Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Springs At Boca Ciega Bay during CMS and state inspections, most recent first.
A resident with multiple serious conditions, documented decision-making capacity, and a signed Florida DNR order had clear physician orders and care plan entries indicating DNR status. During an episode of respiratory distress and severe hypoxia, the assigned LPN obtained orders to transfer the resident to the ER and left to prepare paperwork, while an RN responded with a crash cart, directed suctioning and oxygen, and then ordered staff to lower the resident to the floor and begin chest compressions without verifying code status. Multiple LPNs rotated performing CPR under the RN’s direction, no overhead code was called, and staff assumed someone had checked the code status; the assigned LPN later discovered the DNR while preparing transfer documents. EMS arrived and continued CPR until the yellow DNR form was printed and provided, at which point compressions were stopped after approximately 20 minutes, despite facility policies requiring staff to refer to the DNR form and physician orders before initiating CPR.
A resident with multiple serious diagnoses had clearly documented DNR status, including a signed state DNR form, care plan entries, and advance care planning notes confirming the wish not to be resuscitated. During an episode of respiratory distress and severe hypoxia, an RN led the emergency response, directing staff to bring the crash cart, suction the resident, move the resident to the floor, and initiate chest compressions without verifying code status. Several LPNs performed CPR in succession, EMS was called and took over compressions, and a code blue was not called overhead. Staff later realized the resident was a DNR only after CPR had been in progress and EMS was present; DNR documentation was then provided and compressions were stopped, but CPR had already been performed for about 20 minutes in direct conflict with the resident’s documented wishes.
A resident with multiple serious diagnoses and clearly documented DNR status, including a signed Florida DNR form and care plan entries, experienced respiratory distress and severe hypoxia. After a provider ordered transfer to the ER, the assigned LPN left to prepare paperwork while an RN responded with a crash cart, suctioned the resident, and directed that the resident be lowered to the floor and CPR started. Several nurses rotated performing chest compressions without verifying code status, assuming the resident was full code. Only after EMS arrived and CPR had been ongoing for about 20 minutes was the resident’s DNR status confirmed via the yellow DNR form, at which point compressions were stopped and the resident was pronounced deceased. Surveyors found that staff failed to honor the resident’s DNR order and advance directive, resulting in an Immediate Jeopardy deficiency.
A resident with multiple chronic conditions and a documented DNR order, including a signed state yellow DNR form and corresponding physician orders in the EHR, developed respiratory distress and low O2 saturation. Nursing staff obtained orders to transfer the resident to the hospital, but as his condition worsened, an RN and several LPNs initiated a code response with a crash cart, suction, and a non-rebreather mask, then lowered the resident to the floor and performed chest compressions without first verifying code status. Staff interviews showed that no one checked the EHR or yellow DNR form before starting CPR, the code was not called overhead, and the code blue worksheet/timeline was not completed. Another RN later confirmed in the EHR that the resident was DNR and provided documentation to EMS, who then stopped compressions after about 20 minutes of CPR. Surveyors found that staff failed to follow facility policies on CPR, advance directives, admission/readmission, and resident rights by not honoring the resident’s DNR order, resulting in an Immediate Jeopardy deficiency.
A resident with a documented DNR order experienced a change in condition, during which an RN, LPNs, and a CNA initiated CPR without verifying the resident’s code status, despite hospital and facility records indicating Do Not Resuscitate. Staff demonstrated confusion about whether CNAs were permitted to perform CPR and were inconsistent in their understanding and use of code blue documentation tools that were supposed to be on the crash cart. Interviews showed that some nurses had never seen the code log, others believed a code timeline was standard but not present, and CNAs were unsure of their CPR role, revealing a lack of clear education and implementation of the facility’s QAPI-driven processes for code response and documentation.
Failure to Honor DNR Order During Code Event
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) order and advance directive during a cardiopulmonary arrest. The resident had multiple significant diagnoses, including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, history of TIA and cerebral infarction, and adult failure to thrive. The medical record contained physician orders documenting DNR status on multiple occasions, and the care plan stated the resident had capacity to make health care decisions and had signed a DNR, with the signed Florida DNR form scanned into the electronic health record. A hospitalist progress note also documented that the resident was DNR and had declined invasive measures such as a PEG tube, opting for comfort-focused care and liberalized diet for quality of life. On the day of the incident, the resident complained of shortness of breath and was noted to be hypoxic, with oxygen saturation documented as low as 55%. The assigned LPN assessed the resident, contacted the NP, and obtained orders to transfer the resident to the ER. While the assigned LPN left the room to prepare transfer paperwork, another RN (the nurse manager) was notified and went to the resident’s room with the crash cart. According to interviews and the facility’s internal timeline, the RN found the resident in respiratory distress, drooling, and directed staff to obtain towels, oxygen equipment, suction, and a non-rebreather mask. The resident was suctioned, placed on a non-rebreather, and then lowered to the floor. The RN did not verify the resident’s code status before directing staff to initiate chest compressions. Multiple nurses, including several LPNs, participated in performing chest compressions, rotating as directed by the RN who was leading the code. Staff reported that a code blue was not called overhead and that they assumed someone had checked the resident’s code status. The assigned LPN later stated he did not realize the resident was a DNR because this was not indicated on the face sheet. Another LPN discovered the resident’s DNR status while preparing transfer paperwork and questioned why CPR was being performed. EMS arrived and instructed staff to continue compressions until they could review documentation; compressions continued until the yellow Florida DNR form was produced and provided to paramedics. The facility’s investigation and timeline showed that chest compressions were performed for approximately 20 minutes before being discontinued, despite the presence of a physician-signed DNR order and a scanned Florida DNR form in the record, resulting in the facility’s failure to follow the resident’s advance directive and physician orders. The facility’s own policies on Emergency Care (CPR) and Advance Directives required staff to identify and honor each resident’s choice for treatment, to use the yellow DNR form as the physician order concerning CPR, and to refer to the presence of the yellow form and/or physician orders to determine if CPR should be performed in a cardiac emergency. Interviews with the Nursing Home Administrator and regional clinical leadership confirmed that, prior to this event, the process relied on the nurse to verify code status in the electronic health record and dashboard, and that in this incident the resident’s code status was not verified before CPR was initiated. The surveyors determined that this failure to honor the resident’s DNR and advance directive caused unnecessary physical harm and pain and denied the resident a peaceful death, and that it created a situation resulting in a worsened condition and likelihood for serious injury and/or death, leading to an Immediate Jeopardy determination.
Removal Plan
- Initiated disciplinary action and suspension for two nurses.
- Terminated an RN and reported the RN to the Board of Nursing.
- Reviewed nurse files to confirm CPR certification, licensure, skills checklists, and background checks were present for all nurses.
- Held ad hoc QAPI meetings to discuss the concern and correction plan.
- Held an ad hoc meeting to provide additional education and reinforce prior education on code status and abuse, neglect, and exploitation (ANE), and to review and approve a code blue worksheet and an abuse posttest.
- Held an ad hoc meeting to review, revise, and approve the code blue worksheet.
- Implemented staff review of the revised code blue worksheet on the units and allowed any staff member to complete the code blue worksheet.
- Educated all nurses on advance directives, resident right to make decisions, emergency care (CPR), and ANE.
- Educated new licensed staff on abuse and code status upon hire.
- Reviewed all resident medical records to verify code status orders.
- Audited residents who expired in the facility to confirm code status was honored.
- Initiated and continued mock code drills on varying shifts and days.
- Reviewed and verified code status for all new admissions.
- Provided reinforcement education to nurses to verify and document code status orders.
- Implemented the code drill worksheet and revised it to include a checkbox for full code/DNR.
- Provided additional education to non-licensed staff to reinforce prior education on code status, who can perform CPR and emergency care, advance directives, ANE, and their role during a code blue.
- Continued reinforcement education and required staff to complete it prior to working their next shift.
Failure to Honor DNR Resulting in CPR Performed Against Resident’s Wishes
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Do Not Resuscitate (DNR) status and right to refuse CPR, resulting in CPR being performed against the resident’s documented wishes. The resident had multiple serious medical diagnoses, including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, prior TIA, cerebral infarction without residual deficits, and adult failure to thrive. The medical record contained multiple physician orders documenting DNR status, including a State of Florida yellow DNR form signed by the resident and physician and scanned into the electronic health record. The resident’s care plan documented that the resident had capacity to make health care decisions and had signed a DNR, and advance care planning notes and a hospitalist progress note also confirmed DNR status and the resident’s preference for comfort-focused care. On the day of the event, the resident complained of shortness of breath and was noted to be hypoxic, with oxygen saturation documented as low as 55%. Nursing staff contacted the provider, who ordered transfer to the ER. While the assigned LPN left the room to prepare transfer paperwork, another RN responded to the room after being told assistance was needed. That RN brought the crash cart, suctioned the resident for drooling, and observed agonal breathing followed by cessation of breathing. Multiple witnesses reported that this RN directed the response in the room, instructing staff to obtain oxygen equipment and suction, to place the resident on the floor with a backboard, and to initiate chest compressions. Several LPNs took turns performing chest compressions, and paramedics were called and took over CPR when they arrived. Staff reported that a code blue was not called overhead and that the resident’s code status was not verified before CPR was started. Interviews and record review showed that staff performing and directing CPR either did not check the resident’s code status or assumed someone else had done so. The assigned LPN stated he did not realize the resident was a DNR because the face sheet showed full code, and another LPN stated she began compressions based on the RN’s direction without confirming code status. The RN leading the response did not verify the code status prior to initiating compressions, and staff reported that the resident’s DNR status was only recognized after CPR had been in progress and EMS was already on scene. A timeline from the facility’s investigation documented that chest compressions began at 3:18 p.m., EMS arrived at 3:23 p.m., the DNR status was identified at 3:35 p.m., and DNR documentation was provided to EMS at 3:38 p.m., at which time compressions were discontinued. In total, chest compressions were performed for approximately 20 minutes on a resident who had an active DNR order and documented wishes not to be resuscitated. The surveyors determined that this failure resulted in a situation that created a worsened condition and the likelihood for serious injury and/or death and constituted Immediate Jeopardy. The report also notes that the facility’s policies required staff to identify and follow each resident’s advance directives, including referring to the yellow DNR form and physician orders before initiating CPR. Staff interviews revealed inconsistent understanding and use of tools to verify code status, such as a code status book or code blue sheets, and multiple staff stated they had not seen or used code blue logs or worksheets prior to this event. The Nursing Home Administrator acknowledged that the expectation was for staff to assess a resident and determine code status before initiating CPR, and that if a resident had DNR orders, chest compressions should not be performed. Despite these policies and expectations, the resident’s clearly documented DNR status was not checked or followed before CPR was initiated and continued for an extended period.
Removal Plan
- Disciplinary action/suspension was initiated for two nurses
- RN was terminated and reported to Board of Nursing
- Nurse files were reviewed and it confirmed CPR certification, license, skills checklists and backgrounds were present for 100% of nurses
- Ad hoc QAPI meetings were held to discuss concern and correction plan
- Ad hoc meeting was held to review IJ citations
- Ad hoc meeting was held to provide additional education to evaluate and reinforce education previously provided on code status, abuse, neglect, and exploitation (ANE); reviewed and approved a code blue worksheet; reviewed and approved an abuse posttest to reinforce prior education
- Ad hoc meeting was held to review, revise and approve code blue worksheet
- Revised code blue worksheet was taken to units and staff review of the worksheet was initiated
- Implemented that anyone can complete the code blue worksheet
- Educated 100% of nurses on advance directives, resident right to make a decision, emergency care (CPR), and ANE
- New licensed staff were educated on abuse and code status upon hire
Failure to Honor DNR Order During CPR Event
Penalty
Summary
Facility staff failed to honor a resident’s physician-ordered Do Not Resuscitate (DNR) status when the resident was found unresponsive and staff initiated Cardiopulmonary Resuscitation (CPR), including chest compressions, without first confirming code status. The resident had a documented history of serious medical conditions including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, prior TIA, cerebral infarction without residual deficits, and adult failure to thrive. The medical record contained multiple physician orders documenting DNR status, including a State of Florida DNR form signed by the resident and physician and scanned into the electronic health record, as well as care plan entries and advance care planning notes confirming the resident’s wish to be DNR and to avoid aggressive interventions such as feeding tubes. On the day of the event, the resident complained of shortness of breath and was noted to be hypoxic, with oxygen saturation documented as low as 55%. Nursing staff contacted the provider, who ordered transfer to the ER. While the assigned nurse left the room to prepare transfer paperwork, another RN responded to the resident’s respiratory distress, brought the crash cart, and began directing the emergency response. Staff reported that the resident was drooling, appeared to be in respiratory distress, and was suctioned and placed on a non-rebreather mask. During this process, the resident developed agonal breathing and then stopped breathing. At the direction of the RN leading the event, the resident was lowered to the floor and chest compressions were initiated by an LPN, with subsequent rotation of multiple nurses performing compressions. Multiple staff involved in the code, including LPNs and RNs, acknowledged that the resident’s code status was not verified before CPR was started. Staff assumed the resident was a full code, and one LPN stated she did not check code status because she was specifically called by the RN to start compressions. Another LPN later discovered in the electronic record that the resident was DNR while CPR was ongoing. Paramedics arrived and instructed staff to continue compressions until they could review documentation; CPR continued for approximately 20 minutes until the yellow State of Florida DNR form was produced, at which point EMS stopped compressions and the resident expired. The surveyors determined that by providing CPR, staff failed to honor the resident’s advance directive and signed DNR order, causing unnecessary physical harm and pain and denying the resident a peaceful death, and this failure resulted in a determination of Immediate Jeopardy. Interviews with the Nursing Home Administrator and regional clinical leadership confirmed that the facility’s policy required staff to determine a resident’s code status, including reference to the yellow DNR form and physician orders, before initiating CPR. The NHA stated that if a resident had DNR orders, the expectation was that staff would not perform chest compressions and would instead focus on comfort. The facility’s policies on emergency care (CPR), advance directives, and resident rights all emphasized honoring the resident’s treatment choices and using the signed yellow DNR form as the physician order concerning CPR. Despite these policies and the presence of clear DNR documentation in the record and care plan, staff did not verify code status prior to initiating CPR, leading to the Immediate Jeopardy finding.
Removal Plan
- Disciplinary action/suspension was initiated for two nurses.
- The RN involved was terminated and reported to the Board of Nursing.
- Nurse files were reviewed and confirmed CPR certification, license, skills checklists, and background checks were present for 100% of nurses.
- Ad hoc QAPI meetings were held to discuss the concern and correction plan.
- An ad hoc meeting was held to review IJ citations and to plan additional education on code status and abuse/neglect/exploitation (ANE), approve a code blue worksheet, and approve an abuse posttest to reinforce prior education.
- An ad hoc meeting was held to review, revise, and approve the code blue worksheet.
- The revised code blue worksheet was taken to units and staff review of the worksheet was initiated.
- Education was provided to 100% of nurses on advance directives, resident right to make decisions, emergency care (CPR), and ANE.
- New licensed staff were educated on abuse and code status upon hire.
- A 100% review of resident medical records was completed to verify code status orders.
- An audit of residents who expired in the facility in the past 90 days was conducted with no concerns found related to honoring code status.
- Mock code drills were initiated and continued on varying shifts and days.
- Code status for all new admissions was reviewed and verified.
- All nurses received reinforcement education to verify and document code status orders.
- Implementation of the code drill worksheet began and feedback was incorporated to add a checkbox for full code/DNR.
- Additional education was provided to non-licensed staff to reinforce prior education on code status, who can perform CPR and emergency care, advance directives, ANE, and their role during a code blue.
- Reinforcement education was ongoing and staff were to complete it prior to working their next shift.
Failure to Verify and Honor DNR Order Before Initiating CPR
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff were competent in identifying and honoring a resident’s code status and following physician orders for Do Not Resuscitate (DNR). A resident was admitted and later re-admitted with multiple diagnoses including myasthenia gravis, immunodeficiency, COPD, acute pulmonary edema, peripheral vascular disease, history of TIA and cerebral infarction without residual deficits, and adult failure to thrive. The resident had a State of Florida yellow DNR order signed by the resident and physician and scanned into the electronic health record, and there were physician orders in the record reflecting DNR status, including orders that had been changed from full CPR to DNR. On the day of the event, the resident experienced respiratory distress, with staff noting shortness of breath, low oxygen saturation, congestion, and drooling. Nursing staff contacted the provider and obtained orders to transfer the resident to the hospital. As the resident’s condition worsened, multiple staff responded to the room. A crash cart was brought, suction and oxygen equipment were set up, and the resident was suctioned and placed on a non-rebreather mask. The resident was then lowered to the floor and chest compressions were initiated. Staff interviews consistently indicated that no one verified the resident’s code status in the electronic health record or by locating the yellow DNR form before starting CPR. Staff reported that the nurse manager in the room directed the response, including instructing an LPN and CNA to move the resident to the floor and instructing the LPN to begin chest compressions. Several LPNs took turns performing compressions, and staff stated they assumed someone had checked the code status or believed the resident was a full code. The code blue was not called overhead, and the code blue worksheet/timeline on the crash cart was not completed during the event. During the ongoing CPR, another RN arrived, questioned the resident’s code status, and checked the electronic record, confirming the resident had DNR orders. Staff then informed EMS personnel that the resident was DNR and provided the yellow DNR documentation, at which point paramedics discontinued compressions. Facility investigation and timelines showed that chest compressions were initiated at approximately 3:18 p.m., EMS arrived shortly thereafter, and compressions continued until about 3:38 p.m., totaling roughly 20 minutes of CPR on a resident with an active DNR order. Interviews with facility leadership and regional clinical staff confirmed that the process in place at the time relied on staff checking the electronic health record or the presence of the yellow DNR form to determine whether CPR should be performed, but in this incident, staff did not verify the code status before initiating resuscitation. The facility’s own policies on emergency care (CPR), advance directives, admission/readmission, and resident rights required verification and implementation of the resident’s DNR orders, which did not occur in this case. The surveyors determined that this failure to verify and honor the resident’s DNR order resulted in CPR being performed contrary to the resident’s documented wishes and physician orders. The report states that the CPR provided denied the resident the right to a peaceful death and caused unnecessary physical harm and pain. This situation was determined to have created a worsened condition and the likelihood for serious injury and/or death to the resident and led to a finding of Immediate Jeopardy. Cross-references were made to deficiencies related to resident rights, freedom from abuse/neglect, and quality of life (F578, F600, and F678).
Removal Plan
- Initiated disciplinary action/suspension for two nurses; terminated the RN involved and reported the RN to the Board of Nursing.
- Reviewed nurse personnel files and confirmed all nurses had current CPR certification, active license, skills checklists, and background documentation.
- Held ad hoc QAPI meetings to discuss the concern and develop the correction plan, including review of IJ citations.
- Conducted an ad hoc QAPI meeting to plan additional education reinforcing prior education on code status; reviewed and approved a code blue worksheet; reviewed and approved an abuse post-test to reinforce prior education.
- Conducted an ad hoc QAPI meeting to review, revise, and approve the code blue worksheet.
- Deployed the revised code blue worksheet to units and initiated staff review of the worksheet; allowed any staff member to complete the code blue worksheet.
- Provided education to all nurses on advance directives, resident right to make decisions, emergency care (CPR), and abuse/neglect/ANE.
- Educated newly licensed staff upon hire on abuse and code status.
- Completed a review of resident medical records to verify code status orders.
- Audited residents who expired in the facility and found no concerns related to honoring code status.
- Initiated mock code drills on varying shifts and days.
- Reviewed and verified code status for all new admissions.
- Provided reinforcement education to all nurses to verify and document code status orders.
- Implemented the code drill worksheet and added a checkbox for Full Code/DNR based on feedback.
- Provided additional education to non-licensed staff reinforcing prior education on code status, who can perform CPR and emergency care, advance directives, and abuse/neglect/exploitation (ANE) and their role during a code blue.
- Continued ongoing education so staff complete reinforcement education prior to working their next shift.
Failure to Verify DNR Status and Inconsistent Code Response Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff were educated and equipped to respond appropriately to a resident’s change in condition, specifically regarding verification of code status, CNA involvement in CPR, and use of code documentation tools. Record review showed that Resident #1 had a signed Do Not Resuscitate Order (DNRO) on file, and hospital records uploaded into the facility’s system documented the resident’s code status as Do Not Resuscitate on two separate dates, with no evidence that this order had been rescinded. The facility’s own physician orders also showed a DNR order initiated for this resident. Progress notes documented that Resident #1 experienced a change in condition at the facility, during which an RN assessed the resident, who then stopped breathing and was reported to have no pulse. The RN directed an LPN and a CNA to place the resident on the floor and begin chest compressions. The CNA stated that CNAs were not allowed to perform CPR at the facility, and LPN staff continued CPR until EMS arrived and took over. Interviews with the Nursing Home Administrator and regional leadership confirmed that the involved staff did not verify the resident’s code status prior to initiating CPR, despite the resident’s documented wishes not to be resuscitated. Multiple staff interviews revealed inconsistent understanding of the facility’s code procedures, the role of CNAs in CPR, and the use and availability of code blue forms or timelines. The NHA stated that CNAs were not allowed to perform CPR and that if CPR was started, the code should be documented using paper attached to the crash cart, but acknowledged that staff did not use this documentation during the event. Some LPNs reported that code sheets or timelines were supposed to be on the crash cart, while others stated they had never seen a code blue log or were unaware that a code timeline was used. CNAs expressed uncertainty about whether they were allowed to perform CPR, and one CNA referenced a book at the desk listing residents’ code statuses. Review of the facility’s Quality Management/QAPI policy showed that the facility’s QAPI program was intended to use data and systemic analysis to improve care, but the events described demonstrated that staff were not consistently following or aware of established processes related to code status verification and code response documentation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near South Pasadena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boca Ciega Center | 0.5 mi | ★★★★★ | 1 | 0 |
| Egret Cove Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Gulfport Nursing Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Marion And Bernard L Samson Nursing Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Aviata At The Sea - Pasadena | 1.2 mi | ★★★★★ | 0 | 0 |
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