Boca Ciega Center

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide adequate supervision to prevent resident to resident altercation for two (#5 & #6) of thirteen sampled residents.

Inspectors wroteBased on interview, observation, and record review, the facility did not ensure timely Activities of Daily Living (ADL) related to incontinence care for two (#1 and #2) of three residents.

Inspectors wroteBased on observations, interviews and policy review the facility failed to ensure a clean and sanitary kitchen on three of three observations regarding areas that were not clean or were in disrepair.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a safe, clean, and homelike environment for resident rooms and bathrooms, during four days (4/29, 4/30, 5/01, and 5/02/24) of four days observed, in three of four hallways observed.

Inspectors wroteBased on observations, record reviews, and interviews, the facility 1) failed to revise and review one resident (#60) care plan with the appropriate staff/professionals and resident out of forty-one sampled residents, 2) failed to review and revise the care plan for four residents (#55, #1, #47, and #85) related to psychotropic medications, falls, activities of daily living (ADL), and range of motion (ROM) out of forty-one sampled residents.

Inspectors wroteBased on record review, observations and interviews the facility failed to provide restorative therapy related to applying splints for Resident #30 and did not prevent the further decrease in range of motion for Resident #85 out of twelve residents.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure medication was administered in a clean manner, ensure staff doffed PPE (personal protective equipment) appropriately, and residents were offered hand hygiene prior to meals.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accommodate the needs for one resident (#85) related to placing the call light within the resident's reach out of six residents sampled for environmental concerns.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure two dependent residents (#81 and #13), were provided with Activity of Daily Living(ADL) assistance related to hair and fingernail care out of forty one sampled residents. Finding Included: 1. During an observation on 04/29/2024 at 11:00 a.m., Resident # 81 was observed laying down in bed dressed in his nightgown with his call light within reach. Resident # 81 fingernails were observed long and dirty and he had thick facial hair. Resident # 81 stated he has asked staff to cut his hair and his fingernails, but they will not assist him. During an observation on 04/30 /24 at 02:24 PM Resident #81 was observed laying down in bed with his call light in reach, dressed in his nightgown. Resident # 81 said he has asked his aide to cut his facial hair and his fingernail, but she did not assist him with his care. [...]

Inspectors wroteBased on observations, record reviews, and interviews the failed to ensure two residents (# 68, 13) residing on the same hall were provided with activities out of eight residents sampled. Finding Include: 1. During an observation made on 04/29/2024 at 10:00 a.m., 11:30 a.m., and again at 3:00p.m., Resident# 68 was observed in bed, leaning off the side of her bed. Resident # 68 was dressed in her nightgown, with her call light out of her reach. During an observation made on 04/30/24 at 9:00 a.m. and 11:30 a.m., Resident # 68 was observed in bed, dressed in a nightgown with her call light out of reach. Resident # 68 was observed leaning to the side. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to assess and obtain physician orders for the wounds of two (#60 and #45) out of three residents sampled for skin conditions.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide dialysis care and services to meet the needs of one resident (#53) out of eight residents related to timely assessment and vital signs post dialysis.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to obtain blood pressures for one (#60) out of 5 residents sampled for unnecessary medications related to the physician ordered vasodilator, Hydralazine.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure medications were stored in a safe and secure manner and failed to ensure medications were discarded after manufacturer expiration date and failed to label medications with shortened shelf lifes with open dates.

Inspectors wroteBased on observations, staff/resident interviews and record review, the facility failed to treat residents with respect and dignity as evidenced by five staff members (A, B, D, E, F) failing to knock or announce themselves prior to entering occupied resident rooms in two halls (300 and 400) of four halls for four of four days observed (2/14/2022, 2/15/2022, 2/16/2022, and 2/17/2022).

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure activities were provided for seven dependent residents (#64, #83, #10, #39, #72, #66, and #75) on one hall (Hall 200) of three halls out of a total of twenty one sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to inform representatives of five residents (#34, #9, #54, #93, & #69) of positive cases of COVID-19 in the facility on eight days (1/13/22, 1/17/22, 1/19/22, 1/20/22, 1/23/22, 1/24/22, 1/27/22 and 1/30/22) by 5 p.m. the next calendar day, out of five residents sampled for notification of COVID-19 status.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure a change in condition was identified and addressed in a timely manner for one resident (#83) of fifty sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to identify and develop a care plan with problem areas, goals, and interventions to include the use of an antibiotic and diagnosis of a Urinary Tract Infection (UTI), timely, for one (#62) of fifty sampled residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to update and revise a care plan to reflect non-use of an antidepressant for one (#81) of fifty sampled residents.

Inspectors wroteBased on observations, staff and resident interviews, and medical record review, the facility failed to ensure nail care was provided for one resident (#87) of five sampled residents reviewed for assistance with activities of daily living (ADLs).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure four (#4, #54, #69 and #93) of fifty sampled residents received comprehensive skin assessments weekly in accordance with professional standards, and facility policy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (#67) received services to maintain or promote further range of motion of a contracture related to the application of hand, elbow, knee, and boot splints for four days (02/14/22, 02/15/22, 02/16/22 and 02/17/22) of four days observed of a total sample of 29 residents with contractures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (#4) received care and services to prevent a urinary tract infection of three residents sampled.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory care was consistent with professional standards of practice for one resident (#9) of three sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurate for one resident (#69) related to hospice care of fifty sampled resident records.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a dignified existence for two residents (#3 and #39), with impaired cognitive status and communication deficits, of seven residents, related to direct care staff standing over the residents while assisting them with eating for two of two days.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate and timely completion of grievance reporting, documentation, and resolution for three residents (#2, #51, and #63) of three residents related to maintenance, repair, and replacing of electric wheelchairs and missing personalized wheelchair equipment and an assistive walking device.

Inspectors wroteBased on observations, record review, and interviews, the facility did not ensure that four vials of a Schedule IV medication, Ativan, were stored in a locked, permanently affixed compartment for one medication storage room (300/400 hall) of two medication storage rooms sampled during the performance of the facility task of Medication Storage and Labeling.

Inspectors wroteBased on interview and record review the facility failed to ensure that annual influenza vaccine was offered to one (Resident #73) out of five sampled residents.