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 Carrollwood Care Center during CMS and state inspections, most recent first.
The facility failed to maintain the kitchen dishwashing machine according to specifications, with wash cycle temperatures consistently below the required 160°F. Staff were unaware of the correct temperature requirements, and the temperature log had undocumented checks. The machine's thermostat needed repair, contributing to the deficiency.
The facility failed to securely store medications in several resident rooms and on a medication cart. Observations showed unsecured medications like dermal wound cleanser, antifungal cream, and eye drops left on nightstands. The ADON confirmed these should not be at the bedside without proper orders. Additionally, a medication cart had loose pills and an expired insulin pen. Facility policy requires proper storage and disposal of medications.
A facility failed to implement timely care plan interventions for a resident's contracture management and hand splinting. The resident, dependent on staff for all ADLs, was observed with severely contracted hands without splints or orthotics. Despite a documented order for daily orthotic use, staff were unaware of the need, and the care plan lacked interventions for splint use. The facility's policy outlined contracture management, but there was no specific policy for care planning, leading to a deficiency.
A resident with severe cataracts did not receive a timely ophthalmology referral despite multiple optometrist evaluations and requests. The resident's care plan included vision interventions, but staff cited insurance issues and health concerns as reasons for the delay. Facility policy on prompt referrals was not followed.
Two residents in an LTC facility experienced a decline in their pressure ulcer conditions due to inadequate care. One resident's dressing was not changed for several days, leading to increased pain and wound deterioration. Another resident had worsening wounds with significant drainage and odor. The facility's wound care protocols were not effectively implemented, resulting in inconsistent care and monitoring.
A facility failed to maintain a resident's PICC line according to professional standards. The dressing on the PICC line was not changed for over two weeks, contrary to the facility's protocol requiring changes every seven days. Additionally, there were no physician orders for the PICC line care, which should have included a standard order set for maintenance. This oversight was confirmed by the LPN/Unit Manager, highlighting a lapse in adherence to the facility's policy on vascular access devices.
A facility failed to maintain a medication error rate below 5%, with a 23.08% error rate observed. A resident was administered several crushed medications without a physician's order, contrary to facility policy. Interviews with staff confirmed the need for a physician's order to crush medications, and the consultant pharmacist noted discrepancies in the guidance for crushing Biktarvy.
The facility failed to store nebulizer masks properly for three residents and did not ensure an LPN wore appropriate PPE while administering medication via a G-tube to a resident. The nebulizer masks were found outside their storage bags, contrary to infection control practices, and the LPN did not wear a gown as required by the facility's Barrier Precautions policy.
Dishwashing Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the kitchen dishwashing machine was maintained and operated according to the manufacturer's specifications, specifically regarding the wash cycle temperatures. During a kitchen tour, it was observed that the dishwashing machine was not reaching the required wash temperature of 160 degrees Fahrenheit. Staff N, a Dietary Aide, was operating the machine and was unaware of the required wash and rinse temperatures. The machine's wash cycle was consistently below the required temperature, reaching only 150 to 152 degrees Fahrenheit, while the rinse cycle exceeded the required 180 degrees Fahrenheit. The Dietary Manager, who had been in the position for about three weeks, confirmed the machine's wash temperature requirements and provided a temperature log for review. The log revealed several undocumented temperature checks, and the Dietary Manager acknowledged that these omissions occurred before her tenure. Despite the Dietary Manager's guidance, Staff N and Staff O, another Dietary Aide, were not fully aware of the correct temperature requirements, indicating a lack of proper training or communication regarding the machine's operation. Further observations confirmed that the dishwashing machine's wash cycle consistently failed to meet the required temperature, even after multiple demonstrations. The facility's policy required monitoring of dish machine temperatures at each meal, but this was not effectively implemented. The Dietary Manager later stated that the machine's thermostat needed a part replacement and a temperature water flow adjustment, which contributed to the deficiency in maintaining the required wash cycle temperature.
Medication Storage Deficiencies in Resident Rooms and Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were securely stored in several resident rooms and on a medication cart. Observations revealed that in multiple rooms, medications such as dermal wound cleanser, antifungal cream, hydrophilic wound dressing cream, and preventative ointment were left unsecured on nightstands. The Assistant Director of Nursing (ADON) confirmed that these items should not have been stored at the bedside and should have been kept in the treatment cart or carried by Certified Nursing Assistants (CNAs). In another instance, Ammonium Lactate Cream 12% was found on a dresser at a resident's bedside. The resident stated that the staff placed the lotion there for use by either the resident or staff. The ADON indicated that such medication should not be at the bedside without a physician's order for self-administration. Additionally, a resident was observed with loose eye drop medications in a plastic bowl on the bedside table, which the resident claimed were his. The Director of Nursing (DON) noted that this resident had physician orders for self-administration, but the medications were not properly secured when the resident was not present. Further observations on a medication cart in the 700 hallway revealed six loose pills and an expired insulin pen. The Registered Nurse/Unit Manager (RN/UM) acknowledged the presence of the expired insulin pen, which belonged to a discharged resident, and stated that the cart is cleaned every two weeks. The facility's policy requires medications to be stored properly and accessible only to authorized personnel, and any outdated or deteriorated medications should be immediately removed and disposed of according to procedures.
Failure to Implement Contracture Management Care Plan
Penalty
Summary
The facility failed to develop and implement timely care plan interventions for contracture management and hand splinting/orthotics use for a resident. Observations revealed that the resident, who was dependent on staff for all Activities of Daily Living (ADLs), had severely contracted hands without any splints or orthotics applied. Interviews with Certified Nursing Assistants (CNAs) indicated a lack of awareness regarding the resident's need for splints or orthotics, and they had not observed the resident wearing them. The resident's medical record indicated a diagnosis of contracture in the left elbow and other conditions, with a care plan that did not address the use of splints or orthotics for contracture management. The Medication Administration Record (MAR) documented an order for the resident to wear hand orthotics daily, which was signed off as completed despite observations to the contrary. The Occupational Therapy (OT) plan included goals for the resident to wear a resting hand splint, but nursing staff were not trained on orthotic application or the wearing schedule. Interviews with the Care Plan Coordinator and the Rehabilitation Therapy Department Director confirmed the absence of care plan interventions related to the use of splints/orthotics and contracture management. The facility's Restorative Nursing Program policy outlined the need for contracture management, but there was no specific policy for developing and implementing care planning problem areas. The lack of coordination and communication between therapy and nursing staff contributed to the deficiency in care planning for the resident's contracture management needs.
Failure to Provide Timely Ophthalmology Referral for Resident with Cataracts
Penalty
Summary
The facility failed to ensure a timely ophthalmology referral for a resident with severe cataracts, impacting his vision. The resident, who was cognitively intact, expressed difficulty seeing and mentioned needing glasses. Despite multiple evaluations by an optometrist, who confirmed the severity of the cataracts and requested referrals to an ophthalmologist, the necessary referral was not completed. The resident's care plan had included a focus on vision issues since November 2023, with specific interventions for ophthalmology consults initiated in March 2024, yet these were not fulfilled. Interviews with facility staff revealed a lack of coordination and follow-through in addressing the resident's vision needs. The Registered Nurse/Unit Manager acknowledged difficulties in securing an ophthalmologist due to insurance issues, while the Social Services Director confirmed receiving lists from the optometrist but did not ensure follow-up. The Nursing Home Administrator and Director of Nursing were unable to provide clear reasons for the delay, citing the resident's health issues and potential unsuitability for surgery. The facility's policy required prompt referrals and coordination of services, which were not adhered to in this case.
Inadequate Pressure Ulcer Care for Two Residents
Penalty
Summary
The facility failed to provide adequate pressure ulcer care for two residents, leading to a decline in their conditions. Resident #89 reported that his wound dressing had not been changed for several days, resulting in increased pain and deterioration of the wound. Upon observation, it was confirmed that the dressing was missing, and the resident had not had a bowel movement that could have caused its removal. The facility's records indicated that the dressing should have been changed daily, but this was not adhered to, leading to a lapse in care. Resident #111 also experienced inadequate wound care, as evidenced by the presence of two open areas on his buttocks and coccyx, with a strong foul smell and significant drainage noted during an observation. The resident's right heel wound had worsened over time, despite treatment orders being in place. The facility's wound care team, which included the DON, ADON, and unit managers, conducted weekly rounds, but there were inconsistencies in the documentation and execution of wound care protocols. The facility's policy on wound prevention and treatment was not effectively implemented, as evidenced by the lack of timely dressing changes and inadequate monitoring of wound conditions. The facility's own wound therapy team and a consultant wound company were involved in the care process, but the coordination and communication among staff were insufficient to prevent the decline in the residents' conditions. The failure to adhere to established protocols and ensure consistent care contributed to the deterioration of the residents' pressure ulcers.
Failure to Maintain PICC Line Dressing as per Protocol
Penalty
Summary
The facility failed to maintain a Peripherally Inserted Central Catheter (PICC) for a resident according to current professional standards of practice. During an observation, it was noted that the dressing on the resident's PICC line was dated 12/21/24, which was not changed as per the facility's protocol. The protocol requires that central venous access device dressings be changed every seven days or immediately if compromised. However, the dressing had not been changed for over two weeks, indicating a lapse in adherence to the facility's policy. Further investigation revealed that there were no physician orders for the care of the resident's PICC line, which should have included a standard order set for central line catheter maintenance. The Licensed Practical Nurse/Unit Manager confirmed the absence of these orders and acknowledged that the dressing should have been changed every seven days and assessed per shift. The facility's policy on vascular access devices emphasizes the importance of maintaining a sterile dressing to prevent infection, but this was not followed in the case of the resident, leading to the deficiency.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 23.08% error rate observed during medication administration for a resident. During the observation, a registered nurse administered several medications to a resident, all of which were crushed and mixed with applesauce, despite the absence of a physician's order to do so. The resident refused one of the medications, MiraLax. The medications administered included Glargine, Biktarvy, Metoprolol, Paroxetine HCL, Famotidine, Aspirin, a prebiotic, MiraLax, and Breo. The physician's orders did not include instructions to crush these medications, and the facility's policy requires a specific order from the prescriber to crush medications. Interviews with various staff members, including the consultant pharmacist, LPNs, and the Assistant Director of Nursing, confirmed that there should be a physician's order to crush medications. The consultant pharmacist noted that while some literature suggested Biktarvy could be dissolved in water, the initial guidance was not to crush it. The facility's policy on medication administration emphasizes that medications should be administered as prescribed and in accordance with the manufacturer's specifications. The failure to adhere to these guidelines resulted in a significant medication error rate, highlighting a deficiency in the facility's medication administration practices.
Infection Control and PPE Deficiencies
Penalty
Summary
The facility failed to ensure nebulizer masks for three residents were stored in a safe and sanitary manner. Observations showed that the nebulizer masks for Residents #9, #92, and #221 were laid on top of the provided respiratory storage bags at their bedsides, rather than being stored inside the bags as required by the facility's policy. Resident #221 was receiving nebulizer treatments for shortness of breath due to pleural effusion and heart failure, Resident #9 for respiratory failure with hypoxia due to COPD, and Resident #92 for shortness of breath due to COPD and chronic bronchitis. The Assistant Director of Nursing (ADON) and designated Infection Preventionist (IP) confirmed that nebulizer masks should be stored in the provided bags when not in use to maintain proper infection control practices. Additionally, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) while providing care to a resident with a gastrostomy tube. During a medication administration, Staff G, an LPN, did not wear a gown while administering medication via the gastrostomy tube to Resident #112, who had an order for Gabapentin for neuropathy. The facility's policy on Barrier Precautions requires the use of gowns and gloves during high-contact activities with residents under Enhanced Barrier Precautions, which includes those with G-tubes. The ADON/IP confirmed that staff should wear gowns and gloves when assisting residents with G-tubes.
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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 Tampa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Northdale Rehabilitation Center | 3.8 mi | ★★★★★ | 0 | 0 |
| St. Andrew Post-acute Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Woodbridge Care Center And Rehab | 5.1 mi | ★★★★★ | 0 | 0 |
| Aviata At Fletcher | 5.5 mi | ★★★★★ | 4 | 0 |
| Tampa Lakes Health And Rehabilitation Center | 6.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.