, to remove and replace the 700 hall compressor and replace the 500 hall unit.
Level of Harm - Immediate
jeopardy to resident health or
safety
On May 16, 2025, the estimate noted the project was approved with an anticipated start date of 6/2/25.
Residents Affected - Some
On 5/20/25 at 3:24 p.m., room [ROOM NUMBER]'s temperature was 84.0 F.
Random temperatures obtained on 5/20/25 after 3:00 p.m., revealed:
On 5/20/25 at 3:25 p.m., room [ROOM NUMBER]'s temperature was 84.3 F.
On 5/20/25 at 3:28 p.m., Resident #3's room temperature was 83.4 F.
On 5/20/25 at 3:32 p.m., Resident #1's room temperature was 81.3 F. The room had an air conditioning
window unit. Resident #1's roommate was observed in bed and was not able to answer to interview
questions.
On 5/20/25 at 3:34 p.m., room [ROOM NUMBER]'s temperature was 82.2 F.
On 5/20/25 at 3:37 p.m., the temperature was 82.7 F in the television room of the 500 hallway.
On 5/20/25 at approximately 3:45 p.m., in an interview, the Director of Nursing (DON) discussed measures
implemented to prevent the neglect of residents, ensure each resident's comfort and minimize the risk of
complications from prolonged heat exposure.
The DON said she just implemented the safety plan, today at 3:30 p.m. as the temperatures were never as
high as they have been today.
The DON said she did not have documentation the residents' rooms temperature levels were monitored
and had not been as high as they have been today. She verified the interventions listed in the facility's
Safety Plan Elevated Temperatures-Heat were not implemented until 5/20/25 at 3:30 p.m.
The DON provided a document titled, Safety Plan Elevated Temperatures-Heat.
Review of the Safety Plan Elevated Temperatures-Heat documents revealed:
1. Dedicated staff member to pass ice/water/cool cloths throughout the day/night. Please be sure staff are
staying hydrated as well.
2. Offer popsicles, ice cream etc.
3. Nursing: Please take VS (Vital Signs) to include temperature every four hours.
4. Any resident who shows any change in condition or s/s (signs and symptoms) of being overheated send
to the hospital.
5. Record ambient temperatures in various areas of the bld. (building), and resident rooms. Be sure to keep
a record. If resident rooms are above 81 degrees, please move to a cool zone or cooler area
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 11 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0600
of the facility.
Level of Harm - Immediate
jeopardy to resident health or
safety
6. Keep blinds closed to help keep the area as cool as possible.
Residents Affected - Some
On 5/20/25 at 5:05 p.m., in an interview, Resident #5 said she has been the Resident Council President for
the past six months and the temperature has been an issue for the past six months. She said, A gamut of
issues was raised in the meetings. The temperature was always a concern. She said, If it wasn't too hot, it
was too cold. It was never tempered, never. Resident #5 said, Who can sleep when all you want to do is
strip naked and get in ice. The temperature has never been regulated here, ever. It's been coming up every
month in the meetings. They don't really do anything, it's never comfortable.
During the interview, Resident #5's room temperature was 81.6 F. The room felt warm. Resident #5 said the
room always feels warm. She said it was not a comfortable temperature for her, It's hot for a very small
space, with the bathroom door closed, the hallway door opened and the blinds closed at all times. She said,
If I open the blinds, it would be worse than a sauna.
On 5/21/25, the Administrator provided a document titled, Indian Beach Center A/C (Air Conditioning)
Timeline that included:
4/28/2025: Both 500 Central AC unit and 700 Day room Central AC unit stopped working.
4/28/2025: (Outside company) called for service. They were unable to repair either unit. Their
recommendation was to replace the 500 Central AC unit and replace the compressor for the 700 unit.
4/28/2025: Room air temps on the 700 unit are in range in the mid-70s F. Appropriate Temperatures for the
unit maintained as the residents' rooms units are working and keeping the whole unit cool. Day room
temperatures are In the Mid 70' F range.
Resident Rooms 501, 502, 503, 504 and 505 require window Acs. Each room has a window AC placed in
the window. Proper room temperatures are maintained.
4/28/2025: The center received a quote and approval from (outside AC company) for new Central AC unit
for 500 unit and New Compressor for 700 unit. Estimated start Date for project is contingent on delivery of
the Units.
5/16/2025: (Outside AC company) sent confirmation the project for 500 Unit and 700 unit will begin on/or
about 6/2/2025.
5/20/2025: 400 Central Unit stopped working. Center staff was unable to resolve. The issue appears to be
the compressor will require replacement. The Affected rooms are rooms 401, 402, 403, 404, 406, and 408.
The center purchased and placed window ACs in residents' rooms 401, 402, 403, 404, 406 and 408. The
center also rented two large Portable AC units. One was placed in the 400 Hallway. The second was placed
in the 700 Unit Hallway.
5/20/25: The center implemented the emergency weather Plan. The center initiated hourly Temperature
checks throughout the center.
On 5/22/25 at 11:55 a.m., in an interview, the Administrator said he thought they were doing
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 12 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0600
Level of Harm - Immediate
jeopardy to resident health or
safety
temperature logs twice a week. He said the routine schedule for the temperatures was supposed to be
Mondays and Thursdays.
When asked about taking residents' rooms temperature to ensure they were at a safe and comfortable
level, the Administrator said, If there is a high temperature out in the hallway, then they know to go check in
the residents rooms.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 13 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0835
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Level of Harm - Immediate
jeopardy to resident health or
safety
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The
immediate actions implemented by the facility and verified by the survey team on 5/24/25 included:
Residents Affected - Some
On 5/24/25 verified through observation that the facility placed portable air conditioners and chillers
throughout the facility to maintain temperatures between 71 and 81 degrees.
On 5/24/25, verified through resident interviews that the residents feel the temperature is now comfortable
throughout the facility including in the resident rooms.
On 5/24/25 at 10:30 a.m., temperatures were taken throughout the facility and verified to be within the
temperature range of between 71 and 81 degrees.
On 5/24/25 at 1:00 p.m., temperatures were taken throughout the facility and verified to be within the
temperature range of between 71 and 81 degrees.
On 5/24/25 at 5:00 p.m., temperatures were taken throughout the facility and verified to be within the
temperature range of between 71 and 81 degrees.
The facility is and will continue to maintain hourly temperature logs until all air conditioner units are
repaired.
On 5/24/25, verified that on 5/20/2025 education was completed with the Administrator and Director of
Nursing (DON) by the [NAME] President of Clinical Operations. The education included their responsibility
to implement the facility excessive heat emergency plan r/t broken air conditioning units. The education also
included the monitoring process and notification procedure to the Chief Executive Officer/Chief Nursing
Officer and to ensure residents are provided with a clean, comfortable environment.
The Chief Nursing officer educated the Administrator and DON on their job descriptions 5/20/2025. The
Administrator and DON understand they are responsible to ensure proper temperatures in the center are
maintained and residents reside in a safe, comfortable environment.
On 5/24/25, reviewed the agenda and staff sign in page for the Quality Assurance and Performance
Improvement (QAPI) meeting held 5/23/25. The agenda included a review of the effected regulations and
implementation of the facilities Excessive Heat Emergency Plan.
Based on observation, record review, residents and staff interview, the facility Administration failed to utilize
its resources effectively and efficiently to protect the residents' right to be free from neglect by failing to take
immediate and appropriate actions to maintain a safe and comfortable temperature level throughout the
facility and in residents' rooms when the central air conditioning units of the 400 hall, the 500 hall and the
700 hall common area broke.
Review of the resident council meeting minutes from January through April 2025 noted concerns with the
temperature and the air conditioning units not working. Each month the meeting minutes noted the
concerns were being addressed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 14 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0835
On 4/28/25 the facility administration was aware the central air conditioning unit for the 500 hall broke and
the common area of the 700 hall broke.
Level of Harm - Immediate
jeopardy to resident health or
safety
On 5/19/25 the facility administration was aware the central air conditioning of the 400 hall broke.
Residents Affected - Some
The facility administration contracted with an outside company to make the necessary repairs but failed to
implement immediate and effective measures to maintain a safe and comfortable temperature until the air
conditioning units could be repaired or replaced on June 2, 2025.
On 5/20/25 at multiple times throughout the day, the temperature in random residents' rooms in the 400
hall, 500 hall (with window air conditioning units), room [ROOM NUMBER] and the common area of the 700
hall measured between 81.3 degrees to 84.3 degrees Fahrenheit (F).
On 5/20/25 during interviews, Residents #2, #3, #4, and #5 complained the excessive heat has been
ongoing for weeks and the facility has not addressed their concerns.
The facility administration failure to address residents' concerns and the failure to utilize resources
effectively to ensure a safe and comfortable temperature for all residents created a likelihood of serious
harm, or death of residents due to prolonged exposure to excessive heat and resulted in the determination
of Immediate Jeopardy.
On 5/23/25 at 9:30 a.m., the Administrator was notified of the Immediate Jeopardy (IJ).
The findings included:
Cross reference F584 and F600.
Review of the Administrator's job description signed and dated 9/1/23 revealed, The primary purpose of the
Executive Director (Administrator) is to direct the day-to-day functions of the facility in accordance with
current federal, state, and local standards, guidelines and regulations that govern nursing facilities to
ensure that the highest degree of quality care can be provided to our residents at all times .Duties and
Responsibilities . Ensure a safe, clean and comfortable environment for residents . Resident Rights .
Review resident complaints and grievances and make written reports of action taken. Discuss such actions
with residents and family as appropriate .
Review of the Director of Nursing's job description signed and dated 9/28/23 revealed, As the company
Director of Nursing, you are entrusted with the responsibility of caring for our residents . The primary
purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing
Service Department in accordance with current federal, state, and local standards, guidelines, and
regulations that govern our facility, and as may be directed by the Executive Director to ensure that the
highest degree of quality care is maintained at all times . Job functions . You will assume the primary role in
ensuring the delivery of high quality, efficient nursing care .
Review of the Resident Council Minutes from January 2025 through April 2025 revealed:
On 1/23/25, Temperature [sic] in [NAME] wing need replacing was documented under Old business.
Heat and temps are not 71 or higher and being addressed today .
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 15 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0835
On 2/20/25, Heat and temps being addressed was documented under old business, and AC unit being
fixed under New Business.
Level of Harm - Immediate
jeopardy to resident health or
safety
On 3/20/25, there was no update documented about the AC unit being fixed under old business. Under
New business, 500 hall needs AC compressor but hallway is comfortable temps was documented.
Residents Affected - Some
On 4/17/25, Temps: Regulation temps 71-81 degrees. Working on AC units on 500 and [NAME] halls.
On 5/20/25 at approximately 9:30 a.m., during an initial tour of the facility, the hallways felt excessively
warm.
On 5/20/25 at 10:14 a.m., room [ROOM NUMBER]'s temperature was 82.0 Fahrenheit (F).
On 5/20/25 at 10:25 a.m., in an interview, the Administrator said the central air conditioning unit in the 500
hallway has been down since early April. He said they installed air conditioning window units to the
residents' rooms to keep the temperature between 76.0 degrees F and 77.0 degrees F. He said the central
air conditioning unit of the 400 hallway went down early this morning. He said both units needed either a
new compressor or needed to be replaced.
On 5/20/25 at 11:15 a.m., Resident #2 was observed in her room on the 400 hallway. In an interview,
Resident #2 said her room was a bit hot. Resident #2 said, Last night was terrible, I was cooking (indication
of body heat), it felt like I showered. It's been hot like this for a few days. The room temperature obtained
during the interview was 82.2 F.
On 5/20/25 at 11:34 a.m., Resident #3 was observed in his room on the 400 hallway. In an interview,
Resident #3 said, It's hot, it's hot, I am sweating. I had to come in the hallway to cool off. I stayed by the fan,
not moving around. I thought the hallway would be cooler but it's not. It was hot yesterday, I sweated my ass
off all day and all night. Resident #3's room felt warm. The temperature obtained during the interview was
82.4 F.
On 5/20/25 at 11:40 a.m., Resident #4's room temperature was 82.0 F.
On 5/20/25 at 11:42 a.m., room [ROOM NUMBER]'s temperature (with a window air conditioning unit) was
81.6 F.
On 5/20/25 at 1:59 p.m., in an interview, the Food Service Director said he helps in the maintenance
department with translation. He said 9 window units were purchased and will be installed in residents'
rooms on the 400 hallway in the afternoon. He said, Long term we have 3 new units approved by the
corporate office. They are ordered, waiting to be delivered, I don't know the exact day.
On 5/20/25 at 3:09 p.m., Resident #4 was observed in his room (with a window air conditioning unit). In an
interview, Resident #4 complained about the heat. He said, It's too hot. It's been hot for about two weeks. At
night it's bad, it's hard to sleep. The resident's room temperature obtained during the interview was 83.5 F.
On 5/20/25 at 3:18 p.m., the temperature was 83.4 F in the activity area of the Memory Care Unit.
Random temperatures obtained on 5/20/25 after 3:00 p.m., revealed:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 16 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0835
On 5/20/25 at 3:24 p.m., room [ROOM NUMBER]'s temperature was 84.0 F.
Level of Harm - Immediate
jeopardy to resident health or
safety
On 5/20/25 at 3:25 p.m., room [ROOM NUMBER]'s temperature was 84.3 F.
Residents Affected - Some
On 5/20/25 at 3:32 p.m., Resident #1's room temperature was 81.3 F. The room had an air conditioning
window unit. Resident #1's roommate was observed in bed and was not able to answer to interview
questions.
On 5/20/25 at 3:28 p.m., Resident #3's room temperature was 83.4 F.
On 5/20/25 at 3:34 p.m., room [ROOM NUMBER]'s temperature was 82.2 F.
On 5/20/25 at 3:37 p.m., the temperature was 82.7 F in the television room of the 500 hallway.
On 5/20/25 at approximately 3:45 p.m., in an interview, the Director of Nursing (DON) discussed measures
implemented to ensure each resident's comfort and minimize the risk of complications from prolonged heat
exposure.
The DON said she just implemented a safety plan, today at 3:30 p.m. as the temperatures were never as
high as they have been today.
Review of the document titled, Safety Plan Elevated Temperatures-Heat provided by the DON revealed,
1. Dedicated staff member to pass ice/water/cool cloths throughout the day/night. Please be sure staff are
staying hydrated as well.
2. Offer popsicles, ice cream etc.
3. Nursing: Please take VS (Vital Signs) to include temperature every four hours.
4. Any resident who shows any change in condition or s/s (signs and symptoms) of being overheated send
to the hospital.
5. Record ambient temperatures in various areas of the bld. (building), and resident rooms. Be sure to keep
a record. If resident rooms are above 81 degrees, please move to a cool zone or cooler area of the facility.
6. Keep blinds closed to help keep the area as cool as possible.
The DON said she did not have documentation verifying that the temperatures in the residents' rooms have
not been as high as they have been today. She verified the interventions listed in the facility's Safety Plan
Elevated Temperatures-Heat were not implemented until 5/20/25 at 3:30 p.m.
On 5/20/25 at 5:05 p.m., in an interview, Resident #5 said she has been the Resident Council President for
the past six months and the temperature has been an issue for the past six months. She said, A gamut of
issues was raised in the meetings. The temperature was always a concern. She said, If it wasn't too hot, it
was too cold. It was never tempered, never. Resident #5 said, Who can sleep when all you want to do is
strip naked and get in ice. The temperature has never been regulated here,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 17 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0835
ever. It's been coming up every month in the meetings. They don't really do anything, it's never comfortable.
Level of Harm - Immediate
jeopardy to resident health or
safety
Resident #5's room temperature was 81.6 F. The room felt warm. Resident #5 said the room always feels
warm. She said it was not a comfortable temperature for her, It's hot for a very small space, with the
bathroom door closed, the hallway door opened and the blinds closed at all times. She said, If I open the
blinds, it would be worse than a sauna.
Residents Affected - Some
On 5/21/25 at 4:20 p.m., the Administrator provided a document titled, Indian Beach Center A/C (Air
Conditioning) Timeline. In an interview the Administrator said they noticed the 500 AC unit was not working
on 4/10/25. Facility maintenance was able to repair it at that time and it worked for about 2.5 weeks. On
4/28/25 both the 500 unit and 700 unit went down. Maintenance was unable to repair either of those units.
On 4/28 window units were placed in the 500 hall rooms. In the 700 hall each of the residents' rooms was
on a separate unit so the rooms stayed cool. On 5/20/25 the 400 hall central unit stopped working and
maintenance was unable to fix. Window units were installed in the rooms. He said they had received a
quote from an outside vendor to repair/replace with an anticipated start date of 6/2/25.
Review of the document titled, Indian Beach Center A/C (Air Conditioning) Timeline revealed,
4/28/2025: Both 500 Central AC unit and 700 Day room Central AC unit stopped working.
4/28/2025: (Outside company) called for service. They were unable to repair either unit. Their
recommendation was to replace the 500 Central AC unit and replace the compressor for the 700 unit.
4/28/2025: Room air temps on the 700 unit are in range in the mid-70s F. Appropriate Temperatures for the
unit maintained as the residents' rooms units are working and keeping the whole unit cool. Day room
temperatures are In the Mid 70' F range.
Resident Rooms 501, 502, 503, 504 and 505 require window Acs. Each room has a window AC placed in
the window. Proper room temperatures are maintained.
4/28/2025: The center received a quote and approval from (outside AC company) for new Central AC unit
for 500 unit and New Compressor for 700 unit. Estimated start Date for project is contingent on delivery of
the Units.
5/16/2025: (Outside AC company) sent confirmation the project for 500 Unit and 700 unit will begin on/or
about 6/2/2025.
5/20/2025: 400 Central Unit stopped working. Center staff was unable to resolve. The issue appears to be
the compressor will require replacement. The Affected rooms are rooms 401, 402, 403, 404, 406, and 408.
The center purchased and placed window ACs in residents' rooms 401, 402, 403, 404, 406 and 408. The
center also rented two large Portable AC units. One was placed in the 400 Hallway. The second was placed
in the 700 Unit Hallway.
Review of the temperature monitoring logs for January 2025 through May 2025 revealed the temperature
was documented twice a day (morning and afternoon), two times a month in the following areas:
The 300, 400, 600, 700, and 800 hallways.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 18 of 19
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
105774
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Indian Beach Nursing and Rehab Center
1755 18th St
Sarasota, FL 34230
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 0835
Level of Harm - Immediate
jeopardy to resident health or
safety
The Main Dining Room, the Therapy gym, the Activities room, the East, and [NAME] Nurses Stations, East
and [NAME] Day Rooms.
The temperature range was 71.0 F to 80.0 F.
The most recent temperatures were on May 1, 2025, and ranged from 74.0 F to 80.0 F.
Residents Affected - Some
The log did not include temperature in residents' rooms.
On 5/22/25 at 11:55 a.m., in an interview, the Administrator said he thought they were doing temperature
logs twice a week. He said the routine schedule for the temperatures was supposed to be Mondays and
Thursdays. When asked about taking residents' rooms temperature to ensure they were at a safe and
comfortable level, the Administrator said, If there is a high temperature out in the hallway, then they know to
go check in the residents rooms. The Administrator said he attends Resident Council meetings with an
agenda and talks to the residents about the maintenance issues they are working on. The Administrator
said, I know my residents extremely well, none of those meetings I've been to have the residents brought
up the temperature.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105774
If continuation sheet
Page 19 of 19
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Back to topCitations
3 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.
F835 - Administration
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
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.
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.
FAQ · About this visit
Common questions about this visit
What happened during the May 24, 2025 survey of INDIAN BEACH NURSING AND REHAB CENTER?
This was a inspection survey of INDIAN BEACH NURSING AND REHAB CENTER on May 24, 2025. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at INDIAN BEACH NURSING AND REHAB CENTER on May 24, 2025?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Administer the facility in a manner that enables it to use its resources effectively and efficiently."
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.