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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, resident and staff interview, the facility failed to update the care plan to
accurately reflect safety precautions for 1 (Resident #30) of 2 sampled residents at risk for elopement.
The findings included:
Review of the clinical record revealed Resident #30 was admitted to the facility on [DATE]. Diagnoses
included non-Alzheimer's dementia.
The Elopement risk evaluations completed on 4/26/24, 5/21/24, and 10/14/24 noted Resident #30 scored 2,
indicating the resident was at risk for elopement.
Review of the care plan initiated on 5/21/24 and revised on 10/14/24 noted Resident #30 was at risk for
elopement. The goal was Attempts to prevent resident from eloping from facility will be provided. The
interventions included an alerting bracelet (alerts staff when the resident leaves a designated safe area)
placed to the right ankle. The care plan specified to check the alerting bracelet function and placement
every day.
Review of the Order Summary Report revealed a physician's order dated 10/16/24 to, Check placement of
Alerting Bracelet walker every shift for monitoring.
The care plan was not updated to reflect the alerting bracelet to the resident's walker.
On 10/21/24 at 3:30 p.m., on 10/22/24 at 11:00 a.m., and on 10/23/24 at 11:13 a.m., Resident #30 was
observed in her bedroom. The resident was not wearing an alert bracelet to the right ankle. An alert
bracelet was observed attached to the resident's rolling walker.
On 10/22/24 at 11:02 a.m., in an interview Resident #30 said she used to have an alert bracelet to her right
ankle but she used a butter knife to cut it off.
On 10/23/24 at 4:57 p.m., in an interview Minimum Data Set Registered Nurse (RN) Staff F said the
physician's order and the care plan should match. She verified on 10/16/24 the physician's order for the
alert bracelet to the rolling walker. Staff F said the care plan should have been revised to reflect the alert
bracelet on the rolling walker.
On 10/23/24 5:14 p.m., the MDS coordinator said she verified Resident #30's alert bracelet was attached to
the rolling walker and not to the resident's right ankle. She said the care plan was
(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 7
Event ID:
106102
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
106102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Point Rehabilitation Center
2600 Courtland Street
Sarasota, FL 34237
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 0657
incorrect.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106102
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
106102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Point Rehabilitation Center
2600 Courtland Street
Sarasota, FL 34237
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
Based on observation, record review, resident and staff interviews, the facility failed to provide care and
services in accordance with physician's orders to meet the needs of 1 (Resident #30) of 1 resident
observed with edema (swelling) of the legs.
Residents Affected - Few
The findings included:
Review of the clinical record for Resident #30 revealed an admission to the facility of 4/25/24. Diagnoses
included heart failure.
The physician's orders dated 6/10/24 noted to apply [NAME] hose (compression garment to legs to help
circulation and lower swelling) in the morning and off in the evening for edema.
The care plan initiated on 4/25/24 noted Resident #30 was at risk for altered cardiovascular status related
to hypertension and congestive heart failure. The goal was for the resident to have decreased risk of signs
and symptoms of cardiac complications. The interventions included to observe for changes in lung sounds,
edema or changes in weight.
The care plan initiated on 5/6/24 noted Resident #30 is resistive to care and medications related to
adjustment to admission, and new environment, and on 6/10/24 refused to wear the [NAME] Hose.
Interventions included to allow the resident to make decisions about treatment regime to provide sense of
control, give clear explanation of all care activities prior to and as they occur during each contact.
On 10/21/24 at 3:30 p.m., 10/22/24 at 10:53 a.m., and 10/23/24 at 11:13 a.m., Resident #30 was observed
sitting in her room with her legs in dependent position. Resident #30 was not wearing the [NAME] Hose.
Her legs were swollen.
Review of the Treatment Administration Record (TAR) for October 2024 showed on 10/21/24, 10/22/24 and
10/23/24 the nurse placed her initials indicating the [NAME] hose were applied in the morning.
On 10/22/24 at 10:53 a.m., in an interview Resident #30 said no one offered to apply the [NAME] hose on
10/21/24 or today (10/22/24).
On 10/23/24 at 11:13 a.m., in an interview Resident #30 complained her legs were swollen. She said she
has not refused to wear the [NAME] hose, but no one offered to apply them recently.
Review of the Medication Administration Audit Report revealed the [NAME] hose were scheduled to be
applied at 7:00 a.m. Licensed Practical Nurse (LPN) Staff D documented on the TAR the [NAME] hose
were applied on 10/23/24 at 11:57 a.m.
On 10/23/24 at 12:25 p.m., Resident #30 was observed in her room. She was not wearing the [NAME]
Hose.
On 10/23/24 at 1:09 p.m., in an interview Certified Nursing Assistant (CNA) Staff C said she was assigned
to care for Resident #30. Staff C said she knew Resident #30 needed the [NAME] hose. The resident did
not refuse the [NAME] hose but it slipped her mind and she did not offer to apply the [NAME] hose.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106102
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
106102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Point Rehabilitation Center
2600 Courtland Street
Sarasota, FL 34237
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 10/23/24 at 1:23 p.m., in an interview LPN Staff D said the CNAs are supposed to apply the [NAME]
hose. She said she did not verify Resident #30 had the [NAME] hose on before documenting on the TAR
the [NAME] hose were applied as ordered.
On 10/23/24 at 1:30 p.m., Resident #30 was observed in her room. She was not wearing the [NAME] hose
to her legs as ordered. Unit Manager Registered Nurse Staff E verified Resident #30's legs were swollen
and she did not have the [NAME] hose on. She said staff should not be documenting a treatment before
confirming it was completed.
On 10/24/24 at 10:30 a.m., in an interview the Director of Nursing said staff should not document a
treatment was completed before they confirmed that it was done.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106102
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
106102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Point Rehabilitation Center
2600 Courtland Street
Sarasota, FL 34237
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 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation of medication administration, record review, staff and resident interviews, the facility
failed to ensure 2 (Residents #74 and #38) of 3 sampled residents were free from significant medication
error related to the administration of transdermal pain patches.
Residents Affected - Few
The findings included:
1. Review of the clinical record for Resident #74 revealed a physician's order dated 5/25/23 for Lidocaine
(topical anesthetic) External Patch 4%, apply to hip topically in the morning for pain and remove per
schedule.
Review of the Medication Administration Record (MAR) for October 2024 revealed the Lidocaine Patch was
scheduled to be applied every day at 6:00 a.m. and removed every day at 6:00 p.m.
The MAR for October 2024 had an order dated 5/12/23 to validate the Lidocaine Patch to the right hip was
present every shift. The diagnoses for the Lidocaine Patch was fracture of the right femur.
On 10/22/24 at 9:10 a.m., Licensed Practical Nurse (LPN) Staff A was observed administering medications
to Resident #74. An undated Lidocaine Patch was observed on the resident's right thigh, near his groin.
LPN Staff A said the previous shift applied the Lidocaine Patch. She said the patch should have been
applied to the resident's right hip, not his thigh and should have been dated.
On 10/22/24 at 10:21 a.m., Resident #74 was observed with the Director of Nursing and the Regional
Clinical Director. Resident #74 remained with the undated patch to the right thigh. A Lidocaine Patch dated
10/18/24 was observed to the resident's left thigh.
Review of the packaging for the Lidocaine patch revealed a warning label that said, Do not use more than
one patch on your body at a time . Do not use more than one patch in a 12-hour period. Maximum 2
patches per day.
Photographic evidence obtained.
2. On 10/22/24 review of the clinical record for Resident #38 revealed a physician's order dated 9/28/24 to
apply a Lidocaine Patch 4% topically to the resident's right shoulder in the morning for pain and remove at
bedtime, remove per schedule.
Review of the MAR for October 2024 revealed the Lidocaine Patch was scheduled to be applied every day
at 6:00 a.m., and removed at 5:59 p.m. The MAR noted the Lidocaine Patch was applied as ordered on
10/22/24 at 6:00 a.m.
On 10/22/24 at 10:40 a.m., in an interview Resident #38 said she felt the Lidocaine Patch was just cold and
did nothing to help her pain. She said she had not used the Lidocaine Patch in about 10 days. Resident #38
showed a patch to her right shoulder which she said was a Thermacare Patch. She said Physical Therapy
applied the Thermacare patch to her right shoulder which worked better.
The Director of Nursing and the Regional Clinical Director were present during the interview, and
observation.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106102
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
106102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Point Rehabilitation Center
2600 Courtland Street
Sarasota, FL 34237
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 0760
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of the facility policy and procedure titled Medication Pass and Med Pass with Medication Cart
Updated 8/14/24 noted to, Complete documentation on the medication MAR. Record the name, dose,
route, and time of medication on the Medication Administration Record. Initial the record after the
medication is administered to the resident. Record the reason for not administering the medication.
On 10/22/24 at 10:45 a.m., the DON said there was no separate policy for transdermal patches, but the
process was patches should be dated on the day they are placed. She said she was not aware of an order
for Resident #74 to have a patch on his left thigh and the Lidocaine Patch should not have been left in place
for four days. She also agreed Resident #38's MAR documented the patch as given and it was not in place
on Resident #38's shoulder. The Regional Clinical Director said transdermal patches should be dated when
applied.
Event ID:
Facility ID:
106102
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
106102
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Sarasota Point Rehabilitation Center
2600 Courtland Street
Sarasota, FL 34237
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, record review and staff interviews, the facility failed to ensure 1 (Dietary Staff B) of 1
dietary staff observed operating the dishwasher was trained, and competent to test the sanitizing solution
of the low temp dishwasher to ensure dishes were properly sanitized to prevent foodborne illnesses of
residents consuming an oral diet.
The findings included:
The facility's policy and procedure titled, Testing Sanitizer & Temperature in Low Temp Dish Machines
revised 8/2023 noted, Test sanitizing solution and temperature before cleaning each meal's dishes . Test the
sanitizer with chlorine test strips obtained by the chemical vendor or food distributor. A proper level is 50
ppm (part per million) chlorine in the rinse water. An appropriated temperature is 120 - 160 F (Fahrenheit) .
Record water temperature and sanitizer levels on the Dishwashing Temperature/Sanitizer Record.
On 10/24/2024 at 9:20 a.m., during a tour of the kitchen with the Certified Dietary Manager (CDM), Food
and Nutrition Aide Staff B was observed using the low temp dishwasher. In an interview Staff B said she
has been employed at the facility for 2.5 years and had not received any training or instructions on testing
the sanitizing solution of the dishwasher. Staff B said she signed the Dishwashing Temperature/Sanitizer
log every day she worked but did not know what the log was for. She said, I just sign it because I was told
to. She said she filled in the blanks with numbers on the form but did not know what it was for.
The CDM was present during the observation and interview She told Staff B her where the chlorine test
strips were kept and began to instruct her on how to test the dishwasher sanitizer. The CDM said she did
not know if Staff B had been trained to use the dishwasher. She said Staff B only uses it sometimes and
she signs the logbook for the person who is doing the testing.
On 10/24/24 review of the Dishwashing Temperature/Sanitizer Record for October 2024 showed Staff B
signed the log for 64 of the 67 meals documented. No temperature or sanitizer level was documented for
the dinner meal on 10/21/24, 10/22/24 and 10/23/24.
On 10/24/2024 at 10:30 a.m., documentation of Staff B's training and competency to test the water
temperature and sanitizing solution for the dishwasher was requested. The CDM said she began
employment at the facility six months ago. She did not know what training the dietary staff had received but
she was working on that.
On 10/24/2024 at 12:00 p.m., in an interview the Administrator said Staff B had been trained on using the
dishwasher upon hire but did not provide the requested documentation Staff B was trained upon hire and
competent to use the dishwasher, including measuring the water temperature and the sanitizing solution
level to ensure dishes were properly washed and sanitized.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106102
If continuation sheet
Page 7 of 7
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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.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the October 24, 2024 survey of SARASOTA POINT REHABILITATION CENTER?
This was a inspection survey of SARASOTA POINT REHABILITATION CENTER on October 24, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SARASOTA POINT REHABILITATION CENTER on October 24, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a t..."
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.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.