Inspection visit
Health inspection
6 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, review of facility policies, and staff and family interviews, the facility
failed to implement ordered preventive measures and monitoring to prevent the development of pressure
ulcers for 1 (Resident #32) of 3 sampled residents at risk for developing pressure ulcers.
Residents Affected - Few
The findings included:
The facility policy CS-100-1 (revised 11/19) Skin Observation and Wound Prevention documented, Charge
nurses will observe the condition of the resident's skin on admission and on a routine basis. This system
also provides a communication process for the nursing assistant to report residents with skin changes to
the Charge Nurse . Upon admission the Charge Nurse should complete physical observation, documenting
findings within the admission Data Collection form. If a wound is present on admission the Charge Nurse
will initiate and describe the wound on the Weekly Wound Data Collection Sheet .Weekly: The Charge
Nurse should complete the Skin Integrity Review Form for all residents.Initiate treatment interventions per
healthcare provider order for new or newly identified wounds. If a wound is present, the Charge Nurse will
initiate or continue to describe the wound on the Weekly Wound Data Collection Sheet. The Director of
Clinical Services or Designee should: .Review the Weekly Pressure Ulcer and Weekly Skin Reports to
identify opportunity and implement interventions as indicated.
Clinical record review for Resident #32 showed an admission date of 8/8/21 with a transfer to the hospital
on 9/2/21. Resident #32 returned to the facility on 9/5/21. Diagnoses included peripheral vascular disease
(a circulatory condition with reduced blood flow to the limbs).
The Nursing admission data collection form dated 9/5/21 documented no skin issues.
The care plan documented Resident #32 was at risk for skin impairment. The interventions included
Prevalon boots at all times, except when in therapy and keep heels floated.
The Physician's orders dated 8/25/21 included to apply skin prep (Protective film) to both heels each shift.
A review of the treatment administration record (TAR) for August 2021 and September 2021, did not show
documentation the skin prep was applied as ordered.
The TAR for August 2021 documented the Prevalon boots were discontinued on 8/28/21.
On 9/8/21 at 4:52 p.m., Resident #32 was observed with a nickel size, dark black area on the left heel.
Resident #32 did not have on protective boots and the heels were not offloaded to decrease
(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:
106022
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
106022
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookdale Palmer Ranch Snf
5111 Palmer Ranch Parkway
Sarasota, FL 34238
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 0686
pressure.
Level of Harm - Minimal harm
or potential for actual harm
On 9/9/21 at 1:37 p.m., in an interview, the Director of Nursing confirmed the Weekly Skin Integrity Review
forms had not been completed and said Resident #32 had no wounds.
Residents Affected - Few
On 9/9/21 at 5:06 p.m., observed Resident #32's in bed with grip socks on both feet. The resident did not
have on protective boots and his heels were not offloaded to decrease pressure. With the assistance of
Certified Nursing Assistant (CNA) Staff C and Resident #32's permission the resident's heels were
observed. The right heel was red, no open areas and the left outer heel remained with a dark black area.
Resident #32 said his heels were sore when the CNA removed the socks. CNA Staff C said she was not
aware the resident had protective boots.
A review of the clinical record on 9/10/21 showed a Weekly Wound Data Collection Flow Sheet dated
9/9/21 at 5:54 p.m., documenting an in house acquired suspected deep tissue pressure injury (area of
discolored skin due to damage of underlying soft tissue caused by pressure) on Resident #32's left heel
measuring 1 centimeter (cm) in length and width.
On 9/10/21 at 12:48 p.m., in an interview, Unit Coordinator Licensed Practical Nurse Staff A said, the
nurses were to look at the weekly skin check assignment and complete the form in the electronic record.
Staff A said it was her responsibility to ensure the skin assessments were completed. Staff A said once a
concern is identified an SBAR (an assessment tool used to provide communication between healthcare
providers) and a 3-day charting initiated for each shift. Staff A said she was not notified of the pressure
wounds to Resident #32's heels until 9/10/21.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106022
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
106022
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookdale Palmer Ranch Snf
5111 Palmer Ranch Parkway
Sarasota, FL 34238
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 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a
resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed
consent; and (4) Correctly install and maintain the bed rail.
Based on observation, staff interviews, and facility policy review the facility failed to review the risks and
benefits of bed rails with the resident or resident representative and obtain informed consent prior to
installation of bed rails for 2 (Resident #32 and #34) of 3 residents observed with bed rails.
The findings included:
The facility policy GEN-6, Bedside Mobility Aid (revised 3/2020) specified, Residents utilizing bedside
mobility aids should have a Negotiated Risk Agreement (NRA) or other state required form completed,
making sure risks are fully disclosed. A healthcare provider order for the use of bedside mobility aid should
be obtained prior to its use. The health care provided must indicate that the bedside mobility aid is to be
used for bed mobility and positioning. Specific instructions related to beside mobility aids and their use
should be documented on the resident's care plan, reviewed by associates and updated regularly per
existing standards of upon a residents change in condition .The use of bedside mobility aids should be
reviewed at the time of the scheduled assessment/reassessment or upon a change in condition.
1. On 9/7/21 at 3:34 p.m., observed Resident #32 in bed with an assist bar in the up position.
A review of the clinical record for Resident #32 failed to reveal documentation of a negotiated risk
agreement making sure risks are fully disclosed, an informed consent for the assist bar, or alternatives
attempted prior to use.
On 9/9/21 at 5:06 p.m., in an interview Resident #32 said he had not requested the assist bar and said the
bar was there, so I use it sometimes, but I didn't ask for it.
2. On 9/7/21 at 4:17 p.m., observed Resident #34 in bed with assist bars in the up position on both sides of
the bed.
Resident #34 said she did not ask for the assist bars, they were on the bed when she was admitted to the
facility. Resident #34 said she really did not use the grab bar.
A review of the clinical record for Resident #34 failed to reveal documentation of a negotiated risk
agreement making sure risks are fully disclosed, an informed consent for the assist bar, or alternatives
attempted prior to use.
A review of the resident's care plan showed Resident #34 was at risk for falls. The care plan interventions
did not document the use of assist bars.
On 9/10/21 at 12:30 p.m., in an interview the Administrator confirmed there was no documentation of a
negotiated risk agreement, no interventions attempted prior to use or informed consents for Resident #32
and #34 for the use of the assist bars.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106022
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
106022
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookdale Palmer Ranch Snf
5111 Palmer Ranch Parkway
Sarasota, FL 34238
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, staff interviews, and review of facility policy and procedures, the facility failed to
implement a system to account for periodic reconciliation and disposition of all controlled substances. The
facility also failed to identify and dispose of expired medications to prevent use.
The findings included:
The facility policy MED-9 (revised 9/2017) Controlled Substances Policy, documented, Controlled drugs will
be properly stored and accounted for as outlined by State and Federal regulations. All discontinued drugs
need to be logged and stored in a designated area until drugs can be properly disposed of.
The facility policy Storage and Expiration of medications, Biologicals, Syringes and Needles 5.3(revised
1/1/13) documented, .Facility should ensure that medications and biologicals have an expiration date on the
label; have not been retained longer than recommended by the manufacturer or supplier guidelines . Once
any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with
respect to expiration dates for opened medications. Facility should record the date opened on the
medication container when the medication has a shortened expiration date once opened . Facility should
ensure that medications and biologicals for expired or discharged residents are stored separately away
from use, until destroyed or returned to the provider .
On 9/7/21 at 9:45 a.m., during an observation of the Medication Room refrigerator locked box with Licensed
Practical Nurse (LPN) Staff B, there was an open bottle of liquid Lorazepam (a medication used to treat
anxiety) for Resident #22 with a date opened recorded of 1/14/21 and had instructions to discard the
medication 90 days after opening.
*Photographic Evidence Obtained*
On 9/7/21 at 9:50 a.m., LPN Staff B confirmed the Lorazepam had expired.
On 9/7/21 at 10:00 a.m., observation of the Renaissance medication cart with LPN Staff B revealed the
following:
1. An open bottle of Nitroglycerin (a medication used to treat chest pain) 0.4 milligrams (mg) without a date
opened, making it impossible to determine when the medication would expire.
*Photographic Evidence Obtained*
2. An open bottle of Olopatadine (a medication used to treat eye redness and itchiness) HCL eye drops
prescribed for Resident #34 with an opened date of 7/5/21. The label on the bottle instructed to discard the
medication after 28 days after opening.
*Photographic Evidence Obtained*
3. A plastic bag with label printed 8/26/21 for Proair (a medication used to treat asthma) Inhaler for
Resident #190. The Proair Inhaler had an expiration date of 8/2020.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106022
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
106022
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookdale Palmer Ranch Snf
5111 Palmer Ranch Parkway
Sarasota, FL 34238
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 0755
*Photographic Evidence Obtained*
Level of Harm - Minimal harm
or potential for actual harm
On 9/7/21 at 10:20 a.m., Licensed Practical Nurse (LPN) Staff B confirmed the findings of expired
medications.
Residents Affected - Few
On 9/10/21 at 9:10 a.m., in an interview, the Director of Nursing (DON) said she made rounds weekly to
collect expired narcotic medications and said the staff knew to bring discontinued medications to her. The
DON said, the nurse and I sign the count sheet to ensure accuracy and I lock the medication in a secured
file cabinet in my office. The DON said, once a month the Pharmacist comes, and we destroy them. The
Pharmacist and I sign the destruction sheet. The safe is in my office and I am the only one with a key to the
file cabinet.
The DON said there were narcotics (controlled substances) in the safe waiting for destruction, but she did
not keep a log of the controlled substance submitted. The DON confirmed she had no way to reconcile the
controlled substances in the safe with what was submitted for destruction.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106022
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
106022
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookdale Palmer Ranch Snf
5111 Palmer Ranch Parkway
Sarasota, FL 34238
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, clinical record review, and staff interviews, the facility failed to administer medication
according to physician's orders and manufacturer's specification for 2 (Residents #190 and #191) of 9
residents observed for medication administration. Three licensed nurses on two different shifts with 26
opportunities were observed. Two medication errors were observed resulting in a 7.69% error rate.
Residents Affected - Few
The findings included:
On 9/9/21 at 8:25 a.m., Licensed Practical Nurse (LPN) Staff B was observed administering 7 different
medications to Resident #190.
Upon reconciliation with the physician's orders, it was revealed an order for Voltaren Gel 1% to be applied
topically to the right hip two times a day for pain.
LPN Staff B was not observed applying the Voltaren Gel to the resident's right hip but documented on the
medication administration record the Voltaren Gel was administered at 9:00 a.m.
On 9/9/21 2:44 p.m., in an interview, Resident #190 said the nurse did not apply the Voltaren gel to her hip.
On 9/10/21 at 2:00 p.m., in an interview LPN Staff B confirmed she did not apply the Voltaren Gel as
ordered on 9/9/21 at 9:00 a.m., during the medication administration.
On 9/9/21 at 8:36 a.m., LPN Staff B was observed administering 6 different medications to Resident #191
including one tablet of Spironolactone (a medication used to treat edema) 50 milligrams (mg).
Upon reconciliation with the physician's orders, it was revealed an order for Spironolactone 100 mg daily for
edema (swelling) and HTN (High blood pressure).
On 9/9/21 at 3:34 p.m., Staff B confirmed she administered Spironolactone 50 mg instead of
Spironolactone 100 mg as ordered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106022
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
106022
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookdale Palmer Ranch Snf
5111 Palmer Ranch Parkway
Sarasota, FL 34238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation and interview, the facility failed to administer medications in a sanitary manner for 2
(Resident #190 and #191) of 9 residents observed for medication administration.
Residents Affected - Few
The findings included:
On 9/9/21 at 8:25 a.m., LPN Staff B was observed preparing to administer six oral medications to Resident
#190. She punched one of the pills from a blister card into her ungloved hand, placed it in a medication cup
and administered all medications to the resident.
On 9/9/21 at 8:36 a.m., LPN Staff B was observed preparing to administer 5 oral medications to Resident
#191. She punched out each pill from the blister cards into her ungloved hands and transferred them into a
medication cup. She administered all the medications to the resident.
On 9/9/21 at approximately 8:45 a.m., LPN Staff B verified she touched Resident #190 and #191's
medications with ungloved hands and verified the breach of infection control.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106022
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
106022
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
09/10/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Brookdale Palmer Ranch Snf
5111 Palmer Ranch Parkway
Sarasota, FL 34238
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 0909
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and
mattresses must attach safely to the bed frame.
Based on record review, and staff interview, the facility failed to conduct regular inspection of all bed
frames, mattresses, and side bed rails, as part of a regular maintenance program to identify areas of
possible entrapment.
The findings included:
The facility Bed Entrapment Guide documented, the threat of bed entrapment within bed rails, bed frames,
or mattresses is serious and can result in debilitating chest, head, or neck injuries, sometimes even death.
That is why it is important to take every step to reduce the risk of entrapment.
On 9/10/21 at 10:24 a.m., in an interview the Maintenance Director said he was new in the position at the
facility and was at the facility for two days. The Maintenance Director said he spoke with the Administrator
and there was no record of maintenance completed for the assist bars used in the facility. He confirmed the
facility had no documentation of assessment of a regular maintenance program that included the inspection
of all bed frames, mattresses, and bed rails.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106022
If continuation sheet
Page 8 of 8
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Back to topCitations
6 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F909 - Conduct Regular inspection of all bed frames, mattresses, and bed
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the September 10, 2021 survey of BROOKDALE PALMER RANCH SNF?
This was a inspection survey of BROOKDALE PALMER RANCH SNF on September 10, 2021. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BROOKDALE PALMER RANCH SNF on September 10, 2021?
Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure medication error rates are not 5 percent or greater."
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.