Inspection visit
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings included:
On 01/04/22 at 9:15 a.m., an initial observation was conducted of resident room [ROOM NUMBER] on the
hall of Station 3. During the observation a spot was seen on the wall in the middle of the room, which
extended down to the baseboard in two places. (Photographic Evidence Obtained)
A subsequent observation was conducted on 01/04/22 at 12:47 p.m. During the observation a family
member in the room visiting the resident was interviewed. The family member indicated the resident was
admitted on the evening of 12/31/21, and further revealed he never sees anyone cleaning the room. The
family member stated, The housekeeping could be better. During the interview the family member revealed
he had not spoken to anyone in the facility regarding the spot on the wall that extended down to the
baseboard and could be seen in two places. He further revealed since he had complained about other
housekeeping issues since the resident's admission, he did not want to continue to complain to the facility
and stated, I am tired of talking to them.
On 01/05/22 at 9:00 a.m., an observation was conducted of Resident room [ROOM NUMBER] which
revealed the spot on the wall and on the baseboard in two places.
During a follow-up observation and interview, on 01/05/22 at 3:11 p.m., of Resident room [ROOM
NUMBER], the spot was observed on the wall and baseboard, and the resident's family member indicated
he had not mentioned to the facility the dirty spot on the wall.
On 01/06/22 at 10:18 a.m. an observation was made of the resident room and a chair was placed in front of
the spot on the wall and baseboard. The resident was not in the room at the time.
On 01/06/22 at 11:55 a.m., another subsequent interview and observation was conducted in Resident room
[ROOM NUMBER]. The resident's visitor stated, I am upset by the spot on the wall. I called him (the
resident's spouse) and he told me its been here ever since she came.
During an interview with the Nursing Home Administrator (NHA) on 01/06/22 at 12:03 p.m., she confirmed
the spot on the wall that extended down to the baseboard in two places, while the resident's visitor was in
the room. The NHA indicated she would have housekeeping address the spot and the visitor
(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 9
Event ID:
105537
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
105537
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Boca Ciega Bay
1255 Pasadena Ave S, Suite C
South Pasadena, FL 33707
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
in the room told the NHA the spot on the wall, and the two on the baseboard were not from the present
resident in the room. The NHA acknowledged the visitor and stated Ok.
On 01/06/22 at 12:51 p.m., an interview was conducted with the Environmental Services Director (EVS)
who revealed the floors, and bathrooms should be cleaned every day. He further indicated if the
housekeeping staff see the spot, they should clean it, its part of the cleaning process.
A review of facility policy titled, Environmental Services-Cleaning Schedules Respiratory, read under Policy:
Cleaning Schedules shall be developed and implemented to ensure that our health center is maintained in
a clean and comfortable manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105537
If continuation sheet
Page 2 of 9
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
105537
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Boca Ciega Bay
1255 Pasadena Ave S, Suite C
South Pasadena, FL 33707
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 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Some
Findings included:
Review of the admission Record for Resident #34 showed the resident was admitted to the facility on
[DATE] with diagnoses to include anterior displaced Type II dens (odontoid bone) fracture, subsequent
encounter for fracture with routine healing, spondylolysis of cervical region, repeated falls, pain in right
shoulder and other abnormalities of gait.
A review of the Quarterly Minimum Data Set (MDS) for Resident #34, dated 11/09/21, Section C Cognitive
Patterns showed a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impairment.
Section G Functional Status showed Resident #34 required extensive assistance for activities of daily living
(ADLs) including bed mobility, transfers, locomotion in and off unit, eating, toilet use and personal hygiene.
Review of the current physician orders for Resident #34 printed on 01/06/22 showed Resident #34 wears a
clavicle neck brace with active orders dated 08/03/21. The physician orders included the following:
*Rigid collar on neck on at all times, check skin around and under collar every shift for monitoring.
*Apply [name of product] dressings to L (left) clavicle under neck brace for patient comfort. Change on
shower days, every evening shift every Tuesday and Friday.
The physician orders did not indicate the process for care, cleaning, or replacement of the cervical collar
brace and brace pads.
On 01/04/22 at 1:20 p.m., an observation was made of Resident #34 in his room. Resident #34 was having
lunch and was noted with soup spilling in his neck collar as he ate his lunch.
On 01/05/22 at 12:26 p.m., an observation was made of Resident #34's cervical neck collar with food and
residue from his meal. The neck padding was noted with an orange color from the soup he had been
drinking. Resident #34 was observed spilling soup on himself during the meal. The neck brace pads
inserted on the inside of the cervical collar were noted with a wet sponge like material from the soup.
On 01/05/22 at 1:57 p.m., an interview was conducted with Staff C, Certified Nursing Assistant (CNA). Staff
C stated he worked closely with the resident. Staff C stated Resident #34 does not require assistance with
ADLs and typically requires cueing and supervision for meals only.
On 01/05/22 at 2:00 p.m., Resident #34 was observed in his room, neck collar observed with food residue.
An immediate interview was conducted with Resident #34. Resident #34 was asked if he had received
assistance with cleaning his neck collar after meals. Resident #34 stated that Staff C, CNA had
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105537
If continuation sheet
Page 3 of 9
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
105537
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Boca Ciega Bay
1255 Pasadena Ave S, Suite C
South Pasadena, FL 33707
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 0677
Level of Harm - Minimal harm
or potential for actual harm
wiped it down with a towel. When asked if the neck padding was wet, Resident #34 said, Yes, a little. It gets
wet when I drink anything.
On 01/06/22 at 09:12 a.m., Resident #34 was observed having finished breakfast meal. Resident #34's
neck collar was observed with food residue and an appearance of heavily stained brown marks.
Residents Affected - Some
On 01/06/22 at 09:12 a.m., an interview was conducted with Staff C. Staff C made an observation of
Resident #34's neck collar with food remnants and food stains on the cervical collar and padding. Staff C
stated he would wipe it down. When asked how often the cervical collar brace and pads was cleaned, Staff
C said, I wipe it down with a washcloth after meals. Staff C was observed with a wet towel and wiped down
the collar. Staff C said, I don't know when it is supposed to be changed. Maybe the nurse does it. Staff C
confirmed he had not noted the cervical collar padding being washed.
On 01/07/22 at 10:59 a.m. Resident #34 was observed in his room. Resident #34's neck collar padding was
noted with brown and orange stains. Resident #34 stated he heard they have ordered a new padding for
him. Resident #34 said, It will be nice to have it changed. It will get rid of the smell. Sometimes it [cervical
collar padding] smells like the food I ate.
Review of a Treatment Administration Record (TAR) dated 12/1/21 to 12/31/21 showed an order to apply
[name of product] dressing to L clavicle under neck brace for patient comfort every evening shift every
Tuesday and Friday with missing documentation on 12/3, 12/7, 12/10, 12/14, 12/17, 12/21 and 12/24.
The TAR did not show documentation related to process for care, cleaning, or replacement of the cervical
collar brace and brace pads.
A care plan for Resident #34 showed an ADL Focus initiated on 08/18/21. The
Focus stated Resident #34 has a self-care performance deficit related to dementia, impaired balance,
limited range of motion, (ROM) pain, fracture, cardiac deficits, arthritis, neuropathy, spondylolysis, and
incontinence. The goal indicated the resident would improve current level of function through the next
review. Interventions included to adjust provisions for ADLs to compensate for resident's changing abilities,
encourage participation, wear collar as ordered, encourage to use bell for assistance, monitor for changes
as needed, praise all efforts at self-care and Physical Therapy (PT)/ Occupational Therapy (OT) to eval and
treat per doctor's orders.
The care plan did not indicate expectations for care, cleaning or replacement of cervical collar brace and
brace pads.
On 01/06/22 at 1:45 p.m., an interview was conducted with Staff D, Licensed Practical Nurse (LPN). Staff D
stated the nurses are supposed to apply [name of product] dressing twice a week. Staff D confirmed there
was no process to clean or replace the collar padding. Staff D said, We kind of just wipe it off as needed,
we sponge wash. When asked who was responsible for ensuring the collar was clean and sanitary, Staff D
stated anyone can do it. Staff D stated usually the aides wipe it off after meals. Staff D said she would
expect the collar to be changed or cleaned especially if it looks soiled. Staff D said, It should be clean and
sanitary.
An interview was conducted on 01/06/22 at 1:58 p.m. with Staff B, Registered Nurse (RN)/Unit Manager.
Staff B stated Resident #34 used to be in therapy, and they would clean and maintain the neck
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105537
If continuation sheet
Page 4 of 9
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
105537
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Boca Ciega Bay
1255 Pasadena Ave S, Suite C
South Pasadena, FL 33707
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 0677
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
brace. Staff B stated Resident #34 used to have a second padding for replacement, but she did not know
what happened to it. Staff B confirmed it had been months since the padding was replaced or washed. Staff
B said, It has to be months since he was in therapy. Staff B stated she spoke to the Director of
Rehabilitation (DOR) about ordering a replacement. Staff B stated the expectation would be to maintain the
collar in a clean manner. Staff B said, .it should be cleaned more often especially if he is spilling food on
himself. It does not look good. We will fix that.
A follow-up was conducted on 01/06/22 at 2:36 p.m. with the DOR. The DOR stated Resident #34 was no
longer on therapy case load and was discharged around August 2021. The DOR stated Resident #34 had a
spare neck brace padding that was changed and laundered when he was in therapy. The DOR stated
during meals they used to place a washcloth on the padding to absorb the food spills. DOR stated Resident
#34 was put on a restorative program for ROM. When asked who should be caring for the neck brace and
padding, the DOR stated nursing should be caring for braces or splints. The DOR said, There was definitely
a break down on the process. The expectation would have been that the brace replacements pads are
laundered. The DOR stated wearing a wet or stained neck brace was a dignity issue. The DOR said, It is
not sanitary. The DOR stated central supply had ordered replacement padding for the cervical neck brace.
An interview was conducted on 01/07/22 at 9:53 a.m. with the Director of Nursing. (DON). The DON said, I
looked at the resident's orders. There should be an order to care for the collar. DON stated when Resident
#34 was transferred to restorative nursing they should have picked him up. The DON said, I agree, we
dropped the ball. He should not be in a wet collar after meals.
Review of an undated facility policy titled, Restorative nursing - ADL's assistance (bathing, dressing, and
grooming), showed the facility will provide restorative programming to assist residents in attaining and
maintaining the highest practicable level of function. The benefits of restorative ADL programming may
include increased resident self-esteem as well as improve cognition, social acceptance, strength, balance,
and coordination. Under the procedure the policy section, it stated #1. (c.) grooming includes maintaining
personal hygiene or use of adaptive equipment.
#8. The dressing and grooming programs should be carried out at least 6 days a week with daily being
optimal.
Review of the job description titled, Licensed Practical Nurse, revised 03/02, showed the basic function is to
deliver nursing care to residents of the facility. Essential functions noted to include:
#2 Delivers nursing care to patients/ resident.
#3. Makes observations and reports pertinent information related to the care of the resident.
#4. Implements the resident plan of care and evaluates the resident responses.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105537
If continuation sheet
Page 5 of 9
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
105537
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Boca Ciega Bay
1255 Pasadena Ave S, Suite C
South Pasadena, FL 33707
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 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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).
Residents Affected - Few
Findings included:
On 01/04/22 at 11:38 a.m., an observation was conducted of Resident #193's room. During the observation
the oxygen nasal cannula and tubing was located on top of the oxygen concentrator and not stored
appropriately in a storage bag. (Photographic Evidence Obtained)
On 01/05/22 at 9:44 a.m. an observation was conducted of Resident #193's nasal cannula and tubing to be
on top of the concentrator. Resident #193, who was sitting in a wheelchair and watching television,
indicated she put it there when she was done wearing it because there wasn't a plastic storage bag by the
concentrator to put it in.
An observation was conducted on 01/06/22 at 10:17 a.m., of Resident #193's oxygen tubing and nasal
cannula wrapped around the top of the unit. The resident was not in the room at the time. The plastic
storage bag used to store the nasal cannula and tubing was not on or near the oxygen concentrator.
A subsequent observation was conducted on 01/06/22 at 3:16 p.m. of Resident #193's oxygen tubing and
nasal cannula to be located on top of the oxygen concentrator, and there was no plastic storage bag
located on or near the oxygen concentrator.
On 01/07/22 at 9:15 a.m. an observation was made of Resident #193 sitting in a wheelchair watching
television. The oxygen tubing and nasal cannula was seen draped over the resident's bed and stored
appropriately a plastic storage bag. The resident was asked if the staff place her oxygen tubing in a plastic
storage bag after she was done wearing it since she has been admitted , and Resident #193 pleasantly
stated, No, never seen one.
Record review of Resident #193's admission Record indicated she was admitted on [DATE] and re-admitted
on [DATE] with multiple diagnoses that included acute respiratory failure with hypoxia, anemia and heart
failure. Review of an active physician order, dated 12/27/21, for Resident #193 read: Oxygen@ (at) 1-2
Liters/Minute (L/Min) via Nasal Cannula (NC) continuous inhalation at night to keep Saturation (Sats)
>92% every evening and night shift for low O2 Sats at night.
Review of the Minimum Data Set (MDS), dated [DATE], identified in Section C, Cognitive Patterns that
Resident #193's Brief Interview for Mental Status (BIMS) score was 14, on a 15 point scale, indicating the
resident was cognitively intact.
Further record review of Resident #193's care plan, dated 01/04/22, revealed she was care planned to
wear oxygen NC as ordered and tolerated.
On 01/07/22 at 9:23 a.m., an interview was conducted with Staff B, Registered Nurse (RN)/Unit Manager
(UM) for Station Three. During the interview Staff B confirmed the presence of the nasal cannula and tubing
on top of the oxygen concentrator, in Resident #193's room. Staff B stated, It is the nurse's responsibility to
store the oxygen tubing in the plastic bag. Staff B revealed she would obtain
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105537
If continuation sheet
Page 6 of 9
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
105537
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Boca Ciega Bay
1255 Pasadena Ave S, Suite C
South Pasadena, FL 33707
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 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
a new nasal cannula, and a plastic storage bag from the supply room, and change the present nasal
cannula.
An interview was conducted with the Director of Nursing (DON) on 01/07/22 at 9:40 a.m. The DON stated,
When it's not being used, and is PRN (as needed) or used overnight, it has to be stored in the plastic
storage bag to be protected.
A review of facility policy titled, Respiratory Therapy Equipment, Page 01 of Page 02, read as follows:
Oxygen Administration
7. Keep Oxygen cannula and tubing used PRN (as needed) in a plastic bag when not in use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105537
If continuation sheet
Page 7 of 9
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
105537
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Boca Ciega Bay
1255 Pasadena Ave S, Suite C
South Pasadena, FL 33707
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings included:
Record review revealed Resident #26 was admitted to the facility on [DATE] with diagnoses that included
major depressive disorder, and anxiety disorder according to the resident face sheet. Continued review of
the Physician's Order Summary revealed an order for Xanax (Alprazolam) 0.25 milligram (mg) 1 tab orally
(PO) every 4 hours as needed for anxiety, with a start date of 11/24/21; the end date was listed as
'indefinite.'
On 01/05/22 at 12:35 p.m. Resident #26 was observed sitting upright in bed and eating lunch. The resident
was groomed and paying attention to the television. An interview was attempted; however, the resident was
not interviewable.
In an interview with Staff A, Licensed Practical Nurse (LPN) on 01/05/22 at 12:58 p.m., the LPN confirmed
the resident was on PRN Xanax and gets it occasionally. The LPN stated the resident will occasionally get
'shaky' and that is when she gives her the Xanax. Staff A, LPN confirmed the medication does help
sometimes, and the resident has been on the PRN Xanax for a while.
Review of the Medication Administration Record (MAR) revealed Xanax was administered as follows:
November 2021:
-11/24/21, 11/25/21, 11/26/21, 11/29/21, and 11/30/21.
December 2021:
-12/01/21, 12/03/21, 12/06/21, 12/07/21, 12/09/21, 12/11/21 (2 doses), 12/24/21, and 12/27/21.
-January 2022 (to date):
01/03/22, and 01/06/22.
Review of the Pharmacy Medication Regime Reviews revealed a recommendation dated 11/30/2021, which
read:
-This resident is currently receiving the following psychotropic (non-antipsychotic) medication on a PRN
basis: Alprazolam 0.25 mg every 4 hours as needed for anxiety. Please evaluate the resident for the
appropriateness of this medication. If it is to be extended, please document the rationale in the resident's
medical record and indicate the duration of the PRN order.
The recommendation was signed by an unreadable signature with a note that read:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105537
If continuation sheet
Page 8 of 9
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
105537
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/07/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Springs at Boca Ciega Bay
1255 Pasadena Ave S, Suite C
South Pasadena, FL 33707
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
- okayed to cont [continue] on tel [telephone] 12/2/21 at 11pm.
Level of Harm - Minimal harm
or potential for actual harm
There were no pharmacy recommendations for December 2021.
Residents Affected - Few
On 01/07/22 at 10:33 a.m. in an interview with the Director of Nursing (DON), she confirmed the November
2021 pharmacy recommendation was received and the physician was informed. The DON confirmed there
was no rationale documented in the record for continuation of the medication, nor was there an end date on
the order.
On 01/07/21 at 10:47 a.m. an interview was conducted with the facility's Consultant Pharmacist via
telephone. She confirmed she issued a pharmacy recommendation in November 2021 related to the PRN
Xanax order, and stated it was the expectation the order have a justification for continuation and an end
date documented in the medical record.
Review of a facility-provided policy titled, Behavior Monitoring and Psychoactive Medication Management,
undated, did not address the use of PRN psychotropic medications.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105537
If continuation sheet
Page 9 of 9
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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.
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.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
FAQ · About this visit
Common questions about this visit
What happened during the January 7, 2022 survey of SPRINGS AT BOCA CIEGA BAY?
This was a inspection survey of SPRINGS AT BOCA CIEGA BAY on January 7, 2022. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at SPRINGS AT BOCA CIEGA BAY on January 7, 2022?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiatin..."
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.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.