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Complaint Investigation

Sarasota Health And Rehabilitation Center

May 2, 2025 · Sarasota, FL · 1524 East Avenue South
Citations 2
CMS Rating 1/5
Beds 144
Provider ID 105155
Healthcare Facility
Sarasota Health And Rehabilitation Center
Sarasota, FL  ·  View full profile →
Inspection Summary

SARASOTA HEALTH AND REHABILITATION CENTER in SARASOTA, FL — inspection on May 2, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF600
Immediate Some Review of the facility's Abuse Prevention Program with a change date of November 2024 revealed, Abuse . affected

Review of the clinical record for Resident #14 revealed an admitted [DATE].

Diagnoses included encephalopathy (brain disease that alters brain function), altered mental status, and unspecified dementia.

Review of the Quarterly Minimum Data Set (MDS) assessment with a target date of 2/3/25 noted Resident #14 scored 04 on the Brief Interview for Mental Status, indicating severe cognitive impairment.

The care plan created on 1/22/25 noted Resident #14 becomes agitated with staff when they try to redirect her at times. Resident #14 was resistive to care and exhibited aggressive behaviors towards others at times.

The goal as of 1/22/25 was to Honor Resident's rights.

The interventions included to administer psychotropic medications as ordered.

Observe/document for side effects and effectiveness.

Document episodes of behavior and review to determine the effectiveness of intervention. Do not corner if agitated.

Provide space, remove other residents, remain calm and call for assistance.

Review of the facility's event notes revealed a resident-to-resident altercation between Residents #14 and #13 in the hallway near the nursing station on 3/12/25 at 2:30 p.m.

Resident #14's description of the event was she thought Resident #13 was striking her friend, so she slapped him in the back of the head.

The event note documented the cause of the event was, Close proximity.

Review of the nursing progress note dated 3/12/25 at 3:27 p.m., revealed at 2:30 p.m., the nurse was advised that Resident #14 became agitated while standing at the nurses station and began swatting her hand striking another resident on the top of his head.

The resident was redirected to her room. Resident #14 stated that she struck Resident #13 because she witnessed him hitting another female resident that she knew.

On 3/12/25 at 4:28 p.m., a general progress note documented the Advanced Practice Registered Nurse ordered to increase Depakote 125 milligrams (mg) to two capsules twice daily for mood disorder/agitation.

105155

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 105155 B.

Wing 05/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sarasota Health and Rehabilitation Center 1524 East Avenue South Sarasota, FL 34239

Review of the facility's Abuse/Neglect log for February 2025 revealed the facility investigated four incidents of resident-to-resident allegations of physical abuse and one incident of resident-to-resident verbal abuse.

On 4/7/25 at 2:06 p.m., in an interview the Assistant Director of Nursing (ADON) stated that on 2/15/25 the facility implemented a monitoring program called the eagle eye program to address incidents of resident-to-resident altercations. A Certified Nursing Assistant (CNA) is assigned to monitor the dementia unit to make sure residents are observed every 15 minutes for their safe whereabouts.

The facility provided a document showing the eagle eye CNA documented rounds every 15 minutes.

On 4/7/25 at 2:32 p.m., during a tour of the secured unit, Resident #10 was observed standing in the doorway of room [ROOM NUMBER] facing outside of the room.

Resident #9 was observed sitting in a wheelchair in front of room [ROOM NUMBER], facing Resident #10. No staff was observed supervising the residents.

Residents #9 and #10 started to argue loudly. Resident #9 started to stand up. Resident #10 pushed Resident #9 back in the wheelchair. No staff responded to the resident-to-resident altercation.

Three female staff were observed at the nursing station to the right of the hallway.

Residents #9 and #10 were not visible from the nurse's station.

When notified of the verbal and physical altercation between Residents #9 and #10 the three staff members got up and walked towards room [ROOM NUMBER].

105155

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 105155 B.

Wing 05/02/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Sarasota Health and Rehabilitation Center 1524 East Avenue South Sarasota, FL 34239

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SARASOTA, FL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SARASOTA HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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