Inspection visit
Health inspection
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 0550
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
Based on record review, observation, staff and resident interview, the facility failed to ensure timely
response to call lights to meet the needs of 2 (Resident #94 and #96) of 2 residents reviewed.
Residents Affected - Few
The findings included:
On 6/20/22 at 1:42 p.m., Resident #94 said staff did not respond to the call light at night in a timely manner.
Resident #94 said it would take 10 to 15 minutes for staff to respond to his call light. He said it happened
every night and it was worse on the weekends.
On 6/21/22 at 9:01 a.m., the restroom call light for Resident #94 on the Magnolia hallway observed
sounding and flashing rapidly from the nursing station. Registered Nurse Staff B was observed standing at
a medication cart directly in front of the nursing station. At 9:06 a.m., Resident 94's restroom call light
continued to flash and sound. Staff B continued to stand at the medication cart and did not respond to the
call light. Licensed Practical Nurse Staff A was observed walking to the nursing station, converse, and wash
her hands at a sink next to the nursing station. After several minutes Staff A walked to a room in the back of
the magnolia nursing station as the call light continued to flash and sound. Another unknown staff member
was heard down the Magnolia Hallway was knocking on doors and saying, Activities.
On 6/21/22 at 9:16 a.m., Resident 94's room was observed. After knocking on the resident's door, and the
resident responding, the resident was heard saying be careful. There was fecal material observed from the
bed at the window of the room and leading into the restroom. Resident #94 was observed sitting of the
bathroom toilet with the door open. The resident said, I have been waiting for someone to help me for about
fifteen minutes. The resident continued to ask for assistance. No staff member was observed in the hallway
near the resident at that time. There was an attempt to locate the Director of Nursing (DON). A staff
member said the DON was in a morning meeting. At 9:18 a.m., the Administrator walked to the Magnolia
hallway and the restroom call light was still flashing and sounding. Upon opening Resident #94's door a
staff member was observed assisting the resident. The Administrator said the call light times were
recorded, and she would be able to provide documentation of how long the light was initiated.
Review of the Detailed Patient Activity Report provided by the DON showed the call light response time for
Resident #94. The form shows Resident #94's call light was engaged on 6/21/22 at 8:55 a.m. and was
completed and immediately reengaged on 16 minutes and 33 seconds later. The light was completed and
reengaged 7 seconds later. After 19 minutes had passed the call light is completed and reengaged 2
seconds later. One second later the light is complete and reengaged one second later. The light is then
completed the last time after 22 minutes and 29 seconds had elapsed.
(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 6
Event ID:
106085
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
106085
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Village of Sarasota
8400 Vamo Road
Sarasota, FL 34231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 6/21/22 at 11:00 a.m., Resident #96 was observed with his spouse in his room. The resident's spouse
complained the aides were shorthanded. Resident #96's spouse said there were times when the call light
was not answered for 15 minutes or more. She said this usually occurred during mealtimes when staff are
assisting residents with meals. She said the response time was worse on the weekend.
Review the Patient Detailed Report for Resident #96's room showed on 6/20/22 Resident #94's call light
was engaged at 6:15 p.m. and was not completed until 24 minutes and 45 seconds later.
On 6/23/22 at approximately 11:00 a.m., the Director of Nursing (DON) said the light was going off and
coming back on several times during the time Resident #94 was in the bathroom. The light was observed
from 9:01 a. m., to 9:18 a.m., to continue to be engaged. The DON said Resident #94 was turning the call
light on and off attempting to get assistance from staff. The DON said she had only been spot checking the
call light response time. The DON said she was going to begin auditing the call light response time and
initiate staff in-services to ensure all staff are aware the expectation of the facility is a call light response
time of less than five minutes.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106085
If continuation sheet
Page 2 of 6
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
106085
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Village of Sarasota
8400 Vamo Road
Sarasota, FL 34231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, and interview the facility failed to complete a level one Pre admission Screening and
Resident Review (PASARR), and report significant mental illness changes to the appropriate state
agencies (KEPRO) for 2 (Resident #10 and #25) of 3 residents reviewed with newly diagnosed psychiatric
disorder.
The findings included:
Record review revealed Resident #10 was a [AGE] year-old female who was admitted to the facility on
[DATE]. There was no diagnosis of psychotic disorder or schizophrenia noted at the time of admission.
The Physician's order dated 12/17/21 showed Resident #10 had a new order for Risperidone 0.25 milligram
(mg) twice daily for delirium, and psychotic agitation.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10's
cognition was moderately impaired. Resident #10 was taking an Antipsychotic medication six days a week.
The active diagnoses listed included non Alzheimer's dementia, and anxiety disorder.
On 2/23/22, the physician issued an order for Resident #10 for Risperidone one mg by mouth twice daily for
Schizophrenia.
The quarterly MDS dated [DATE] revealed Resident #10 had a diagnosis of anxiety disorder and
Schizophrenia.
On 6/22/22 at 11:22 a.m., in an interview, Resident #10's nephew said he was never told his aunt had been
diagnosed with Schizophrenia. Resident #10's nephew said his aunt had had a history of anxiety, but she
was never diagnosed with schizophrenia. The resident's nephew said the facility had informed him that his
aunt had a new antipsychotic medication because she was yelling out a lot.
On 6/22/22, record review revealed no evidence a Level 1 PASARR was completed for Resident #10 when
she was diagnosed with schizophrenia.
On 6/22/22 at 10:52 a.m., the DON said all the residents in the facility are long term care and they usually
have the same staff members working with them to identify if they have a new mental illness diagnosis. The
DON said the Risk Manager would decide if a resident with a significant change in mental status was
reported to the appropriate state agencies. The DON verified the facility did not have a system to identify
residents with significant changes to their mental status and report the changes to the appropriate state
agency.
On 6/22/22 at 11:54 a.m., the Social Service Director said she could not complete a level one PASSAR
because she was not a Registered Nurse (RN). The Social Worker said the only staff member who
completed the Level one PASARR's was the Staff Developer who is a RN.
On 6/22/22 at 12:05 p.m., the Staff Developer said the Director of Nursing (DON) would be responsible to
refer any resident with a new diagnosis of mental illness to the appropriate state agency. The Staff
Developer said she had never completed a level one PASARR for and resident who had been
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106085
If continuation sheet
Page 3 of 6
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
106085
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Village of Sarasota
8400 Vamo Road
Sarasota, FL 34231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
diagnosed with a new mental illness while residing at the facility.
Level of Harm - Minimal harm
or potential for actual harm
On 6/23/22 at 9:47 a.m., in a telephone interview the Supervisor of Keystone Peer Review Organization
Inc. (KEPRO), which is the state agency responsible for reviewing changes to resident's mental health
status, said if while residing at a nursing home facility a resident receives a new diagnosis of mental illness,
and is receiving treatment with medications such as antipsychotics, it would be the responsibility of the
nursing home to file a level one PASARR for patient review and this would automatically trigger a level two
PASARR screen of the resident with KEPRO.
Residents Affected - Few
A Resident Review Evaluation form dated 6/23/22 revealed Resident #10 had previously never had a level
two PASARR determination. The Resident Review Documented Resident #10 had an increase in
behavioral, psychiatric, or mood-related symptoms. The documentation revealed Resident #25 has had
Behavioral, psychiatric, or mood related symptoms that have not responded adequately to on-going
treatment.
On 6/23/22 at 10:54 a.m., the DON and the Social Worker verified the facility currently did not have a
system in place to report changes in mental health to KEPRO for residents after they are admitted to the
facility.
2. Review of The Annual MDS assessment dated [DATE] revealed Resident #25 was rarely understood and
is moderately cognitively impaired. Section I of the MDS shows Resident #25 was diagnosed with
Non-Alzheimer's Dementia, Depression and Bipolar Disorder. The MDS revealed Resident #25 was
receiving an antipsychotic medication seven days a week.
The Quarterly MDS assessment dated [DATE] revealed Resident #25 was rarely understood and
moderately impaired mentally. Resident #25 was receiving an antipsychotic medication seven days a week.
Resident #25 had a new diagnosis of Schizophrenia.
A physician's order dated 1/10/22 read, Zyprexa [antipsychotic] 5 mg by mouth every evening for
schizoaffective disorder.
A physician's order dated 6/9/22 read, Zyprexa 10 mg by mouth daily for schizoaffective disorder.
On 6/22/22, record review revealed no evidence a Level 1 PASARR was completed for Resident #25 when
he was diagnosed with schizophrenia.
On 6/23/22 at 10:54 a.m., the DON and the Social Worker verified the facility currently did not have a
system in place to report changes in mental health to KEPRO for residents after they were admitted to the
facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106085
If continuation sheet
Page 4 of 6
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
106085
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Village of Sarasota
8400 Vamo Road
Sarasota, FL 34231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on record review and interview the facility failed to ensure a psychotropic (medication that affects
brain activity) as needed medication (PRN) had a fixed duration of time for 1 (Resident #10) of 5 residents
reviewed for unnecessary medications.
The findings included:
Review of the monthly pharmacy review for Resident #10 revealed a pharmacy recommendation printed on
4/12/22 to the physician that read,
Lorazepam 1 mg [milligram] by mouth every 4 hours as needed for severe anxiety. (Since 3/22/22).
The new Mega Rule guidelines require PRN psychoactive orders to have a duration of 14 days for the initial
order. Then the resident should be seen by the prescriber who may reorder the medication for a fixed
duration after fully documenting the need for the medication by the resident.
There was no documentation in Resident #10's medical record the as needed Lorazepam was changed
and no documentation from the physician of the benefit of the lorazepam or the set duration of the
medication. The order for the PRN Ativan remained in place.
The monthly pharmacy recommendation printed on 6/7/22 read,
Lorazepam 1 mg [milligram] by mouth every 4 hours as needed for severe anxiety. (Since 3/22/22).
The new Mega Rule guidelines require PRN psychoactive orders to have a duration of 14 days for the initial
order. Then the resident should be seen by the prescriber who may reorder the medication for a fixed
duration after fully documenting the need for the medication by the resident.
The Practitioner documented on 6/16/2022 to continue the orders as the resident was under hospice care
and continued to require the medication for anxiety. The prescriber's response did not document a set
duration for the PRN medication.
Another pharmacy recommendation for Resident #10 printed on 6/22/22 noted, Lorazepam 1 mg by mouth
every 4 hours as needed for severe anxiety. (Since 3/22/22).
The new Mega Rule guidelines require PRN psychoactive orders to have a duration of 14 days for the initial
order. Then the resident should be seen by the prescriber who may reorder the medication for a fixed
duration after fully documenting the need for the medication by the resident.
On 6/22/22 at 2:30 p.m., the Consultant Pharmacist said he had been making monthly referrals to the
physician to write an order for changing the as needed lorazepam order for Resident #10 since April of
2022. The Pharmacist verified there had been no change to the as needed lorazepam order since March of
2022.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106085
If continuation sheet
Page 5 of 6
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
106085
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/23/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bay Village of Sarasota
8400 Vamo Road
Sarasota, FL 34231
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0943
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to
report abuse, neglect, and exploitation.
Based on staff interview and record review, the facility failed to ensure 5 (Staff C, D, E, F and G) of 10 staff
reviewed had the required education and training in abuse, neglect, and exploitation. Failure to provide staff
with abuse, neglect, and exploitation training prior to working with facility residents could lead to staff not
knowing how to prevent and report abuse, neglect, and exploitation.
The findings included:
On 6/21/22, review of Administrator (ADM) Staff C's employee record revealed her start date was 7/15/19.
Review of her employee training records revealed she did not receive education or training in abuse,
neglect, and exploitation prior to working with the facility residents.
On 6/21/22, review of Dietary Aid (DA) Staff D's employee record revealed her start date was 5/2/22.
Review of her employee training records revealed she did not receive education or training in abuse,
neglect, and exploitation prior to working with the facility residents.
On 6/21/22, review of Security Guard (SG) Staff E's employee record revealed her start date was 2/21/22.
Review of her employee training records revealed she did not receive education or training in abuse,
neglect, and exploitation prior to working with the facility residents.
On 6/21/22, review of Renovation Maintenance Supervisor (RMS) Staff F's employee record revealed her
start date was 12/20/21. Review of her employee training records revealed she did not receive education or
training in abuse, neglect, and exploitation prior to working with the facility residents.
On 6/21/22, review of Certified Nursing Assistant (CNA) Staff G's employee record revealed her start date
was 3/30/22. Review of her employee training records revealed she did not receive education or training in
abuse, neglect, and exploitation prior to working with the facility residents.
On 6/21/22 at 2:01 p.m., interview with Human Resources Director, confirmed Staff C, was a current
employee and had resident contact. She confirmed Staff C's hire date and confirmed as of 6/21/22 she had
not had onboarding required training in abuse and neglect and exploitation as required for new hires.
On 6/23/22 at 9:30 a.m., interview with the Infection Preventionist/Staff Development Coordinator,
confirmed Staff D, E, F, and G were current employees and had resident contact. She confirmed Staff D's,
E's, F's, and G's hire dates and confirmed as of 6/23/22 they had not had the onboarding required training
in abuse and neglect and exploitation as required for new hires.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106085
If continuation sheet
Page 6 of 6
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Back to topCitations
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.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F943 - Abuse, neglect, and exploitation
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
FAQ · About this visit
Common questions about this visit
What happened during the June 23, 2022 survey of BAY VILLAGE OF SARASOTA?
This was a inspection survey of BAY VILLAGE OF SARASOTA on June 23, 2022. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at BAY VILLAGE OF SARASOTA on June 23, 2022?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.