F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, review of the facility's policies and procedures, staff and resident interview the facility failed
to implement their policies and procedures and demonstrate ongoing coordination to promote residents'
rights and ensure 1 (Resident #45) of 25 residents reviewed for Advanced Directives accurately reflected
their expressed wishes.
The findings included:
The facility policy Advanced Directives Policy (revised [DATE]) documented Each resident has the right to
be informed and provided written information to all concerning the right to accept, refuse or discontinue
medical treatment, to participate in or refuse to participate in experimental research and the right to
formulate and advanced directive. The facility will provide a written description of the facilities policy to
implement advanced and applicable state law, evaluate and document each residents advance care
planning decision. The facility will evaluate the residents desired code status decision and ensure they are
honored. The facility will document those decisions, and obtain the state required documentation as
needed.
Review of Resident #45's clinical record revealed an admission date of [DATE] with diagnoses including
malignant neoplasm of the parotid gland, dementia, dysphagia, vertigo and dry mouth.
Review of the electronic record revealed a physician order dated [DATE] for Do Not Resuscitate (DNR).
Review of the paper chart showed Resident #45 had a yellow DNR order in the front of the chart. Under the
Advanced Directive tab of the chart there was an Advanced Directives Discussion Document that had a
checked box indicating the resident wanted Cardiopulmonary Resuscitation (CPR).
Photographic evidence obtained.
On [DATE] at 3:17 p.m., in an interview Resident #45 said she had wanted to be a full code but since her
caner diagnosis she knows that if there can't be anything done for me then let me go. The resident said she
knew the meaning of DNR and it was what she wanted.
On [DATE] at 3:30 p.m., in an interview Unit Manager Staff A confirmed the residents chart contained both
an advanced directive form signed [DATE] that documented the resident wanted to be a full code and the
DNR form dated [DATE].
(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 8
Event ID:
105983
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
105983
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harborview Sarasota
4783 Fruitville Road
Sarasota, FL 34232
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 0578
Level of Harm - Minimal harm
or potential for actual harm
On [DATE] at 3:40 p.m., in an interview the Director of Nursing (DON) confirmed to avoid confusion the
facility should have had Resident #45 complete a new Advanced Directives Discussion Document. The
DON said, oh that was when she first came in she wanted to be a full code. The DNR was signed after, we
would go by the DNR and not the other form. The nurses go by the yellow DNR. It isn't confusing, the
nurses know to follow the yellow DNR.
Residents Affected - Few
Review of the care plan initiated [DATE] (revised [DATE]), documented the resident has advanced
directives. Full Code. Will have advanced directive followed.
On [DATE] at 11:27 a.m., in an interview the DON reviewed Resident #45's care plan and confirmed the
care plan documented the resident was a full code. The DON said once the conflicting documents were
identified I had the Social Service Director do a full house audit to make sure everyone's advanced
directives were correct. The DON said it would not have made a difference if anything had happened to the
resident because the staff have been instructed to open the chart and look for the yellow DNR. They have
to have the yellow DNR, that is what they would go by.
On [DATE] at 8:49 a.m., in an interview the DON said the process for Advanced Directives was at a new
admission the Social Service Director gets involved and speaks with the resident about their wishes. We
have the sheet they sign that want CPR or they don't want CPR. Then we get an order for the yellow sheet
DNR and it goes on the front of the Chart. We make sure everything is signed and put it in the care plan.
Nurses go by the yellow sheet in the front of the chart and 2 nurses check that. They go by the yellow sheet
of paper in the front of the chart. I understand there was the care plan and the advanced directive form
stating a full code but the nurse is only to look for a yellow DNR.
On [DATE] at 9:30 a.m., in an interview Licensed Practical Nurse Staff G said, if a resident coded you get
the chart and you check the Advanced Directive tab to see if they want to be full code or not. Some charts
have a yellow DNR in the front and you check the advanced directive section of the chart. You still check the
Advanced directive form, if they don't have the yellow form, that is how you know what their wishes are.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105983
If continuation sheet
Page 2 of 8
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
105983
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harborview Sarasota
4783 Fruitville Road
Sarasota, FL 34232
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, staff, and resident interviews the facility failed to identify and promptly notify the
physician of a rapid significant weight gain for 1 (Resident #67) of 1 with a diagnosis of congestive heart
failure and observed with swelling of the abdomen, legs, and feet.
Residents Affected - Few
The findings included:
Review of a facility policy titled, Weight Management dated 5/22/23 noted, It is the policy of the facility to
provide care and services related to weight management in accordance to state and federal regulations .
Dietary will evaluate all weights by the seventh of each month. A re-weight will be obtained for any weight
change of +/- (plus or minus) (3) lbs. from the previous weight unless other parameters have been ordered
by the physician .The physician and the resident or resident representative will be notified by the resident's
nurse of any significant unexpected and or unplanned weight changes. The nurse will document the
notification in the resident electronic medical record by completing the Event Report.
Review of the clinical record revealed Resident #67 was admitted to the facility on [DATE]. Diagnoses
included Atrial Fibrillation (type of abnormal heart rhythm), Chronic Kidney Disease, and Chronic
Congestive Heart Failure (chronic condition in which the heart doesn't pump blood as well as it should).
The Quarterly Minimum Data Set (MDS) with a target date of 1/5/24 noted Resident #67 had a Brief
Interview for Mental Status score of 14, indicating intact cognition. Resident #67 was dependent on staff for
toileting, bathing, dressing and personal hygiene.
The MDS noted the resident's weight was 220 pounds (lbs.) at the time of the assessment.
The care plan initiated on 10/13/23 noted the resident had altered cardiovascular status related to
Congestive Heart Failure (CHF), and Atrial Fibrillation. The goal was for the resident to be free from
complications of cardiac problems.
The interventions included to monitor, document and report as needed any signs and symptoms of
coronary artery disease, including shortness of breath, dependent edema (swelling due to excess fluid
collection into body tissues).
Review of the Physicians Encounter note dated 1/30/24 revealed the resident was positive for chronic leg
swelling, positive for cough and shortness of breath. The resident had 2+ edema (three to four millimeters
of depression when pressure is applied) to the lower extremity.
The resident had a wet cough, moderate rales (rattling sound) in the lung bases bilaterally but no wheezing
or respiratory distress.
Resident #67's medications as of 1/20/24 included Bumex 2 milligrams (diuretic used to remove excess
water from the body), 1.5 tablet daily related to Chronic Congestive Heart Failure.
On 2/12/24 at 12:04 p.m., Resident #67 was observed laying in his bed with the head of bed elevated
approximately 30 degrees. Resident #67 was wearing a hospital gown and was covered from the waist
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105983
If continuation sheet
Page 3 of 8
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
105983
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harborview Sarasota
4783 Fruitville Road
Sarasota, FL 34232
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 0684
down. Resident #67's abdomen appeared distended. The resident's face and hands looked puffy.
Level of Harm - Minimal harm
or potential for actual harm
was dressed in a hospital gown and was covered to his waist with sheet and blanket. Resident was
observed to be a large man with a large, distended abdomen. Resident face and hands appeared to be
puffy.
Residents Affected - Few
On 2/12/24 at 12:59 p.m., in an interview Resident #67 said his legs and feet were very swollen and felt it
was an issue. Resident #67 also said he'd like to get up but staff did not get him out of bed very often. He
said he was not able to keep his strength.
On 2/14/24 at 10:40 a.m., two staff members were observed providing extensive assistance to turn
Resident #67 from side to side in bed. Resident #67's legs and feet looked extremely swollen. Resident #67
was apologizing to the staff for not being able to help more.
A review of Resident #67's weight from 12/25/23 through 2/14/24 showed:
12/25/23: 217 lbs. via mechanical lift.
1/4/24: 220 lbs. via mechanical lift. (Gain of 3 lbs. in 10 days)
2/2/24: 230 lbs. via mechanical lift (Gain of 10 lbs. in 29 days)
2/14/24: 244.4 lbs. via mechanical lift (Gain of 14.4 lbs. in 12 days).
Resident #67 had a 27.4 lbs. weight gain from 12/25/23 to 2/14/24.
On 2/14/24 at 2:52 p.m., in an interview Licensed Practical Nurse (LPN) Staff I said Resident #67 had
significant edema in his legs, feet, and abdomen.
On 2/14/24 at 3:20 p.m., in an interview LPN Staff B stated Resident #67's weight has been fluctuating. She
verified Resident #67 experienced a three lbs. weight gain between December and January and an
additional 10 lbs. weight gain between 1/4/24 and 2/2/24.
LPN Staff B said she was aware of the weight gain and stated, I am going to be totally honest with you I did
not get a reweigh on him after the 10 pounds weight gain. I did not notify the dietitian and I did not call the
doctor.
LPN staff B verified she did not follow the facility's weight management policy.
On 2/15/24 at 10:37 a.m., in an interview LPN Staff G said the Restorative Certified Nursing Assistant
(CNA) Staff H obtains the weight and reports it to the Restorative Nurse and the Registered Dietitian.
On 2/15/24 at 10:53 a.m., in an interview CNA Staff H said she does the weekly and monthly weights and
documents them on paper. She said she can see the previous weight. CNA Staff H said, I knew Resident
#67 weight was up so I re-did the weight again right there and it was correct.
CNA Staff H said she gives the weights to LPN Staff B, the restorative nurse who puts them into the
electronic clinical record. CNA Staff H said she was not responsible to report the weights to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105983
If continuation sheet
Page 4 of 8
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
105983
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harborview Sarasota
4783 Fruitville Road
Sarasota, FL 34232
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 0684
Dietitian or the nurse on the cart. She was just supposed to report the weights to the Restorative Nurse.
Level of Harm - Minimal harm
or potential for actual harm
On 2/15/24 at 11:14 a.m., in an interview Resident #67's physician said Resident #67 had cardiorenal
syndrome (acute or chronic problem in the heart and kidneys that could result in acute or chronic problem
of the other) and was delicate. He said he encourages staff to get him out of bed. He should be getting up
at least twice a day. The physician said the facility did not inform him of the weight gain. He said the facility
should have notified him of the 10 lbs. weight gain on February 2nd.
Residents Affected - Few
He would have addressed it right away. The physician said he expected the facility to follow their weight
management policy, and report and weight changes of three lbs.
On 2/15/24 at 12:08 p.m., in a telephone interview, the Registered Dietitian said, I do not have anything to
do with the weight gain if I know the person is a person with water weight gain. I do not address weight gain
or make a note if the weight gain is due to water weight gain. I cannot make notes on every resident that
gains weight due to water weight and not from over amount of food intake.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105983
If continuation sheet
Page 5 of 8
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
105983
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harborview Sarasota
4783 Fruitville Road
Sarasota, FL 34232
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, review of facility's policies and procedures, resident and staff interviews, the facility failed to
maintain respiratory care equipment in accordance with manufacturer's specification for 1 (Resident #59) of
16 residents reviewed with oxygen therapy.
Residents Affected - Few
The findings included:
Review of the facility's policy titled, Physical Environment-Safe Environment dated 10/1/2023 showed
documentation, The facility will maintain all essential mechanical electrical and patient care equipment in
safe operating condition.
Review of the clinical record revealed Resident #59 was admitted to the facility on [DATE].
On 2/12/24 at 10:00 a.m., Resident #59 was observed receiving oxygen through a nasal cannula attached
to an oxygen concentrator (medical device that gives extra oxygen). In an interview, Resident #59 said she
has not seen anyone changing the concentrator's filter.
On 2/13/24 at 4:09 p.m., in an interview the Director of Nursing (DON) said the maintenance department
was responsible for the maintenance of the oxygen concentrators' filters.
Review of the Oxygen Concentrator User Manual provided by the facility noted, Between-Patient
Maintenance: The concentrator must be serviced and reconditioned between patients as follows: . Replace
the cabinet filter and Air In-Take Filter . Weekly caregiver/Patient Maintenance: . Clean the cabinet filter .
Wash the filter with water and mild detergent . Set the filter aside to air dry . Be sure the filter is completely
dry before re-installing .
On 2/13/24 at 4:19 p.m., in an interview the Maintenance Director said the housekeeping department was
responsible to clean the filters.
On 2/13/24 at 4:21 p.m., in an interview the Director of Nursing (DON) said the facility owned the
concentrators. The DON then told the Maintenance Director his department was responsible to clean the
oxygen concentrators' filters. The DON turned to the Administrator and said they needed to write up
something for that.
On 2/15/24 at 11:22 a.m., in an interview the Housekeeping Supervisor said the housekeeping department
only did the terminal cleaning of the oxygen concentrators between residents but they do not replace the
filters. She said they use a multipurpose peroxide cleaner on the outside, remove the filters and wash them
with soap and water. She said once the filter is dry, they put it back on the concentrator and bag the
machine for the next resident's use. The Housekeeping Supervisor said they did not have replacement
filters for the concentrators and did not know who would order them.
On 2/15/24 at 11:26 a.m., in an interview the administrator said she did not know the concentrators needed
a new filter between residents and will be ordering the filters.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105983
If continuation sheet
Page 6 of 8
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
105983
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harborview Sarasota
4783 Fruitville Road
Sarasota, FL 34232
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.
Based on observation, review of facility's policy and procedure, and staff interview the facility failed to safely
store medications to prevent unauthorized access.
The findings included:
A Review of a facility policy titled, Storage of Medications (no dated) specified,
Policy - Drugs and biologicals should be stored in a safe, secure, and orderly manner.
Policy Interpretation and Implementation
6. drugs and biologicals are locked when not in use and items are not left unattended.
7. Drugs are stored in an orderly manner in cabinets, drawers, or carts.
On 2/13/23 at 8:15 a.m., a large package was observed on a credenza in the front lobby of the facility
approximately five feet from the door. The package was labeled, Pharmacy Returns. The package was next
to the outgoing mailbox located approximately 10-15 feet from the front desk where the receptionist sat.
On 2/13/24 at 8:17 a.m., Receptionist Staff J did not answer when asked about the content, and who was
watching the bag labeled, Pharmacy returns.
On 2/13/24 at 8:18 a.m., in an interview the Administrator stated the medications should be secured and
removed the bag.
On 2/13/24 at 8:20 a.m., the Director of Nursing (DON) verified the unsecured bag labeled Pharmacy
returns contained medications to be returned to the pharmacy.
Observation of the content of the bag with the DON revealed the following medications:
Pravastatin 40 milligrams, 25 tablets (Medication for high cholesterol).
Sertraline 50 milligrams, 11 pills (Medication for depression).
Farxiga 5 milligrams, 14 pills (Medication for chronic kidney disease, heart failure and type 2 diabetes).
Carvedilol 25 milligrams, 30 pills (Medication for high blood pressure).
Carvedilol 25 milligrams, 6 pills (Medication for high blood pressure).
Potassium Chloride 10 milligrams, 27 pills (medication to treat hypokalemia).
Diltiazem 120 milligrams, 21 pills (Medication to treat high blood pressure).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105983
If continuation sheet
Page 7 of 8
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
105983
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/15/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harborview Sarasota
4783 Fruitville Road
Sarasota, FL 34232
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
Albuterol inhaler (Medication to treat breathing problems).
Level of Harm - Minimal harm
or potential for actual harm
Omeprazole 20 milligrams, 27 pills (Medication to treat heartburn, stomach ulcers and reflux disease).
Dicyclomine 20 milligrams, 24 pills (medication to treat gut spasms for irritable bowel syndrome).
Residents Affected - Few
The DON verified the medications on the front lobby credenza were left unsecured and unattended and will
change the process for returning medications to the pharmacy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105983
If continuation sheet
Page 8 of 8