Springs at Boca Ciega Bay

Inspectors wroteBased on record review and interviews, the facility failed to ensure an injury of unknown source-an acute right subcapital femoral neck fracture, was reported to the Agency for Healthcare Administration (AHCA), Adult Protective Services (APS), and local law enforcement within 24 hours of becoming aware of the X ray results, for one resident (#2) of six sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to implement a care planned intervention for the use of floor mats for one resident (Resident #2) of six sampled residents. Resident #2's care plan included the use of floor mats when the resident was in bed; however, the intervention was not in place at the time of the resident's fall on 04/08/2026.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide adequate supervision to reduce the risk of accidents for one resident (#3) of six sampled residents. Resident #3 experienced six falls between 05/13/2026 and 06/06/2026. Only four of the falls were recorded in the facility's fall log, and the required post fall investigations and care plan revisions were not consistently completed.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident experiencing a new onset of significant pain was assessed, had pain characteristics documented, and the pain was reported to the physician and hospice in a timely manner for one resident (#2) of six sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure advanced directive wishes and physician orders were followed for one resident (#1) out of six residents sampled for advanced directives. On [DATE], facility staff initiated cardiac compressions (Use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly causes physical damage including fractured ribs or sternum, bruising, and internal organ injury) on Resident #1 after determining no pulse or respirations. The resident had wishes to not be resuscitated and had a physician order for Do Not Resuscitate (DNR), dated [DATE]. Emergency Medical Services (EMS) were called and paramedics took over compressions. Facility staff informed EMS Resident #1 was a DNR and provided the State of Florida DNR form to the paramedics. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents were free from abuse by performing Cardiopulmonary Resuscitation (CPR) against the resident's wishes for one resident (#1) out of six residents sampled for Advance Directives. On [DATE], Resident #1 experienced a change of status when his oxygen saturation levels dropped to 55% (Normal oxygen saturation levels range from 95%-100%). Resident #1 stopped breathing and was without a pulse. The facility staff initiated CPR. Resident #1 had a physician order for Do Not Resuscitate (DNR), dated [DATE]. Cardiac compressions (Use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly causes physical damage including fractured ribs or sternum, bruising, and internal organ injury) were initiated by staff. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to honor a Do Not Resuscitate (DNR) order for one resident (#1) out of three residents sampled. Facility staff unnecessarily provided chest compressions for twenty minutes causing physical harm and a traumatic end of life. On [DATE], Resident #1 was found unresponsive by facility staff. Facility staff performed Cardiopulmonary Resuscitation (CPR), including chest compressions, without confirming Resident #1's preferred resuscitation status. The resident had a physician order for DNR, dated [DATE]. Emergency Medical Services (EMS) were called to the facility, and paramedics took over chest compressions. After twenty minutes of CPR, facility staff informed EMS Resident #1 was a DNR and provided the State of Florida DNR form to the paramedics. Paramedics ceased chest compressions and Resident #1 expired. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure nursing staff were competent in identifying residents code status and following physician orders for Do Not Resuscitate (DNR) for one resident (#1) out of six residents sampled. On [DATE], Resident #1 stopped breathing and was without a pulse. The facility staff initiated CPR. Resident #1 had a physician order for Do Not Resuscitate (DNR), dated [DATE]. Cardiac compressions were initiated by staff (Use of hands to push down hard and fast to manually pump blood through the heart. The pressure from cardiac compressions commonly caused physical damage including fractured ribs or sternum, bruising, and internal organ injury). Emergency Medical Services (EMS) were called and paramedics took over compressions. Facility staff informed EMS Resident #1 was a DNR and provided the documentation to the paramedics. [...]

Inspectors wroteBased on record reviews, policy reviews, Quality Assurance Performance Improvement (QAPI) documentation, and interviews the facility failed to ensure staff were educated and had the tools to respond to a resident's change in condition related to knowing if the Certified Nursing Assistant's (CNA) were allowed to perform cardiopulmonary resuscitation (CPR) and if code blue forms were utilized during a code.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety as indicated by the following: - Refrigerated, ready-to-eat, Time/temperature Control for Safety foods were stored too long under refrigeration and not date-marked to indicate when the food must be consumed or discarded. - The kitchen area was not protected from contamination from unauthorized employees entering the area and not wearing hair restraints. - Stored packaged food was not protected from potential cleaning chemical contamination in the food storage room. - The surface material of equipment was not kept in good condition and was not smooth and easily cleanable. - Clean eating equipment was not stored in a manner to prevent contamination of the mouth/food contact surfaces. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement appropriate plans of actions to correct identified quality concerns related to resident falls. This concern has the potential to affect all residents in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide resident centered restorative services to maintain or improve mobility for three residents (#62, #47, and #46) of three residents sampled for restorative services.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the appropriate transfer/discharge notice to the resident and their responsible party and failed to notify the Office of the State Long-Term Care Ombudsman of a resident's discharge for one resident (#98) of two sampled residents reviewed for transfer and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the care plan for one resident (#13) of 20 sampled residents whose care plans were reviewed, to reflect the current interventions to manage healing and prevention of pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and meal tray identification, the facility failed to provide the correct therapeutic diet to one resident (#55) of two residents reviewed for nutritional status who was at nutritional risk.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to document observed wandering behaviors to ensure an accurate medical record for one (Resident #46) of one resident observed with wandering behaviors.

Inspectors wroteBased on observations interviews and record reviews the facility failed to ensure necessary services to maintain a rehabilitation device in a sanitary manner for four days (01/04/22, 01/05/22, 01/06/22 and 01/07/22) for one resident (#34) out of 29 sampled residents.

Inspectors wroteBased on of observations, interview and policy review the facility failed to ensure a clean and sanitary homelike environment related to a spot on the wall and baseboard in two places for one resident room (48) of twenty-six rooms observed on Station 3 for three days (01/04/22, 01/05/22 and 01/06/22) of four days.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure appropriate and sanitary storage of respiratory equipment of an oxygen nasal cannula for one resident (#193) of sixteen residents who use oxygen for four of four days (01/04/22, 01/05/22, 01/06/22 and 01/07/22).

Inspectors wroteBased on interview and record review, the facility failed to ensure a PRN (as needed) psychotropic medication order was limited to a 14 day duration for one resident (#26) of five residents reviewed.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to ensure that a standard infection control was utilized during incontinent care with one (#30) resident out of 35 sampled residents; that a blood monitoring device was cleaned and disinfected in-between three (60, 9 & 17) residents out of a total of nine residents with blood monitoring orders; contaminated dressing of bodily fluids were removed after completion from one (#4) resident environment; and that supervision was provided to one (#23) of one resident with conjunctivitis to prevent recontamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor residents' rights to dignity for 1 of 35 (#83) sampled residents, related to the dining experience and the height of the table.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan that included instructions needed to provide care, related to the use of an elastic wrap bandage for 1 of 35 (#149) sampled residents.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure residents were free of accidents hazards, related to bed not maintained in the low position while in bed, for 1 of 35 (#52) sampled residents.

Inspectors wroteBased on observation, interview and medication storage, the facility failed to ensure that one (high hall) out of three medications carts were stored according to professional principles, related to the cart contained: medication without a resident identifier, medication without an active Physician order, and a torn controlled substance card holding a pill in place with a piece of tape, out of a total of six medication carts identified by the facility. Findings Included: On [DATE] at 11:45 a.m. the medication cart on high hall was observed, alongside Licensed Practical Nurse I (LPN I). A box contained a label for albuterol for 7 days. LPN I indicated that the last day for the medication was on [DATE]. She confirmed no active order was in place (photographic evidence was obtained). One box of debrox ear drops were noted that had a written date of [DATE]. [...]

Inspectors wroteBased on observation, interview and medical record review, the facility failed to ensure that dental services were provided to one (#4) out of thirty-five residents for over for twenty months. Findings Included: On 01/22/20 at 10:17 a.m., Resident #4 was observed lying in bed. He was asked if he had any problems chewing or swallowing. He made eye contact with stimuli. His lower bottom teeth were crooked and yellow in appearance. The lower left was lacking teeth. He was asked if he had any pain or soreness in his mouth, as he continued to watch the surveyor and not respond. On 1/23/2020 at 10:15 a.m., a wound care observation was conducted with the facility Wound Care Licensed Practical Nurse (WN). Resident #4 was observed lying in his bed and appeared comfortable when approached. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the kitchen in a clean and sanitary manner, related to the dish machine, cleaning of dish cloths and a stove backsplash.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all kitchen equipment in a safe operating condition, related to 2 of 6 (top left, top middle) burners on the stove and a reach-in refrigerator located in the satellite kitchen.