Boca Ciega Center

In the surveyor’s words

From the most serious findings on record at Boca Ciega Center, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 25, 2026

  Based 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. Findings included: A review of Resident #6's admission record showed an admission in 02/2020. The diagnosis information included: chronic pain syndrome; neuromuscular dysfunction of bladder; muscle wasting and atrophy not elsewhere classified; idiopathic progressive neuropathy; generalized anxiety disorder; bipolar disorder; type 2 diabetes; atherosclerotic heart disease of native coronary artery without angina pectoris; . A review of Resident #6's BIMS, dated 02/03/2026, documented a score of 14, which indicated cognitively intact. […]

• No harm, potential for more than minimal, widespreadF812May 2, 2024

  Based 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. Finding included During an observation on 4/29/2024 at 11:00 a.m. showed on an initial tour in the kitchen a dirty trash can next to the hand washing station. Food trays were observed piled up on kitchen sink, next to the hand washing station during meal preparation. Dirt and food particles were observed on the walk-in refrigerator floor. During a follow-up kitchen visit on 04/31/2024 at 11:00 a.m., showed the kitchen stove dirty with grease stuck on the side of the stove and missing stove knobs covers. An open garbage can was observed next to cooked food on the stove. […]

• No harm, potential for more than minimal, widespreadF585Feb 17, 2022

  Based on interviews and policy review, the facility did not ensure residents could voice grievances in a safe manner and did not respond to grievances in a timely manner regarding concerns expressed by 8 named residents (Resident #79, #1, #6, #22, #302, #46, #71 and #76) out of 50 sampled residents, and additional unnamed residents. Findings include: On 02/14/22 at 12:44 p.m., an interview was conducted with Resident #6. Resident #6 stated her sister filed a grievance on her behalf related to a staff member in the kitchen who was rude and mean. Resident #6 stated a meeting was held with herself, her sister the Nursing Home Administrator (NHA) and the Director of Nursing (DON). […]

• No harm, potential for more than minimal, patternF584May 2, 2024

  Based 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. Findings included: 1) On 4/29/2024 at 9:53 AM the nightstand of the occupied room [ROOM NUMBER] B was observed to have three drawers. The front of the middle drawer was not attached to the base on the right side, leaving the drawer lopsided and resting on the bottom drawer. (Photographic Evidence Obtained). On 4/29/2024 at 10:00 AM the door to the bathroom in the occupied room [ROOM NUMBER] was observed with a cylindrical metal piece protruding from where the doorknob should be. No doorknob was found. […]

• No harm, potential for more than minimal, patternF657May 2, 2024

  Based 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. Findings included: 1. Review of Resident #60's Admission Record revealed the resident was initially admitted on [DATE] and readmitted on [DATE]. The record included diagnoses not limited to Type 2 Diabetes Mellitus, unspecified peripheral vascular disease, and unspecified sequelae of cerebral infarction. […]