Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Pruitthealth-north Tampa, Llc during CMS and state inspections, most recent first.
A staff member was assigned to CNA duties and provided direct resident care without verification of CNA certification or registry status. Facility leadership and HR staff were unaware of the lack of credentials, and the staff member was scheduled for multiple shifts in a CNA role, contrary to facility policy requiring active CNA certification.
Three residents with non-pressure skin conditions did not receive timely wound care, and their dressings were not dated as required. One resident's tracheostomy dressing was left unchanged for days after admission without proper orders, another had an undated neck dressing despite daily wound care orders, and a third had undated, visibly soiled bandages that were not promptly changed. Staff interviews and facility policy confirmed that dressings should be dated and changed if soiled, but these procedures were not consistently followed.
Three residents experienced significant delays in receiving prescribed pain medications, resulting in periods of uncontrolled pain. Issues included unavailable medications, delays in order entry, and lack of timely communication with providers. Staff interviews confirmed confusion about medication processes and failure to utilize available resources, leading to inadequate pain control.
The facility did not provide enough nursing staff to meet residents' needs for ADLs and meal assistance, resulting in family members and other residents stepping in to help with basic care tasks. Staff reported being unable to complete all required duties, and the restorative program was not operational. Facility leadership was unaware of the staffing shortfalls, and no staffing policy was provided.
Multiple newly admitted residents did not receive prescribed pain and essential medications for up to two days due to delays in pharmacy delivery, lack of staff training on medication dispensing systems, and insufficient communication with providers, resulting in unmanaged pain and missed doses of critical medications.
The facility did not ensure that residents and their representatives were properly informed about binding arbitration agreements or their right to refuse, resulting in several residents or their representatives signing agreements without adequate explanation or understanding. In some cases, residents with cognitive impairment signed without surrogate involvement, and others did not recall any discussion about arbitration.
Staff failed to follow infection prevention protocols, including not using PPE or performing hand hygiene when entering rooms with contact isolation signage, inconsistently cleaning reusable drinking cups, and not adhering to hand hygiene and aseptic technique during medication administration. Staff interviews revealed confusion about required practices, and there was no clear process for cup sanitation.
A resident with a history of antibiotic-resistant infection received IV Vancomycin without clear documentation of the infection type or diagnosis, and there was no use of McGreer's Criteria or contact precautions. Facility leadership confirmed that the antibiotic stewardship program was limited to color-coded charting and lacked systematic monitoring or infection control measures.
Surveyors observed that during a meal service, some residents were not served their meals at the same time as others at their table, and staff referred to residents needing assistance as "feeders" in a loud manner. Staff also failed to remove food items from trays before assisting residents, contrary to facility policy. Interviews confirmed these actions did not align with expected practices for maintaining resident dignity.
A resident with multiple complex medical conditions, including cognitive impairment, fall risk, and skin tears, was admitted without a baseline care plan being developed within 48 hours as required. Staff interviews revealed confusion over a recent process change assigning responsibility for care plan initiation to the admitting nurse, resulting in the omission.
A resident with Parkinson's disease and mobility issues reported increasing weakness and loss of endurance after being discharged from therapy, as staff did not provide the required supervision for walking. Interviews revealed that CNAs did not have time to assist and the restorative program was not operational, leaving the resident without needed support. The care plan was not updated to reflect these changes or the lack of restorative services, contrary to facility policy.
A resident with significant physical and cognitive impairments was not provided with needed meal assistance by staff, resulting in another resident feeding her during a meal. Staff interviews confirmed that help was not consistently given, and there was an assumption that family members would provide this care, despite facility policy and the resident's care plan requiring staff assistance.
Two residents received medications that were improperly crushed by an RN, including gabapentin and nifedipine extended-release, both of which were listed as 'do not crush' per facility policy and ISMP guidelines. The RN was unaware of the facility's list of medications that should not be crushed, resulting in a medication error rate of 8.0%, exceeding the acceptable threshold.
Surveyors found that medication and treatment carts were repeatedly left unlocked and unattended, with prescription and controlled drugs accessible and not properly secured. Medications were left on top of carts during administration, and medication carts were observed to be dirty. Staff interviews confirmed lapses in following facility policy for medication security and cleanliness.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and follow-up on quality issues.
A resident with a nephrostomy tube did not receive appropriate care, as the dressing at the insertion site was not changed since hospital discharge and there were no physician orders for nephrostomy care. The DON was unable to describe the care provided, and the care plan lacked specific interventions for the nephrostomy tube, resulting in a deficiency in meeting professional standards.
The facility failed to properly monitor and care for surgical wounds in two residents, leading to deficiencies in wound care management. One resident had a left hip surgical site that was not consistently monitored for infection or staple removal, while another resident with a right femur fracture had delayed suture removal and inconsistent documentation of the surgical site. Interviews revealed that the facility's wound care nurse was not always available, and the facility's policy for wound care documentation was not consistently followed.
The facility failed to provide sufficient nursing staff, resulting in delayed responses to call lights and inadequate assistance with daily living activities. Residents reported non-functional call lights and reliance on family for care. Staff interviews revealed challenges due to staffing based on census rather than resident needs.
The facility failed to maintain a functioning nurse call system, with residents reporting non-operational call lights and ineffective table bells as alternatives. The Director of Maintenance was aware of the issue but did not conduct a complete audit, and the Nursing Home Administrator believed table bells sufficed for resident needs. The facility lacked a policy for Equipment Repair and Maintenance.
A resident was admitted to a facility with no musculoskeletal impairments noted, but later an X-ray revealed a fracture in the left femur. Despite this finding, the facility did not conduct an investigation into the cause of the fracture. The interim DON, who was covering multiple roles, did not interview staff or investigate the incident. It was later noted that the resident had falls at an ALF prior to admission, but this was not initially considered. The facility lacked a policy for conducting investigations.
The facility failed to ensure competent nursing care staff, particularly in the care of an unresponsive resident and wound monitoring for two other residents. A resident admitted for rehabilitation after a hip replacement was found on the floor and became unresponsive after being placed in a wheelchair. The LPN on duty left the resident to retrieve equipment, delaying response. Two other residents with surgical wounds had inconsistent documentation and monitoring, with delays in contacting physicians for staple and suture removal. The DON confirmed that surgical incisions should be monitored and documented until resolved.
Uncertified Staff Member Assigned to CNA Duties Without Verification
Penalty
Summary
The facility failed to ensure that a staff member assigned to Certified Nursing Assistant (CNA) duties was properly trained, certified, and listed on the CNA registry. Staff E was transferred from a dietary aide position to a CNA role and performed direct resident care duties without evidence of CNA licensure or registry verification. Review of Staff E's personnel file revealed no documentation of CNA certification, and background screening confirmed the absence of a professional license. Staffing assignment sheets showed that Staff E was regularly scheduled and assigned to provide direct care to residents in various rooms over multiple shifts. Interviews with facility leadership, including the Nursing Home Administrator (NHA), Regional Nurse Consultant (RNC), and Human Resource Manager (HRM), confirmed that Staff E had been working as a CNA without the required credentials. The NHA and RNC attributed the oversight to a lack of process and possible misconduct by a former HR staff member, who was later terminated for unrelated reasons. The current HRM and staffing coordinator were unaware of Staff E's lack of certification, and the facility's job description for the CNA position explicitly required active, unrestricted CNA certification.
Failure to Provide Timely Wound Care and Date Dressings
Penalty
Summary
The facility failed to provide timely wound care and ensure dressings were dated for three residents with non-pressure skin conditions. One resident was admitted with a tracheostomy stoma covered by a bandage dated from the hospital, which remained unchanged for two days after admission. There were no wound care orders in place upon admission, and the dressing was not assessed or changed until several days later. Staff interviews revealed confusion about who was responsible for entering wound care orders, and documentation confirmed that wound care was not performed or recorded until after a delay. Another resident was observed with an undated dressing on the left side of the neck, and the resident was unsure when the dressing had last been changed. Physician orders specified daily wound care, and the treatment administration record indicated that care was provided, but the dressings were not dated as required. Staff interviews confirmed that dressings should be dated and changed if soiled, but this was not consistently done. The facility's policy and wound care protocol both required documentation and dating of dressings, but these procedures were not followed. A third resident was observed with undated and visibly soiled bandages on the upper extremities, including a wet bandage with dark red liquid seeping onto the bed sheets. Orders were in place for regular wound care, but there was no documentation of the soiled bandages being addressed. Staff interviews indicated that bandages were not being dated and that soiled dressings were not changed promptly. The medical director and regional nurse both stated that bandages should be clean, dry, and dated, and that staff should notify the physician if dressings are repeatedly soiled, but these expectations were not met.
Failure to Provide Timely and Effective Pain Management
Penalty
Summary
The facility failed to ensure effective pain management for three residents who required such services, resulting in periods where pain was not controlled. One resident, admitted with multiple pain-related diagnoses including sepsis, cutaneous abscess, and spondylosis, did not receive prescribed pain medications for the first two days of admission. The resident reported pain at a level of 10 out of 10 and refused tube feedings due to severe discomfort. Medication administration records confirmed that several pain medications, including methadone, baclofen, morphine, and gabapentin, were either unavailable or not administered as ordered during this period. Staff interviews revealed confusion about the medication ordering process and delays in obtaining medications from the pharmacy or electronic dispensing machine. Another resident, admitted with a recent femur fracture and chronic pain, experienced a delay of a day and a half before receiving prescribed pain medication. During this time, the only pain relief provided was over-the-counter acetaminophen, which the resident reported as ineffective for severe pain experienced with movement. Review of records showed that the hospital discharge orders for stronger pain medications were not promptly entered into the facility's system, resulting in a delay in administration. A third resident, admitted for orthopedic aftercare and spinal stenosis, also experienced a delay of several days before receiving prescribed pain medications. The resident reported pain levels of 7-8 out of 10 and stated that only acetaminophen was available initially, which did not provide adequate relief. Medication administration records indicated that several ordered medications, including morphine and pregabalin, were not available or not administered as ordered. Staff interviews and physician statements confirmed issues with medication availability, order transcription errors, and lack of timely communication with providers regarding unavailable medications. The facility's own policy required regular pain assessments and prompt management, but these procedures were not followed, leading to unmanaged pain for the affected residents.
Insufficient Staffing for Resident Care and Meal Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, particularly in assisting with activities of daily living (ADLs) and meal assistance. Multiple interviews with residents, family members, and staff revealed that residents were not receiving adequate supervision or help with walking and meal times. One resident reported becoming weaker and losing endurance after being discharged from therapy, as no staff were available to supervise walking except during family visits. Staff members acknowledged that there were not enough CNAs to complete all required tasks, including range of motion exercises and walking assistance, and that the restorative program was not operational due to lack of oversight. Observations over several days showed family members and even other residents stepping in to assist with meals and coffee service in the dining area, indicating a lack of available staff during critical times. Family members expressed frustration at having to help with basic care tasks, and staff confirmed that families regularly assisted with meals due to insufficient staffing. Staff also described challenges in completing their work, especially during meal times, and noted that the number of residents needing assistance exceeded the available staff capacity. Interviews with facility leadership, including the staffing coordinator, DON, and administrator, revealed a lack of awareness or acknowledgment of staffing concerns, despite direct evidence from staff and families. The staffing coordinator based assignments on census and was unaware of specific needs during meal times, while the DON and administrator did not recognize any issues with staff coverage or the expectation for families to assist. Additionally, the facility was unable to provide a requested staffing policy and procedure.
Failure to Provide Timely Pharmaceutical Services for New Admissions
Penalty
Summary
The facility failed to ensure that newly admitted residents received their prescribed medications in a timely manner, resulting in multiple residents experiencing significant delays in pain management and other essential medications. Several residents reported not receiving their pain medications for up to two days after admission, despite having active orders for medications such as methadone, morphine, baclofen, gabapentin, oxycodone-acetaminophen, and pregabalin. Documentation in the Medication Administration Records (MAR) and interviews with residents and staff confirmed that medications were marked as unavailable, and residents experienced high levels of pain during this period. In some cases, only over-the-counter acetaminophen was administered, which residents reported as ineffective for their pain levels. Interviews with nursing staff revealed a lack of awareness and training regarding the use of the facility's electronic medication dispensing machine and backup pharmacy services, particularly during weekend admissions. Staff reported waiting for medications to arrive from the pharmacy and did not consistently utilize available emergency drug supplies or contact prescribing providers for alternative orders. There was also a lack of communication with the pain management physician and medical director regarding the unavailability of medications, and no evidence that responsible parties or providers were notified when medications were not administered as ordered. In addition to pain medications, at least one resident did not receive prescribed antihypertensive medications for two days, with documentation indicating the drugs were not available and the pharmacy had been notified. The facility was unable to provide a policy and procedure for pharmacy services when requested. The deficiency was further compounded by the facility's lack of a systematic process to ensure medication availability and administration upon admission, especially during weekends, as acknowledged by the nursing home administrator and consultant pharmacist.
Failure to Ensure Informed Consent for Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents and their representatives were properly informed about the contents of binding arbitration agreements and their right to refuse such agreements. For three sampled residents, documentation and interviews revealed that either the resident or their representative signed the arbitration agreement without adequate understanding or explanation of its terms. In one case, a resident with advanced dementia and a designated healthcare surrogate signed the agreement personally, despite medical documentation indicating the resident was unable to provide meaningful information and required a surrogate for decision-making. The surrogate confirmed not being present or involved in the signing process. In another instance, an alert and oriented resident and their spouse did not recall any discussion or explanation regarding arbitration, despite the agreement being signed. Similarly, a third resident and their representative, who was the power of attorney, did not recall signing or having the arbitration agreement explained to them. Interviews with facility staff, including the Senior Nurse Navigator and the Nursing Home Administrator, confirmed that the process should involve reviewing and explaining the arbitration agreement to the resident or their representative, ensuring understanding, and informing them of their right to refuse. However, the facility did not have a specific policy regarding arbitration agreements, and the documented process was not consistently followed, as evidenced by the lack of informed consent and understanding among the sampled residents and their representatives.
Failure to Implement and Maintain Infection Prevention and Control Program
Penalty
Summary
Surveyors observed multiple failures in the implementation and maintenance of the facility's infection prevention and control program. Staff were seen not adhering to posted contact isolation precautions, including not donning personal protective equipment (PPE) such as gowns and gloves when entering rooms with contact isolation signage, and not performing hand hygiene before and after resident contact or between tasks. For example, an occupational therapist and several certified nursing assistants (CNAs) entered and exited rooms with contact isolation signage, assisted residents, delivered meal trays, and touched resident environments without using PPE or performing hand hygiene. Staff interviews revealed a lack of understanding regarding when PPE and hand hygiene were required, with some staff believing these precautions were only necessary during specific care activities, such as toileting, rather than for all resident contact or environmental interaction as indicated by facility policy and CDC guidelines. Additionally, the facility failed to ensure proper cleaning and sanitation of reusable resident drinking cups. Residents and staff reported inconsistent cleaning practices, with some cups being washed in resident room sinks or nourishment rooms using hand soap and water, and others sporadically sent to the kitchen for dish machine cleaning. There was no established or communicated schedule for cup sanitation, and staff were unclear about the process. The registered dietitian and director of nursing were not aware of the specific cleaning schedule, and staff provided conflicting information about cup handling and cleaning responsibilities. Further deficiencies were noted during medication administration. Nursing staff, including LPNs and RNs, were observed not performing hand hygiene before preparing or administering medications, and not changing gloves or using hand sanitizer as required by facility policy. In one instance, an RN dropped IV tubing on the floor, picked it up, and proceeded to use it without replacing it, contrary to facility expectations. Interviews with staff and the DON confirmed that these actions did not align with facility policy, which requires aseptic technique and hand hygiene during medication administration and when handling IV equipment.
Failure to Implement Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of a system to monitor antibiotic use and antibiotic-resistant organisms for a resident admitted with a history of Methicillin-resistant Staphylococcus aureus and an unspecified bacterial infection. Review of the resident's Medication Administration Record (MAR) showed administration of intravenous Vancomycin over several weeks, but there was no documentation specifying the reason for the antibiotic, the type of infection being treated, or a corresponding diagnosis. Physician orders did not include contact precautions, and there was no use of McGreer's Criteria to monitor or classify the infection. Interviews with facility leadership revealed that the antibiotic stewardship program consisted only of color-coded charting of residents on antibiotics, without systematic tracking or use of standardized criteria. The Director of Nursing confirmed that McGreer's Criteria were not in use for monitoring, and the Nursing Home Administrator stated that there was no established infection control or antibiotic monitoring program in place at the time of the resident's admission and treatment. The facility's policy required an antibiotic stewardship program, but it was not effectively implemented or maintained.
Failure to Maintain Resident Dignity During Dining Service
Penalty
Summary
During a lunch meal service in the dining room between the 400 and 500 hallways, surveyors observed that the facility failed to maintain resident dignity during dining. Multiple residents were seated at tables where not all individuals received their meals at the same time, resulting in some residents waiting while others began eating. Staff were seen assisting residents with eating without removing food items from the trays, contrary to facility policy. Additionally, staff referred to residents needing assistance as "feeders" in a loud manner that was audible to other residents and visitors, further compromising resident dignity. Interviews with staff confirmed that all residents at a table should be served simultaneously, food should be removed from trays before serving, and residents should not be referred to as "feeders." The facility's dining policy also specifies that plates, side dishes, and drinks should be removed from trays and placed on the table, and that domes, lids, and trays should be cleared away. The administrator stated there was no specific policy on dignity, but that the facility follows regulatory requirements.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for one resident. The resident was admitted with multiple diagnoses, including metabolic encephalopathy, mood disorder, anxiety disorder, difficulty walking, cognitive communication deficit, left hip osteoarthritis, cognitive impairment, and a history of falls. Documentation showed the resident had impaired hearing, generalized weakness, a urinary tract infection, lactic acidosis, incontinence, a need for two-person assistance with transfers, and skin tears on both the left upper and right lower extremities. The resident was also identified as high risk for falls based on the Morse Fall Risk score. Interviews with facility staff revealed that the responsibility for completing baseline care plans had recently shifted from the MDS Director to the admitting nurse, but not all nurses understood the new process. The MDS Director and DON both confirmed that a baseline care plan had not been completed for the resident within the required timeframe. Despite requests, no baseline care plan was provided for the resident, and staff acknowledged the process change and the additional time required to complete the care plan. The facility's policy required a baseline care plan to be initiated within 24 hours and completed within 48 hours of admission, but this was not followed in this case.
Failure to Update ADL Care Plan After Therapy Discharge
Penalty
Summary
The facility failed to revise the Activities of Daily Living (ADL) care plan to reflect a resident's current condition following discharge from therapy. The resident, who has diagnoses including Parkinson's disease, difficulty in walking, and other comorbidities, reported feeling weaker and losing endurance since therapy ended, stating that no staff were available to supervise her walking except during family visits. Therapy had instructed the resident to ensure supervision while walking, but this was not consistently provided after discharge from therapy. Interviews with staff revealed that Certified Nursing Assistants (CNAs) did not have time to assist with walking or range of motion exercises, and these tasks were typically assigned to a restorative aide. However, the restorative aide position had not been filled, and the restorative program was not operational, leaving no one to oversee or provide the necessary support. The Director of Rehabilitative Services confirmed that although the resident was discharged from therapy with a home exercise program, the facility lacked a restorative program and staff to implement it. A review of the resident's care plan showed it had not been updated to address the resident's current needs or the lack of restorative services. The care plan continued to list general approaches such as providing assistive devices and encouraging independence, but did not reflect the resident's need for supervised walking or the absence of restorative support. Facility policy requires care plans to be updated with any change in condition, but this was not done in this case.
Failure to Provide Required Meal Assistance
Penalty
Summary
A deficiency occurred when a resident who required assistance with eating was not provided the necessary help by facility staff during a meal. Observation showed another resident feeding the affected resident, stating that if she did not help, no one else would. The resident in question had a history of muscle weakness, hand contractures, dysphagia, and moderate cognitive impairment, and her care plan specifically indicated the need for assistance with feeding at meals. Multiple records, including progress notes and nutritional assessments, confirmed her ongoing need for meal assistance due to her physical limitations and recent decline in self-feeding ability. Interviews with staff revealed that assistance was not consistently provided, with one CNA stating she only helped after distributing trays and that the resident's family member usually provided the help. The DON acknowledged that while staff are responsible for meal assistance, there was an assumption that family members would be present to help during mealtimes. Facility policy emphasized the importance of providing competent and respectful care for activities of daily living, including eating, but this was not followed in the observed instance.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing of Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as required. During medication administration observations, two errors were identified out of twenty-five opportunities, resulting in an 8.0% error rate. In one instance, a registered nurse crushed and administered gabapentin, which is listed by the facility and the Institute of Safe Medication Practices (ISMP) as a medication that should not be crushed. In another instance, the same nurse crushed and administered nifedipine extended-release, despite the medication administration history specifically stating 'DO NOT CRUSH' as a special instruction. The nurse also crushed other medications for the same resident, including calcium carbonate, buspirone, and vitamin D3. Interviews revealed that the nurse was unaware of where to find the facility's list of medications that should not be crushed. The facility's policy on medication administration requires staff to follow physician orders, pharmacy instructions, and facility policy, including not crushing long-acting or enteric-coated dosage forms unless specifically ordered by a physician. The Director of Nursing confirmed that staff are expected to be familiar with these requirements. The failure to adhere to these protocols directly contributed to the identified medication errors.
Medication Storage and Security Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication storage and handling practices across several halls. Unlocked and unattended medication and treatment carts containing prescription medications were found on multiple occasions, with no staff present in the vicinity. Controlled drugs stored in an emergency drug kit were not kept in a permanently affixed compartment as required, and staff were unaware of proper storage protocols. Additionally, medications, including IV antibiotics and various oral medications, were left unattended on top of medication carts during administration, and staff admitted to forgetting to lock the carts or mistakenly believing it was acceptable due to the presence of a surveyor. Further observations revealed that medication carts were not maintained in a clean condition, with sticky, gummy residue found in the drawers of carts on different halls. Staff interviews confirmed that nurses are responsible for cleaning the carts and that medication carts should be locked and not left unattended. The facility's own policy requires that medication storage areas be locked or attended by authorized personnel and kept clean and organized, but these procedures were not consistently followed as evidenced by the survey findings.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process to identify, analyze, and address quality issues within the facility. The lack of such a group meant that quality deficiencies were not consistently reviewed or acted upon, as required.
Failure to Provide Nephrostomy Tube Care per Standards
Penalty
Summary
The facility failed to provide appropriate nephrostomy care and services consistent with professional standards of practice for a resident with multiple urological diagnoses, including obstructive and reflux uropathy, chronic kidney disease, and hydronephrosis. Upon observation, the resident's nephrostomy insertion site dressing was found to be not intact and had not been changed since before admission, as confirmed by the resident, who stated the last dressing change occurred at the hospital. The resident reported asking a nurse to change the dressing but was told there were no orders to do so. The urine in the nephrostomy bag appeared serosanguinous. Review of the medical record revealed no physician orders related to nephrostomy tube care, and the care plan did not include specific interventions for dressing changes or tube flushing. During interviews, the DON was unable to describe the care provided for the nephrostomy tube and acknowledged that orders for care had not been obtained. The facility's care plans addressed infection prevention and catheter care in general terms but did not specify nephrostomy tube management. Professional standards recommend changing the nephrostomy dressing at least every seven days or sooner if soiled or wet, which was not followed in this case. The lack of physician orders and failure to provide timely dressing changes led to the deficiency in care for the resident's nephrostomy tube.
Deficiencies in Surgical Wound Monitoring and Care
Penalty
Summary
The facility failed to ensure proper monitoring and care of surgical wounds for two residents, leading to deficiencies in wound care management. Resident #1 was admitted with a left hip surgical site and a left ankle skin tear. Despite having a physician's order for a portable x-ray due to pain, the facility did not consistently monitor the surgical site for signs of infection or follow up on the removal of surgical staples. The resident's skin assessments were inconsistent, and there was a lack of documentation regarding the condition of the surgical incision, which was not monitored from the resident's return to the facility until a later date. Resident #7 was admitted with multiple incisions related to a right femur fracture. The facility failed to document the appearance of the surgical incision and the number of staples present. Despite the resident experiencing discomfort and signs of erythema at the surgical site, the facility did not consistently monitor the site or document the condition of the incision. The removal of sutures was delayed, and there was a lack of daily monitoring of the surgical site, as evidenced by the absence of documentation in the resident's clinical record. Interviews with staff, including the Director of Nursing, revealed that the facility had a wound care nurse who was not always available to focus solely on wound care. The facility's policy required documentation of skin and wound care, including weekly assessments and monitoring of surgical sites, but these procedures were not consistently followed. The lack of adherence to the facility's policy and the inconsistent monitoring and documentation of surgical wounds contributed to the deficiencies identified in the care of these residents.
Inadequate Staffing and Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple instances of delayed response to call lights and inadequate assistance with activities of daily living. Resident #9 reported that their call bell had not worked since admission, and despite being provided with a metal table bell, staff did not respond when it was rung. This resident expressed feeling unsafe due to the lack of timely assistance. Similarly, Resident #13 and their representative reported that the call light was ineffective, and assistance was only available when the representative was present. Resident #8's representative also noted that the call light was not functional and that they had to personally assist the resident due to the lack of staff response. The facility's grievance logs revealed multiple complaints related to insufficient assistance with daily care needs, such as hearing aid assistance, meal setup, and personal hygiene. These grievances highlighted a pattern of neglect in addressing residents' needs, with some residents resorting to calling family members for help. Observations confirmed that call lights were not being answered promptly, with one instance showing a 15-minute delay before a therapist entered a room after a call light was activated. Interviews with staff members, including CNAs and the Staffing Coordinator, indicated that staffing levels were determined based on census rather than the specific needs of residents. Staff members expressed challenges in managing their assignments due to the facility's layout and the number of residents requiring care. The facility's policy on staffing emphasized the need for adequate staff to ensure residents' health, safety, and welfare, but the observed practices did not align with this policy, leading to the identified deficiencies.
Failure to Maintain Functioning Nurse Call System
Penalty
Summary
The facility failed to maintain a functioning nurse call system, which was observed to be non-operational during a two-day survey. Residents reported that their call lights were not working, and they were provided with table bells as an alternative, which were also ineffective in summoning assistance. Resident #9 and Resident #8's representative both confirmed the call lights were not functioning, and the table bells provided did not result in timely assistance. The Director of Nursing initially claimed all systems were functional, but later acknowledged awareness of the issue in some rooms. The Director of Maintenance (DOM) admitted to being aware of the malfunctioning call lights in certain rooms and had issued table bells as a temporary solution. However, a complete facility audit was not conducted, and only a sampling of rooms was checked weekly. The DOM demonstrated altering the logbook documentation, changing a 'Fail' to 'Pass', which was claimed to be an error. Staff members, including a Registered Nurse, reported the issue to administration, but not all affected residents received table bells due to a shortage. The Nursing Home Administrator (NHA) stated that a vendor was contacted for repairs, but the facility was busy due to recent hurricanes. The NHA believed that providing table bells met the requirement for residents to notify staff of their needs. However, the facility lacked a policy and procedure for Equipment Repair and Maintenance, contributing to the ongoing issue with the nurse call system.
Failure to Investigate Fracture of Unknown Origin
Penalty
Summary
The facility failed to conduct an investigation into a fracture of unknown origin for a resident. The resident was admitted from the hospital with various diagnoses, including urinary tract infection and vascular dementia, and was assessed to have no musculoskeletal impairments upon admission. However, an X-ray ordered due to complaints of pain revealed a fracture in the left femur, leading to the resident being sent to the hospital. Despite the discovery of the fracture, no investigation was conducted by the facility to determine its cause. Interviews with staff revealed that the interim Director of Nursing, who was also covering multiple roles, did not conduct interviews or investigate the incident. It was later mentioned that the resident had experienced falls at an assisted living facility prior to hospital admission, but this information was not initially considered. The facility's policy on patient abuse and neglect did not include guidelines for conducting investigations, and the Director of Nursing confirmed the absence of such a policy.
Inadequate Nursing Competency and Wound Monitoring
Penalty
Summary
The facility failed to ensure competent nursing care staff, particularly in the care of an unresponsive resident and wound monitoring for two other residents. Resident #10, who was admitted for rehabilitation after a hip replacement, was found on the floor by a CNA. The resident was initially responsive but became unresponsive after being placed in a wheelchair. The LPN on duty, Staff G, left the resident to retrieve a vital signs machine, during which time the resident became unresponsive. CPR was initiated, but there was a delay in response as Staff G left the unit to get another nurse, Staff P, who confirmed that the resident was unresponsive and CPR was needed. The Director of Nursing (DON) stated that the resident should have been left on the floor and 911 called immediately, and that the nurse should not have left the resident alone. Resident #1's care was also deficient in terms of wound monitoring. The resident was admitted with a hip fracture and had a surgical site with 19 staples. However, the facility's documentation was inconsistent, with some records failing to note the presence of the surgical incision or the condition of the skin. The resident's MAR did not show consistent monitoring of the surgical site for signs of infection, and there was a delay in contacting the correct surgeon for staple removal. The DON acknowledged that the incision should have been monitored until the staples were removed, and that staff should have reached out to the physician sooner. Resident #7 also experienced inadequate wound monitoring. The resident had a right femur fracture with multiple surgical incisions, but the facility's documentation was inconsistent, with some notes failing to describe the appearance of the surgical incision or the number of staples present. The resident's MAR did not show daily monitoring of the surgical site, and there was a delay in obtaining orders for suture removal. The DON confirmed that surgical incisions should be considered an alteration in skin until resolved and should be documented accordingly. The facility's policy on skin and wound care documentation was not consistently followed, leading to gaps in the monitoring and care of residents' wounds.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 332 citations issued within 25 miles in the last 12 months — including the 18 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lutz
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Luxe At Lutz Rehabilitation Center (the) | 0.4 mi | ★★★★★ | 1 | 0 |
| St. Andrew Post-acute Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Tampa Lakes Health And Rehabilitation Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Northdale Rehabilitation Center | 4.6 mi | ★★★★★ | 0 | 0 |
| Aviata At Fletcher | 6 mi | ★★★★★ | 4 | 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.