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Inspection visit

Health inspection

HARBORVIEW SARASOTACMS #1059834 citations on this visit
4 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, review of the clinical record, review of facility policy and procedure, and resident, family and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 1(Resident #999) of 3 residents reviewed for activities of daily living.The findings included:Review of the facility policy Activities of Daily Living (ADLs) implemented 3/1/22 (revised 6/1/25) documented, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain grooming, and personal and oral hygiene.Review of the clinical record revealed Resident #999 had an admission date of 1/25/23 with a re-admission date of 8/22/25. Diagnoses included displaced intertrochanteric fracture of right femur on 8/22/25, type 2 diabetes mellitus, dementia, anxiety, and fracture of right femur 2/8/23.Review of the End of Part A stay Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 10/24/25 documented Resident #999 required partial to moderate assistance with oral hygiene, and substantial to maximum assistance with showers/bathing.The MDS noted the resident scored 12 on the Brief Interview for Mental Status, indicating the resident's cognitive skills for daily decision making were moderately impaired.Review of the plan of care revealed Resident #999 had an ADL self-care performance deficit and required assistance of one staff. The interventions included for staff to provide set up, one assist with extensive assistance for personal hygiene and oral care.On 12/8/25 at 9:00 a.m., Resident #999 was observed in bed in his room. The room had a very strong, foul odor of urine. The resident was noted to be unkempt, unshaven with a long scraggly beard and mustache. The bed sheets were soiled with a brown substance. His hair was matted, greasy and uncombed and extended past his ears.On 12/8/25 at 11:00 a.m., in an interview Resident #999 said he has not been shaved or had a hair cut in a very long time. He said he would like to be shaved. Resident #999's teeth had black spots and a thick, white coating. His mouth was dry with foul breath.Review of the clinical record revealed Resident #999's admission photo of a clean-shaven male with no beard or mustache and neatly trimmed hair.Review of the Certified Nursing Assistants (CNA) documentation for October 2025, and November 2025 revealed the resident's scheduled shower days were Mondays and Thursdays on the 7:00 a.m., to 3:00 p.m., shift. There was no documentation Resident #999 received his scheduled showers on 10/2/25, 10/9/25,10/23/25, 11/3/25, 11/6/25, and 11/10/25.On 12/9/25 at 1:45 p.m., in an interview the [NAME] President of Operations said Resident #999 was shaved last evening and just received a haircut. The [NAME] President of Operations said the facility's policy was for staff to shave men two to three times a week or at their preference.On 12/9/25 at 2:40 p.m., in an interview CNA Staff G said men are shaved when they have their shower or if they ask. The CNA said they brush the residents' teeth. If the residents can brush their own teeth, they get things ready and are there to help. Residents Affected - Few Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 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 12/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, record review, review of facility's policies and procedures and staff interviews, the facility failed to have documentation of fall investigations and failed to implement care planned interventions to reduce the risk of avoidable accidents for 1 (Resident #999) of 3 residents reviewed with multiple falls at the facility.The findings included: Review of the facility policy Fall Prevention Program implemented 3/1/22 (revised 1/1/25) revealed, Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.High Risk Protocols:a. The resident may be placed on the facility's Fall Prevention Program.i. Indicate fall risk on care plan.Implement appropriate interventions.c. Provide interventions that address unique risk factors measured by the risk assessment tool.d. Provide additional interventions as directed by the resident's assessment, may include but not limited to:i. Assistive devices.ii. Increased frequency of rounds.iv. Low bed.8. Interventions will be monitored for effectiveness.Review of the clinical record for Resident #999 revealed an admission date of 1/25/23. Diagnoses included Dementia, generalized anxiety disorder, difficulty in walking, abnormalities of gait and mobility, and fracture of the right femur.Review of the fall risk evaluations dated 5/25/25 and 8/17/25 noted Resident #999 was at high risk for falls. Review of the care plan initiated on 1/27/2023 revealed Resident #999 was very impulsive and will not use call light to ask for assistance with transfers and will attempt to self-transfer. Resident #999 would tell his family that he was feeding squirrels through the window in his bedroom and has also shown physical aggression towards staff. The goal was to monitor the resident daily for his behaviors.The care plan initiated on 5/13/25 noted Resident #999 displayed behaviors which include hitting during care, playing in feces, shouting, spitting, tearing things up, yelling out during care, refusing medications and care, and placing self on the floor.The goal was for the resident not to harm self or others daily. The care plan initiated on 1/31/23 and revised on 8/26/25 revealed Resident #999 was at high risk for falls related to gait/balance problems and medications that put him at risk.The care plan noted the resident would not use the call light to ask for assistance with ambulation around his room, to or from the bathroom with or without the use of an assistive device, due to impaired cognition.The goal for Resident #999 was to Minimize the risk of falls through next review date.The care plan noted Resident #999 sustained a fall on 5/12/25, 5/25/25, 7/19/25 and 8/17/25.The interventions included:Bed in lowest locked position. Date initiated: 1/31/23. Revision on 9/30/25.Dycem (non-slip mat) to wheelchair. Date initiated 5/22/23. Revision on 6/25/24.Offer toileting assistance prior to meals. Date initiated 5/25/25. Revision on 8/18/25.Perimeter mattress (mattress with raised borders to help guide the patient back toward the center of the mattress and away from dangerous position near the edge of the bed). Date initiated 4/24/23. Revision on 8/18/25.Review of the progress notes revealed on 5/26/25 at 12:19 a.m., Unwitnessed fall at 1600 [4:00 p.m.], without severe injury. Abrasions on bilateral legs. Patient was found in room on [sic] sitting in front of door.On 5/28/25, an interdisciplinary progress note documented the resident was reviewed related to fall. Resident is identified as a fall risk related to behavior of placing self on floor, aggression, and unstable gait. Resident is noncompliant with requesting assistance and requires frequent cueing. Resident will be offered toileting assistance prior to meals in an attempt to reduce risk of falls.The progress note did not include the root cause of the fall to determine toileting assistance before meals was an appropriate intervention to prevent further falls.On 7/19/25 at 10:08 p.m., a nursing progress note documented the Certified Nursing Assistant found Resident #999, with head and upper body on floor and feet still on bed. Resident alert with confusion cannot explain what happened. No visible (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 2 of 7 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 12/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hematoma (collection of blood outside of blood vessels), skin tear noted to R (right) leg behind the knee. EMS [Emergency Medical Services] called . The resident was taken to a local hospital via stretcher.On 7/21/25 a progress note documented the resident was reviewed by the Interdisciplinary Team related to safety. Resident had a fall from the bed on 7/19/25. Resident with diagnosis of confusion and unable to verbalize cause of fall. Interventions in place at time of fall include bed maintained in lowest position while occupied with fall recovery matt at bedside in an attempt to prevent injury in the event of a fall, resident is offered toileting assistance prior to meals, and nonskid footwear is provided. Intervention for this event is that when staff place resident to bed for HS (bedtime), and HS snack is offered and comfort needs ensured prior to leaving room .The progress note did not document that the perimeter mattress initiated on 4/24/23 was in place at the time of the fall.On 8/17/25 at 9:46 p.m., a nursing progress noted, Unwitnessed fall, the patient was found behind his room door seated. Vitals WNL (within normal limits), no injuries noted. Alert to self.On 8/18/25 a progress note documented the resident was reviewed by the interdisciplinary team for safety. Resident had an unwitnessed fall on 8/17/25. Current interventions include: resident's bed maintained in lowest position while occupied, Dycem is in w/c (wheelchair) to prevent slipping, bilateral assist rails to bed frame to promote independence with bed mobility. Resident provided toileting assistance prior to meals, and nonskid footwear. Current interventions are providing toileting assistance prior to returning to bed . Will continue to monitor per facility's guidelines for effectiveness of interventions and need for additional interventions.The progress notes did not include a root cause of the incident or specify if the resident was in a wheelchair or the bed with the perimeter mattress in use before the fall.On 8/18/25 a post fall progress note documented Resident #999 was complaining of pain to the right leg.On 8/19/25 an X-ray of the right femur documented findings of an acute intertrochanteric right femoral fracture.On 8/19/25, Resident #999 was transferred to an acute care hospital for evaluation. Resident #999 underwent a surgical repair of the right femur fracture.On 8/22/25 a nursing progress note documented Resident #999 returned to the facility. Bilateral rails were in place to promote independence with bed mobility. Perimeter mattress in place to increase awareness of parameters of bed surface. Ensured a pair of nonskid footwear were in the room. The call light was placed within reach of the resident and demonstrated usage. Bed was placed in the lowest position. Staff was reminded that toileting assistance will be offered at bedtime and meals.Review of the End of Part A Stay Minimum Data Set (MDS) assessment with a reference date of 10/24/25 revealed Resident #999 scored 12 on the Brief Interview for Mental Status, indicating moderate cognitive impairment.The MDS noted the resident required partial to moderate assistance to come to a standing position from sitting in a chair, wheelchair, on the side of the bed, or to get on and off the toilet.On 11/14/25 at 10:30 a.m., a nursing progress note documented the resident was in the television room in his wheelchair and was trying to reach his shoes, lost his balance and fell on his side, no injuries were noted. Resident #999 sustained superficial skin tears to his left knee.The fall report documentation dated 11/14/25 at 12:33 p.m. noted Resident #999 was Not oriented to person, place, time or situation.The active physician's orders included:Bed maintained in lowest position while occupied. Nurse to validate each shift. Start date 9/5/25.Bilateral enabler bar to standard bed to promote independence with bed mobility. Start date of 8/25/25. On 12/8/25 review of the Medication Administration Record (MAR) for December 2025 revealed the nurse signed, validating the bed was maintained in the lowest locked position when occupied on 12/8/25 for the 7:00 a.m., to 3:00 p.m. shift.The nurse also signed, validating that on 12/8/25, the bilateral enabler bar [sic] was in place to the standard bed to promote independence with bed mobility for the morning shift.On 12/8/25 at 11:00 a.m., Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 3 of 7 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 12/09/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete #999 was observed in bed. The fall prevention interventions specified in the care plan and signed by the nurse in the MAR for 12/8/25 for the morning shift were not in place. The bed was not in the lowest position. The perimeter mattress was not in place. The bed had no enablers bilaterally. In an interview, Resident #999 said he remembered falling and breaking his leg but did not remember how it happened.On 12/8/25 at 12:15 p.m., the Director of Nursing (DON) verified through observation that Resident #999's bed was not in the lowest position and the enablers were not in place. The DON said he was not aware that the resident's fall interventions in the care plan included a perimeter mattress. The DON verified the nurse documented on the MAR that the fall prevention interventions were in place when they were not.On 12/8/25 at 12:37 p.m., in an interview the Administrator said she did not have documentation of Resident #999's fall investigation for 8/17/25 and the right femur fracture identified on 8/19/25.The Administrator said she initiated an abuse/neglect investigation on 9/23/25 when the resident's responsible party alleged that Resident #999 was being abused or neglected. The responsible party said his concern was with the fall and he wanted full side rails on the bed. She said her investigation did not address the fall since the incident occurred with the former administration. She said she did not know if they investigated the fall and fracture. The Administrator said she spoke with Resident #999 who had no concerns regarding care.Review of the facility provided incident investigation for an incident date of 9/23/25 revealed an allegation of physical abuse and neglect. The allegation details noted the resident's responsible party alleged that Resident #999 was being abused or neglected. No other information had been provided at that time. The investigation noted the representative voiced allegation of neglect regarding the use of full side rails. Resident #999 stated that he had no concerns with care and felt safe at the facility. The investigation noted Resident #999 has had previous falls, care plan reflects noncompliance with fall interventions and Activities of Daily Living care. The conclusion noted after investigation the facility was not able to verify abuse and neglect due to care plan interventions followed per individualized plan of care. The investigation noted the resident was not deemed incapacitated and had a Brief Interview for Mental Status score of 13 (which is indicative of intact cognition). The resident was able to make his own decisions regarding use of full length side rails.On 12/9/25 at 8:37 a.m., in an interview the Administrator said as part of the fall prevention program, the facility implemented daily fall and change of shift huddles, walking rounds, and would provide the documentation.On 12/9/25 at 4:00 p.m., at the time of exit, the Administrator failed to provide documentation of an investigation for Resident #999's fall on 8/17/25 resulting in fracture of the right femur and emergency transfer to an acute care hospital. Event ID: Facility ID: 105983 If continuation sheet Page 4 of 7 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 12/09/2025 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, record review and interviews, the facility failed to maintain an effective pest control program to contain and eradicate common household pests.The findings included:Review of the facilities Pest Control Program policy (last revised on 3/1/2022) stated, it is the policy of this facility to maintain an effective pest control program that eradicated and contains common household pests and rodents. The policy further states effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats).Review of the facilities Resident Environmental Quality policy (last revised on 3/1/2025) states the facility shall maintain an effective pest control program so the facility is free from pests and rodents.On 12/8/25 at 9:04 a.m., in an interview Resident #2 said she has a problem with bugs. She said there were little cockroaches in the bathroom. She has let everyone know but they were still there. She said there are times she won't take a shower because of the cockroaches. She said they come up from the shower drain. She said when it rains they come in as well. She said, I get a couple of brown paper bags and take care of them by squishing them.On 12/8/25 at 9:14 a.m., in an interview Resident #3 said she has issues with cockroaches. She said she saw one a couple of days ago.On 12/8/25 at 9:18 a.m., in an interview Resident #4 said, I see the little roaches crawling around. She said when her family comes in to visit, they have to squish them in the bathroom.On 12/8/25 at 9:25 a.m., in an interview Resident #5 said there are cockroaches in the bathroom and they crawl on the walls. She said the cockroaches also come out of the air conditioning vent. She said she did not know when the last time someone sprayed for cockroaches. During the interview a small brown bug was observed crawling on the bathroom floor. Photographic evidence obtained.On 12/8/25 at 9:30 a.m., in an interview Resident #6 said she sees cockroaches around her room. She could not recall when she last saw one but said it was not long ago, they are around. On 12/8/25 at 9:34 a.m., in an interview Resident #7 said there are cockroaches in his room. He said, I feel them crawling on me at night. Observation of the resident's room and bathroom revealed 3 black bugs crawling in the bathroom above and below the resident's toilet. On 12/8/25 at 9:38 a.m., in an interview Resident #15 said he has a problem with ants. He said the ants come from the detached baseboard. He said the staff tape the baseboard, but it never stays.Observation of the resident's floor revealed the baseboard was detached from the wall and laying on the resident's floor. Photographic evidence obtained.On 12/8/25 at 9:49 a.m., in an interview Resident #8 said she saw a cockroach the day before in her room and another one a few days ago. She said, they are baby roaches. They are everywhere. She said she used to tell the staff but it didn't help so now she squishes them herself.On 12/8/25 at 9:43 a.m., in an interview Resident #9 said, I had a roach in my bed a month ago crawling on me. She said the nurse aide found the cockroach on her while changing her brief. She said when the nurse aid took the brief off, the roach came crawling out from inside her brief.On 12/9/25 at 11:12 a.m., a small brown bug was observed crawling in Resident #10's room. Photographic evidence obtained.On 12/8/25 at 1:04 p.m., in an interview Resident #13 said they have a problem with cockroaches. Resident #13 said when her family comes to visit, they have to open the drawers and kill all of the roaches. She said, It is embarrassing. During the interview a small brown bug was observed on the floor. Photographic evidence obtained.On 12/8/25 at 9:22 a.m., in an interview Licensed Practical Nurse (LPN) Staff C said, We have a problem with roaches. Staff C said if there is a pest sighting, it goes in the pest logbook. Staff C said, They are never going to fully fix the problem. On 12/8/25 at 9:22 a.m., in an interview LPN Staff D said, I see roaches around here but not today. Staff D said she lets maintenance know when she sees one.On 12/8/25 at 9:47 a.m., in an interview LPN Staff E said, I've seen big roaches Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 5 of 7 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 12/09/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some around here. Staff E said when she sees one, she kills it, throws it away and then let maintenance know.On 12/8/25 at 12:08 p.m., review of the facility provided Pest Sighting Log showed on 12/1/25 Resident #16 reported roaches in dresser drawer. This sighting was not listed as treated. On 11/19/25, Resident #11 reported roaches around bed, bathroom and soap dispenser. The sighting was marked as treated by the pest control company. On 11/6/25, the activities department reported roaches, activity room cabinets. The sighting was marked as treated by the contracted pest control company.Review of the Resident Council Minutes reviewed for 11/12/25 revealed, Resident #11 talked about having roaches in her room and needing someone to come and take care of them.On 12/8/25 at 12:10 p.m., in an interview Resident #11 said she reported the roaches a month ago and there has been no change. Resident #11 said the roaches are in the bathroom, by her bed, they climb up and down the wall, behind the television and are behind the soap dispenser. Resident #11 said she just saw a cockroach last night go behind her television. Resident #11 said she also saw a cockroach in the bathroom this morning on the ceiling while showering. She said she let the Nursing Assistants know. A small brown bug was observed crawling on the floor next to the resident's bed. A small brown bug was observed on the bathroom wall. Photographic evidence obtained.On 12/8/25 at approximately 12:15 p.m., Staff F was observed removing the cover of the soap dispenser affixed to the bathroom wall. Multiple brown bugs were observed scurrying from behind the soap dispenser. Staff F dropped the soap dispenser, brushed off and washed her hands. Black bio growth was also observed inside of the soap dispenser. Photographic evidence obtained.On 12/8/25 at 12:22 p.m., in an interview the Housekeeping Supervisor said the soap dispensers are changed monthly and, That soap has not been changed for a while.On 12/8/25 at 12:30 p.m., in an interview Resident #12 said there were cockroaches in her dresser drawers. Resident #12 said she let the staff know but the roaches were still there. With Resident #12's permission, the dresser drawers were observed. Upon opening the top drawer, a large brown bug was observed scurrying deeper into the dresser. Resident #12 said, There is roach poop in the drawer. Black bio growth observed in the Resident #12's drawer which contained medical equipment, soap, ear plugs and deodorant. Resident #12 said she was extremely embarrassed that anyone had to see the condition of her drawer. Multiple brown bugs observed stuck to a sticky mat trap on the ground next to the resident's toilet. Photographic evidence obtained.On 12/8/25 at 1:17 p.m., a kitchen tour was conducted with the [NAME] Supervisor. In an interview the [NAME] Supervisor said the pest company bombed the kitchen and food storage area last week due to roaches. The [NAME] Supervisor was unable to give a timeline for how long the pest problem had been going on. Dead brown bug observed outside of the kitchen door. Multiple dead brown bugs observed in the food storage area.On 12/8/25 at 2:20 p.m., the activities room was observed with the cabinets open and emptied. The items in the cabinet were observed on the table in the center of the room. In an interview the Activities Director said her assistant reported a roach on her desk and sent a picture of it. The Activities Director said they are in the process of removing things out of the cabinet and a family member volunteered to take things home to wash them.Review of the contracted pest control company log revealed:On 7/16/25 the pest control technician noted under Cockroach program that Only had one room ready for me when arrived. Rooms were to be ready by 10 am.On 8/20/25 the pest control technician noted under Cockroach problem that No rooms were fogged today. They did not have any rooms ready.On 8/27/25 the pest control technician noted under Cockroach problem that Arrived at location it's 1020. No rooms were ready. An email was sent on Monday and there was notes at the nurses station but no rooms were ready.On 9/17/25 the pest control technician noted under Cockroach problem that I am stopping my weekly visits. Any structural or sanitation issues that have been marked down have not been addressed yet. It has been a few months. Will resume (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 105983 If continuation sheet Page 6 of 7 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 12/09/2025 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete after structural issues have been resolved and sanitation.On 12/4/25 the pest control technician noted, Some of the rooms still had personal belongings in the drawers, so it's not able to fog nightstand.On 12/8/25 at 2:48 p.m., in a telephone interview the pest control technician said he serviced the building but, I won't get into too much detail. He said he was going to the facility weekly at one point. He said that he stopped coming weekly because the rooms were not ready when he arrived.On 12/8/25 at 3:30 p.m., in an interview the Maintenance Director said there is a pest sighting logbook at every nurse's station. The Maintenance Director said the pest control company sprays weekly. Upon reviewing the pesto control documentation showing the weekly visits had stopped on 9/17/25, the Maintenance Director said weekly visits started again last week. When asked about the pest control technician documentation that rooms were not ready to be treated multiple times when he arrived, causing him to stop the weekly visits, the Maintenance Director said they were working on it. The Maintenance Director said his expectation is if rooms need to be ready, they should be ready for the pest control technician. When asked about the live crawling insects observed behind the soap dispenser in Resident #11's room, the Maintenance Director said, I did not know to look behind the soap dispenser. The Maintenance Director said the photographic evidence of Resident #11's drawer looked like pest droppings. The observation of the live crawling insect in Residents' drawers was shared with the Maintenance Director. He said the expectation was to document on the log to be treated during the weekly pest control visits on Thursdays. On 12/9/25 at 12:40 p.m., an interview was held with the Nursing Home Administrator related to the lack of an effective pest control program. The Administrator said if there is a pest sighting, it is to be put in the log immediately. The Nursing Home Administrator confirmed the pest control company came out to service the facility on 9/17/25, 10/16/25, 11/21/25 and 12/4/25. The pest control recommendations were not completed when the technician arrived. The Administrator said the facility resumed the weekly visits last week.Review of the facility's provided documentation revealed the pest control company has been providing services to the facility since 10/4/24. Review of the contracted pest control company's website revealed, Cockroaches can carry diseases such as Salmonellosis (Salmonella food poisoning), Staphylococcus infections (gastrointestinal illness), Escherichia coli (bacterial infection), Typhoid fever (life-threatening illness that can multiply and spread into the bloodstream) and Gastroenteritis (inflammation of the stomach, small and large intestines). Event ID: Facility ID: 105983 If continuation sheet Page 7 of 7

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Citations

4 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.

  • 0695GeneralS&S Dpotential for harm

    F695 - Respiratory care, including tracheostomy care and tracheal suctioning

    Provide safe and appropriate respiratory care for a resident when needed.

  • 0677GeneralS&S Dpotential for harm

    F677 - A resident who is unable to carry out activities of daily living receives

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • 0689GeneralS&S Epotential for harm

    F689 - Accidents

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • 0925GeneralS&S Epotential for harm

    F925 - Maintain an effective pest control program so that the facility is free of

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

FAQ · About this visit

Common questions about this visit

What happened during the December 9, 2025 survey of HARBORVIEW SARASOTA?

This was a inspection survey of HARBORVIEW SARASOTA on December 9, 2025. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at HARBORVIEW SARASOTA on December 9, 2025?

Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide safe and appropriate respiratory care for a resident when needed."

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.

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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.