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 Luxe At Lutz Rehabilitation Center (the) during CMS and state inspections, most recent first.
A resident admitted with an indwelling urinary catheter did not have timely physician orders specifying catheter size, balloon, or diagnosis, and catheter care orders were not entered until weeks after admission. Staff interviews confirmed that required orders were missing, making it impossible to verify if catheter care was provided as per standards.
The facility failed to provide continuous oxygen therapy for two residents, leading to emergency hospitalizations. One resident experienced respiratory distress due to inaccurate physician orders and lack of monitoring, while another was readmitted without reinstated oxygen orders, prompting a family member to call emergency services. Staff interviews revealed discrepancies in order transcription and administration.
The facility failed to safeguard resident medical records, allowing unauthorized access. Binders with sensitive information were left unsecured in hallways, accessible to anyone, including residents and visitors. Additionally, resident paperwork was found on nursing station counters without staff present. The DON and NHA acknowledged the accessibility issue, which violated the facility's confidentiality policies.
The facility failed to maintain proper infection control practices, with observations showing empty PPE supply carts and staff entering isolation rooms without appropriate PPE or performing hygiene. Staff interviews revealed a lack of adherence to protocols, and the DON acknowledged inconsistencies in compliance and signage, contributing to the deficiency.
A resident with multiple diagnoses, including difficulty in walking, fell in his room and sustained injuries, but the facility failed to update his care plan with new interventions. Despite the resident's dependence on staff for all ADLs and transfers, the care plan was not revised after the fall, and a Change in Condition evaluation was initiated but not completed. Staff interviews highlighted the resident's need for close supervision, yet the facility did not adhere to its policy on managing and preventing falls.
A resident experienced delays in care due to the facility's failure to implement timely care orders for a skin condition, while two other residents faced issues with medication administration. One resident's medication was inconsistently documented without explanation, and another reported not receiving medications on time, affecting her condition. Staff interviews revealed communication lapses and non-compliance with facility policies.
The facility failed to ensure effective infection control practices, including hand hygiene, sharps container management, and PPE usage. Observations revealed staff did not sanitize hands between tasks, a full sharps container was left accessible, and PPE was not used for a resident on Contact Isolation.
A facility failed to implement a care plan for a resident with CHF, Hypertension, and obesity, missing required weights and medication doses. The LPN Unit Manager confirmed the lapses, which were against facility policies, leading to the resident's hospitalization.
The facility failed to ensure resident privacy as staff and visitors were observed entering rooms without knocking. Incidents involved a CNA, a PTA, and a visitor with a dog entering rooms without waiting for an invitation, despite residents being cognitively intact and expressing their preferences. Staff confirmed that the facility's policy requires knocking and waiting for an invitation before entering resident rooms.
The facility failed to confirm the accuracy of the PASRR documentation for multiple residents, resulting in incomplete records that did not reflect all current diagnoses. The ADON admitted that the facility lacked a policy for completing PASRRs, and audits revealed significant discrepancies.
The facility failed to provide adequate personal hygiene care for two residents, both of whom were observed with unwanted facial hair despite expressing their desire for it to be removed. Staff interviews revealed inconsistencies in the provision of grooming services, and the residents' care plans indicated a need for assistance that was not met.
The facility failed to ensure that two residents received proper wound care, as multiple dressings were found unlabeled and undated. One resident had an unlabeled dressing applied after admission, and another resident had multiple undated bandages, with staff failing to follow wound care protocols.
The facility failed to maintain a medication error rate below 5%, resulting in a 25% error rate. Errors included missing medications for three residents, lack of follow-up by LPNs, and unavailability of medications in the cart. The DON acknowledged issues with medication administration timeliness and access to emergency supplies.
A facility failed to inform the physician and resident representative about missed medications and unperformed weights for a resident with serious health conditions. The resident's care plan required daily weights and specific medications, but these were not consistently administered or recorded, and the physician was not notified of the omissions.
Failure to Ensure Timely and Complete Urinary Catheter Orders and Care
Penalty
Summary
The facility failed to ensure that appropriate urinary catheter care was provided in accordance with standards of care for one resident who was admitted with an indwelling urinary catheter due to obstructive uropathy and other urological diagnoses. Upon admission, documentation confirmed the presence of a Foley catheter, but there was no corresponding physician order for the catheter, including details such as catheter size, balloon size, or the medical diagnosis necessitating its use. The treatment administration record did not reflect an order for catheter care until more than two weeks after admission, and the care plan referenced catheter care and monitoring for infection, but lacked supporting physician orders during this period. Interviews with nursing staff and the DON revealed that the facility's process required batch orders for residents with indwelling catheters, specifying catheter details and the reason for use. However, these orders were not entered at the time of admission, and staff acknowledged that without such orders, there was no way to verify if catheter care was being completed as required. The facility was unable to provide a policy regarding catheter care, and the deficiency was identified through record review and staff interviews.
Failure to Ensure Continuous Oxygen Therapy for Residents
Penalty
Summary
The facility failed to ensure continuous care and suctioning for two residents, leading to significant health issues. Resident #18, who had a history of acute respiratory failure and required continuous oxygen therapy, was not provided with accurate and active physician orders or ongoing assessments of their status and response to treatment. This oversight resulted in the resident experiencing respiratory distress and requiring emergency hospitalization. The resident's oxygen saturation was critically low, and there was a lack of documentation and monitoring of their oxygen therapy, which was not administered as per the physician's orders. Resident #12 also experienced a deficiency in care related to oxygen therapy. The resident, who had a history of respiratory failure and was dependent on supplemental oxygen, was readmitted to the facility without reinstated orders for oxygen therapy. Despite the resident's known diagnosis and historical use of oxygen, the facility failed to ensure that the necessary orders were in place upon readmission. This led to a family member calling emergency services due to the resident's need for oxygen, resulting in the resident being transferred to the hospital. Interviews with facility staff, including the DON and RNC, revealed that there were discrepancies in the transcription and administration of physician orders for both residents. The facility's electronic medical records did not accurately reflect the necessary orders for oxygen therapy, and there was a lack of monitoring and documentation in the MAR/TAR. The facility's failure to adhere to professional standards of practice and ensure proper care and suctioning for residents in need of continuous oxygen therapy resulted in significant health risks and emergency hospitalizations.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #18 no longer resides in the facility. Discharged. Resident #12 no longer resides in the facility. Discharged. On Staff LPN "D", was immediately re-educated on care and suctioning with emphasis on continuous with emphasis on accurate and active physician's orders and ongoing assessment of the resident's status and response to by the Director of Nursing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By a quality review was completed by Director of Nursing/designee on continuous with emphasis on accurate and active physician's orders. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By, Clinical staff were educated on the components of care and suctioning with emphasis on continuous, with emphasis on accurate and active physicians orders and ongoing assessment of the resident's status and response to by Director of Nursing/Designee. By clinical staff completed competency for Recognizing Change in Condition. By, nursing staff completed RN/LPN competency checklist. Newly hired licensed nurses will be educated on the components of care and suctioning with emphasis on continuous with emphasis on accurate and active physicians orders and ongoing assessment of the resident's status and response to by Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents with continuous daily x 4 weeks, then 5 x a week for 4 weeks then 2 x a week for 4 weeks then weekly for 1 month to ensure that accurate and active physicians orders and ongoing assessment of the resident's status and response to are in place. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Unauthorized Access to Resident Medical Records
Penalty
Summary
The facility failed to safeguard resident medical records and confidential information, leading to unauthorized access. During a tour of the 200 hall, a two-tiered rack containing white binders with room numbers and a book with resident-specific information was observed in the hallway. These binders, which included sensitive information such as resident names, dates of birth, diagnoses, and insurance details, were easily accessible to anyone walking down the hallway, including residents, family members, vendors, and visitors. Similar observations were made during subsequent tours, indicating that the binders remained unsecured and accessible. Additionally, during a tour of the nursing station, resident paperwork containing specific medical information was found on top of the nursing station counter, also easily accessible to anyone who approached. There were no staff members present at the nursing stations during these observations, further increasing the risk of unauthorized access to sensitive information. The Director of Nursing (DON) acknowledged that resident records have always been kept on the cart in the hallway and not secured behind the nurse's stations, and that papers should not be left on medication carts or counters without being turned over. The Nursing Home Administrator (NHA) confirmed that the resident records have been in the hallway since her arrival and agreed that they were easily accessible to anyone in the halls. The facility's policy on resident rights and medical records emphasizes the importance of maintaining confidentiality and safeguarding resident information, yet the observed practices did not align with these standards. The facility's failure to secure resident records and prevent unauthorized access constitutes a deficiency in maintaining the confidentiality of resident information.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Two tier racks and paperwork were relocated to a secured and confidential area for 100 and 200 hallways. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; By, a quality review was completed by Nursing Home Administrator on two tier racks and paperwork for 100 and 200 hallways were relocated to a secured in confidential area. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By, staff were educated on the components of Resident Records - Identifiable Information with an emphasis safeguarding resident medical records and confidential medical information in a confidential manner that would prevent unauthorized access by the Nursing Home Administrator. Newly hired staff will be educated on the components of Resident Records - identifiable Information with an emphasis safeguarding resident medical records and confidential medical information in a confidential manner that would prevent unauthorized access by the Nursing Home Administrator/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Nursing Home Administrator/Designee to conduct random audits of 4 nursing stations 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that resident medical records and confidential medical information are safeguarded in a confidential manner. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Inadequate PPE and Hygiene Practices in Facility
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were in place, particularly concerning the use and availability of personal protective equipment (PPE) and hygiene practices. Observations revealed that PPE supply carts outside rooms with isolation signs were often empty, lacking essential items such as gowns, gloves, masks, and eyewear. This deficiency was noted across multiple rooms with various precautionary signs, including contact, enhanced barrier, and droplet precautions. Staff members, including CNAs, housekeepers, and activities assistants, were observed entering these rooms without the appropriate PPE, failing to perform necessary hygiene practices, and not adhering to the required precautions. Interviews with staff members indicated a lack of awareness and adherence to PPE protocols. For instance, a CNA acknowledged knowing the resident was on contact precautions but failed to don gloves or perform hand hygiene before providing care. Similarly, a housekeeper was unaware of the droplet precautions required for a resident's room and did not know where to obtain PPE supplies. An activities assistant also failed to wear the correct PPE and did not sanitize equipment after use, despite being aware of the droplet precautions. The Director of Nursing (DON) confirmed the expectations for PPE use and acknowledged the inconsistency in staff compliance. The DON also noted the presence of different droplet precaution signs with varying instructions, which could lead to confusion among staff. Additionally, improper storage practices were observed, with non-linen items stored on clean linen carts, further compromising infection control measures.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On [date], clean linen cart on 200 unit was removed and cleaned. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], central supply personnel replenished supply cart for # with personal protective equipment. On [date], Employee "A" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Employee "G" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Central supply personnel were re-educated by the Director of Nursing on supply cart replenishment. On [date], Employee "B" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Employee "C" was immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], staff members were immediately re-educated by the Director of Nursing on isolation precautions/proper PPE use and hygiene. On [date], Visitor education and encouragement for Control/PPE use and proper hygiene posted conspicuously in reception area by Director of Nursing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By [date], a quality review was completed by Director of Nursing/designee on Prevention & Control with emphasis on PPE use, PPE availability, and hygiene. Any issues identified were immediately corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: By [date], staff were educated on the components of Prevention & Control with an emphasis on use and availability of personal protective equipment (PPE) and performing hygiene by the Director of Nursing/Designee. Newly hired staff members will be educated on the components of Prevention & Control with an emphasis on use and availability of personal protective equipment (PPE) and performing hygiene by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 resident rooms with transmission-based precautions 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure use and availability of personal protective equipment (PPE) and proper hygiene. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update and implement a comprehensive care plan for a resident following a fall that resulted in injuries. The resident, who was observed sitting in a wheelchair outside his room, reported stumbling and falling in his room while trying to reach his bed, which he described as being too high to sit on. This incident led to the resident sustaining an open wound on his right arm and stitches on his forehead, necessitating a hospital visit. Despite these injuries, the resident's care plan was not updated to reflect new interventions or precautions to prevent future falls. The resident was admitted with multiple diagnoses, including difficulty in walking, and was dependent on staff for all activities of daily living and transfers. A progress note indicated that the resident was found on the floor with injuries, and a Change in Condition (CIC) evaluation was initiated but not completed. The resident's care plan, which included interventions such as using the bed in the lowest position and encouraging the use of a call bell, was not revised after the fall to address the new risks and needs. Interviews with staff revealed that the resident required close supervision due to his condition, which included periods of confusion and unawareness of his surroundings. The facility's policy on managing and preventing falls emphasized the need for a resident-centered prevention plan and updating care plans based on evaluations and current data. However, the facility did not adhere to these guidelines, as evidenced by the lack of timely updates to the resident's care plan following the fall.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On , Resident #21 was immediately assessed by a licensed nurse. No concerns were noted. On post-care plan for Resident #21 was updated and intervention was implemented by Director of Nursing. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; By , a quality review was completed by Director of Nursing for post-care plan updates and interventions. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , clinical staff were educated on the components of Develop/Implemented a Comprehensive Care Plan with an emphasis on post-care plan updating and intervention in timely manner by the Director of Nursing. Newly hired licensed nurses will be educated on the components of Develop/Implemented a Comprehensive Care Plan with an emphasis on post-care plan updating and intervention in timely manner by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents with post-care plan and intervention 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure that the facility is within compliance. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Deficiencies in Care Orders and Medication Administration
Penalty
Summary
The facility failed to ensure timely implementation and completion of care orders for a resident with skin issues. The resident was admitted with various diagnoses, including idiopathic conditions, and had a documented open wound that required specific treatment. However, the necessary care orders were not put in place until after the resident's second visit to an outside provider. Interviews with staff revealed a lack of communication and follow-up regarding the resident's treatment orders, resulting in a delay in care. Additionally, the facility did not administer medications appropriately for two other residents. One resident's medication administration record showed inconsistencies in the administration of sleep medication, with no corresponding nurse notes to explain the discrepancies. Another resident reported not receiving her medications on time, which affected her condition. The resident expressed frustration over the facility's repeated excuses for the medication delays, which included issues with pharmacy orders and availability. The facility's policies on medication administration and care procedures were not followed, as evidenced by the lack of documentation and communication with physicians when medications were withheld or care orders were not implemented. Interviews with staff, including the Director of Nursing, confirmed these lapses in protocol, highlighting a failure to adhere to professional standards of practice and ensure residents' needs were met in a timely manner.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was immediately assessed by a licensed nurse. No concerns were noted. Resident #22 was immediately assessed by a licensed nurse. No concerns were noted. Resident #10 no longer resides in the facility. Discharged on (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: By , a quality review was completed by Director of Nursing/Designee on Quality of Care with emphasis on care orders put in place and completed within a timely manner. No additional residents were found to be affected by the alleged deficient practice. By , a quality review was completed by Director of Nursing/Designee on Quality of Care with emphasis on ensuring medications are administered appropriately. No additional residents were found to be affected by the alleged deficient practice. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , clinical staff were educated on the components of Quality of Care with emphasis on care orders put in place and completed within timely manner by Director of Nursing/Designee. By , clinical staff were educated on the components of Quality of Care with emphasis on ensuring medications are administered appropriately by Director of Nursing/Designee. Newly hired licensed nurses will be educated on the components of Quality of Care with emphasis on care orders put in place and completed within timely manner and on ensuring medications are administered appropriately by the Director of Nursing/Designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents for care orders put in place and completed within timely manner 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that care orders put in place and completed within timely manner. Director of Nursing/Designee to conduct random audits of 5 residents medication administration 5x a week for 4 weeks, then 2x a week for 4 weeks and then monthly for 1 month to ensure that medications are administered appropriately. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure effective infection control practices related to hand hygiene, sharps container management, and the use of Personal Protective Equipment (PPE). Observations on the TCU unit revealed that a CNA did not sanitize or wash hands before and after delivering meal trays to multiple residents, including those in enhanced barrier rooms. This was confirmed through interviews and a review of the facility's hand hygiene policy, which mandates hand hygiene before and after direct resident contact and meal assistance. On the Lakeview unit, a medication cart with an attached sharps container was observed to be full and unable to close, making sharps accessible. This issue persisted over several hours, and the Director of Nursing confirmed that the sharps container should not have been left in that condition. The facility's policy on sharp disposal emphasizes the importance of minimizing the risk of needle sticks by ensuring proper storage of hazardous supplies. Additionally, a resident on Contact Isolation reported that staff did not wear the required PPE when entering the room. This was corroborated by observations of a Licensed Practical Nurse administering medication without donning the necessary PPE. The Infection Control Preventionist/Assistant Director of Nursing acknowledged the need for facility-wide education on proper PPE usage. Further observations in the main dining room and during lunch tray distribution revealed sporadic hand hygiene practices among staff, including a CNA who handled food without washing hands between tasks.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to implement the Comprehensive Resident-Centered Care Plan for a resident with multiple health conditions, including Congestive Heart Failure (CHF), Hypertension, and obesity. The care plan required daily weights for three days, then weekly for four months, and administration of Acetazolamide 375 mg twice a day for elevated bicarbonate levels. However, the facility did not perform the required weights on several occasions and failed to administer the medication as ordered on multiple instances. Specifically, the medication was not given on 03/29/24 and 03/30/24, and weights were not performed on 03/16/24, 03/17/24, 03/18/24, 03/20/24, and 03/27/24. The resident was admitted with acute respiratory failure and other severe conditions, and the failure to follow the care plan potentially contributed to his health deterioration and subsequent hospitalization on 04/02/2024. During an interview, the Licensed Practical Nurse (LPN) Unit Manager confirmed that the weights were not performed as ordered and that the medication was not administered due to issues with the pharmacy delivery. The facility's policies on Weight Assessment, Medication Administration, and Physician Orders were reviewed and showed that the guidelines were not followed. The LPN Unit Manager acknowledged that the assigned nurse did not document or notify the physician about the missed weights and medication doses, which was against the facility's policy. The failure to adhere to the care plan and facility policies resulted in a deficiency in the resident's care.
Failure to Uphold Resident Privacy
Penalty
Summary
The facility failed to ensure the resident's right to privacy was upheld, as staff and visitors were observed entering resident rooms without knocking. Specifically, a CNA entered a resident's room without knocking because the door was open, and she assumed it was acceptable. Another incident involved a PTA entering a resident's room without knocking and waiting to be invited in. Both residents were cognitively intact, as indicated by their BIMS scores of 14 and 15, respectively. Additionally, a visitor with a dog was observed entering multiple resident rooms without knocking, despite a resident explicitly expressing a dislike for dogs. Interviews with staff, including an LPN Unit Manager and the Acting Activities Director, confirmed that the facility's policy requires all staff and visitors to knock and wait to be invited into resident rooms. The facility's policy on Resident Rights emphasizes the importance of treating residents with respect, dignity, and privacy.
Inaccurate PASRR Documentation for Multiple Residents
Penalty
Summary
The facility failed to confirm the accuracy of the Pre-Admission Screening and Resident Review (PASRR) and to correct the document for six residents. The Assistant Director of Nursing (ADON) admitted that the facility did not have a policy and procedure for completing the PASRR. For Resident #24, the PASRR Level I did not include the diagnosis of schizoaffective disorder, and a Level II PASRR should have been completed. The ADON confirmed that the PASRR was not accurate and did not reflect all current diagnoses, including schizoaffective disorder, dementia, and anxiety disorder. Resident #2's PASRR Level I Screen was also incomplete, showing only a diagnosis of anxiety disorder and not including other diagnoses such as bipolar disorder, adjustment disorder with anxiety, major depressive disorder, and persistent mood disorder. The ADON confirmed that she only looked at physician orders to complete the PASRR and not the list of diagnoses. The Director of Nursing (DON) acknowledged that PASRRs were not complete and accurate, prompting the initiation of audits. Other residents, including Resident #43, Resident #49, Resident #238, and Resident #388, also had incomplete PASRRs that did not reflect their full range of diagnoses. For example, Resident #43's PASRR did not include anxiety, depression, or alcohol dependency, despite these being documented in the care plan and physician orders. Similarly, Resident #49's PASRR did not include depression, and Resident #238's PASRR did not include depression, anxiety, or PTSD. Resident #388's PASRR was not completed correctly, missing diagnoses of dementia and depression. The ADON confirmed these inaccuracies during interviews.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care related to personal hygiene for two residents. Resident #55, who is cognitively intact and has impairments in both upper extremities, was observed with gray facial hair on her chin on multiple occasions. Despite expressing her dislike for the facial hair and her desire for it to be removed, no assistance was provided. The resident's care plan indicated that she should receive help with personal hygiene, but staff interviews revealed inconsistencies in the provision of grooming services, including shaving, which was not offered to the resident as needed. Similarly, Resident #10, who has moderate cognitive impairment and is dependent on substantial assistance for showering, was observed with white facial hair on her chin. The resident expressed her desire for the facial hair to be removed, but no assistance was offered. Staff interviews indicated that while CNAs are responsible for grooming tasks, they only provide shaving assistance upon the resident's request, which was not effectively communicated or acted upon in this case. Both residents' records and care plans highlighted the need for assistance with personal hygiene, but the facility failed to meet these needs consistently.
Failure to Label Dressings According to Protocol
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice related to unlabeled dressings. Resident #340 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction. Observations revealed an unlabeled and undated dressing on the resident's left hand, which was not present upon admission. Staff interviews indicated uncertainty about the dressing's origin, suggesting it may have been applied after a blood draw, but no clear documentation or labeling was provided to confirm this. The resident's family also confirmed that the dressing was not present upon admission, indicating a lapse in proper wound care protocol adherence. Resident #389 was observed with multiple bandages on his right leg, right arm, and lower legs, many of which were not dated. The resident expressed dissatisfaction with the care, noting that the bandages often fell off. A review of the resident's physician orders and Treatment Administration Record (TAR) showed that the prescribed wound care treatments were not consistently documented as completed. Staff interviews confirmed that bandages should be labeled with the date of application, but this protocol was not followed. The Director of Nursing and Unit Manager both stated that they expect nurses to follow orders and label bandages correctly, highlighting a failure in adherence to facility protocols and professional standards of practice.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was less than 5%, resulting in a 25% error rate. During medication administration observations, multiple errors were identified for three residents. For Resident #42, the LPN did not administer Metoprolol and Eliquis due to their unavailability in the medication cart and failed to follow up with the Unit Manager or request the medications electronically. The LPN admitted to forgetting to put in the request and inform the Unit Manager, leading to the resident missing critical medications for hypertension and atrial fibrillation. For Resident #241, the LPN did not administer Calcium Carbonate as it was not available in the medication cart. The LPN moved on to the next resident without ensuring all medications were administered. The resident's MAR indicated that Calcium Carbonate and Vitamin D3 were due at 0900, but these were not given. The LPN failed to follow up on the missing medication, resulting in incomplete medication administration. For Resident #24, the RN did not have Sodium Chloride tablets available in the medication cart and refused to administer Sodium Bicarbonate as a substitute. The Unit Manager eventually obtained the correct medication from a local pharmacy. The Director of Nursing acknowledged that agency nurses do not have access to the emergency administration cart and agreed that multiple factors contribute to the timeliness of medication administration. The facility's policy states that medications should be administered safely and as prescribed, but this was not adhered to in these cases.
Failure to Inform Physician and Resident Representative of Medication and Weight Issues
Penalty
Summary
The facility failed to ensure that the physician and resident representative were informed of medications not given and weights not performed for a resident. The resident, who was admitted with multiple serious health conditions including acute respiratory failure, COPD, heart failure, and obesity, had orders for daily weights and specific medications. However, the facility did not perform the required weights on several occasions and failed to administer the medication Acetazolamide as prescribed. The medication was not given on multiple instances, and the physician was not notified of these omissions as required by the facility's policy. The resident's care plan included monitoring vital signs and weights, and notifying the physician of any significant changes. Despite this, the weights were not consistently recorded, and the medication was not administered as ordered. The Licensed Practical Nurse (LPN) Unit Manager confirmed that the weights were not performed and that the medication was not in the Emergency Drug Kit. The facility's policies on medication administration and physician orders were not followed, leading to a failure in communication and documentation regarding the resident's care.
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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 Lutz
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth-north Tampa, Llc | 0.4 mi | ★★★★★ | 1 | 0 |
| St. Andrew Post-acute Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Tampa Lakes Health And Rehabilitation Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Northdale Rehabilitation Center | 4.8 mi | ★★★★★ | 0 | 0 |
| Aviata At Fletcher | 6.1 mi | ★★★★★ | 4 | 0 |
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