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 Rehabilitation And Healthcare Center Of Tampa during CMS and state inspections, most recent first.
A cognitively intact resident with chronic medical conditions reported having no money available for personal needs after admission, despite previously receiving higher income and being entitled to a state Personal Needs Allowance (PNA) in addition to SSI. The resident and a family member stated only $30 per month was received, and the resident reported going two years without any additional funds. The Business Office Manager confirmed the resident should receive a $130 state PNA but was not, and business office records lacked documentation of any timely inquiry or follow-up to resolve the missing PNA. The Social Services Director had not spoken with the resident about the concern and was unaware of any complaint, and the facility did not provide a policy outlining social services expectations related to such financial support.
The facility failed to ensure smoking safety for three residents, leading to a deficiency in maintaining a safe environment. A resident was found with smoking materials in her room, and two others were observed smoking without proper supervision. Staff interviews revealed inconsistencies in smoking supervision and a lack of documented assessments for smoking safety measures.
A resident undergoing dialysis had an inaccurate care plan that failed to reflect a physician-ordered fluid restriction and omitted the resident's desired discharge location. The MDS coordinator and Social Services Director acknowledged these discrepancies, which were not in line with the facility's care plan policy.
The facility did not ensure accurate PASRR evaluations for two residents with serious mental illnesses and dementia. One resident had diagnoses including schizophrenia and dementia, but a Level II PASRR was not completed. Another resident with similar conditions also did not receive the necessary Level II evaluation. Staff interviews confirmed these oversights, which were contrary to the facility's policy requiring such evaluations.
A resident dependent on staff for all ADLs due to multiple health conditions was primarily cared for by private sitters hired by the family, rather than CNAs as required by the care plan. The sitters performed tasks such as turning, incontinence care, and range of motion exercises without consistent oversight from facility staff, and the NHA was unaware of the extent of their involvement. The facility's policy did not mandate these sitters to provide necessary care, leading to a deficiency in ensuring qualified care.
Two residents in an LTC facility were not provided with individualized activities, leading to a deficiency in enhancing their quality of life. One resident, weakened by cancer treatments, was not offered bedside activities despite a care plan indicating the need for staff assistance. Another resident, who only spoke Creole, was left without activities and had a care plan that was not followed due to language barriers. The facility's policy on activities was not adhered to, resulting in a failure to meet the residents' individual needs.
The facility failed to provide necessary emergency tracheostomy supplies for three residents, leading to deficiencies in respiratory care. A resident did not have the required tracheostomy set in their room, another resident's room lacked essential respiratory care equipment, and a third resident's suction canister was nearly full with no replacement available. The facility's policies and physician orders were not followed, indicating a failure to maintain adequate respiratory supplies.
A resident with severe cognitive impairment and requiring substantial assistance fell from bed during care, resulting in a scalp hematoma and clavicle fracture. The CNA attempted to provide care alone, despite the care plan indicating the need for two-person assistance. The incident occurred when the resident rolled out of bed while the CNA was calling for help. The facility investigated the incident and provided staff education on abuse, neglect, exploitation, and misappropriation.
The facility failed to ensure a safe, clean, and homelike environment for residents on the 3rd and 4th floors. Observations revealed lifting flooring and damaged walls in rooms 409 and 311-B, which were not reported or addressed in a timely manner. Staff interviews indicated a lack of awareness and communication regarding these maintenance concerns.
The facility failed to ensure accurate resident assessments and discharge documentation for three residents. Two residents were observed with bed rails up, contrary to their MDS assessments, and another resident's discharge status was inaccurately documented as being sent to a hospital instead of home.
The facility failed to obtain informed consent and properly assess bedrail use for three residents, leading to the installation of bedrails without documented alternative methods or consent. Observations and interviews revealed that the residents' care plans and medical records did not reflect the use of bedrails, and staff were uncertain about the assessment process.
A facility failed to provide a necessary mobility device for a resident with Multiple Sclerosis, obesity, and Lupus Erythematosus. Despite the resident's care plan indicating the need for a high back wheelchair and her quarterly MDS assessment showing recent use of a wheelchair, the resident was left without one. Interviews with staff revealed inconsistencies and a lack of clarity regarding the provision of the wheelchair.
A resident with intact cognition reported missing clothes multiple times, but the facility failed to resolve the grievance to the resident's satisfaction. Despite filing an official grievance and the facility's attempts to address the issue, the resident remained dissatisfied with the response and continued to report missing items.
The facility failed to ensure accurate Level I PASRR assessments for three residents with serious mental illness and dementia, leading to missed Level II evaluations. Errors were acknowledged by the DON and Social Service Director, who cited confusion during the PASRR completion process.
The facility failed to update a resident's care plan after the discontinuation of a physician's order for a foot brace. Despite the resident's cognitive intactness and confirmation of not wanting to wear the shoe, the care plan still included outdated interventions. Interviews with staff revealed that the care plan should have been revised to reflect the resident's current health status.
A resident with an ADL self-care performance deficit did not receive necessary nail care despite requests and visible need. The facility lacked clear guidelines, and staff were unclear about their responsibilities regarding nail care.
The facility failed to ensure active and ongoing communication with hospice providers for two residents, resulting in missing hospice notes in medical records and inadequate pain management for a resident with Alzheimer's Disease. Staff interviews and observations confirmed the lack of proper documentation and communication, breaching the facility's Hospice Agreement.
The facility failed to maintain a medication error rate of less than 5%, resulting in a 7.41% error rate. Two residents received incorrect medications due to a nurse's failure to verify the correct dosages and types as per physician's orders.
Failure to Ensure Resident Received Entitled Personal Needs Allowance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary medically-related social services to ensure a resident received their entitled personal needs allowance (PNA). A cognitively intact resident, admitted in 06/2024 with diagnoses including need for assistance with personal care, cervical spinal stenosis, and chronic kidney disease, reported having no money coming to the facility despite previously receiving $800 per month before admission and then only $30 from Social Security. The resident stated that for two years in the facility he had received no money and had been told there were no additional funds. A family member also reported that the resident only received $30 per month. The resident’s Minimum Data Set showed a BIMS score of 15, indicating he was cognitively intact at the time of these reports. The Business Office Manager confirmed the resident was an SSI recipient with $30 monthly income and that he should also receive a $130 state PNA through the Department of Children and Families, but acknowledged the resident was not receiving this PNA. Business office notes showed Medicaid coverage authorized effective 08/2024, but contained no documentation of any inquiry or follow-up regarding the missing $130 PNA. The BOM stated she had discussed the reduced SSI check with the resident and family in 05/2025 but did not document the call, and the Social Services Director reported she had not spoken with the resident and was unsure whether any complaint had been received. The facility was unable to provide a policy or procedure outlining social services expectations related to this issue. Surveyor contact with the former DCF representative revealed that PNA issues could be easily corrected in the system, but the facility’s records did not show effective action or documented efforts to resolve the resident’s lack of PNA.
Inadequate Smoking Safety Measures and Supervision
Penalty
Summary
The facility failed to ensure a process was in place for smoking safety for three residents, leading to a deficiency in maintaining a safe environment free from accident hazards. Resident #8 was observed with cigarettes and a lighter in her room, despite not being listed as an active smoker in the facility's records. She admitted to occasionally smoking outside the designated smoking area and providing cigarettes and lighters to other residents. This indicates a lack of supervision and control over smoking materials within the facility. Resident #29 was seen with a lighter while waiting to access the smoking patio, and during a scheduled smoking time, no staff or residents were present in the designated area. This suggests inadequate supervision during smoking times, as well as a failure to adhere to the facility's smoking policy, which requires staff supervision during smoking activities. Resident #164 was observed smoking on the patio without staff presence, further highlighting the lack of supervision and adherence to safety protocols. Interviews with staff revealed inconsistencies in the smoking supervision process and a lack of clear assessment procedures for determining residents' need for smoking safety measures, such as aprons. The Director of Nursing admitted that there was no formal smoking assessment documented, and observations of smoking sessions were not recorded. The facility's policy mandates that smoking materials be kept in a secure location and that residents should not possess them within the building, yet this was not enforced, contributing to the deficiency.
Inaccurate Care Plan for Dialysis Resident
Penalty
Summary
The facility failed to ensure an accurate comprehensive care plan for a resident undergoing dialysis. The resident, who was admitted and readmitted with diagnoses including acute respiratory failure and end-stage renal disease, was observed to have a care plan that inaccurately reflected his fluid restriction status. Despite having a physician order for a 1200 cc fluid restriction, the care plan incorrectly marked fluid restriction as 'no'. This discrepancy was acknowledged by the MDS coordinator, who confirmed that the care plan needed correction to align with the physician's orders. Additionally, the discharge planning section of the resident's care plan was incomplete. The resident expressed a desire to be discharged to a facility closer to his girlfriend, a preference he had communicated to the staff. However, this information was not documented in the care plan. The Social Services Director confirmed that the discharge location should have been included in the care plan and acknowledged the need for correction. The facility's policy mandates that discharge planning be part of the care plan process, which was not adhered to in this case.
Inaccurate PASRR Evaluations for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for two residents, leading to deficiencies in their care. Resident #67 was initially admitted with diagnoses including unspecified dementia, depressive episodes, schizophrenia, and unspecified psychosis. Despite these diagnoses, the Level I PASRR did not indicate the need for a Level II evaluation, which was incorrect according to the facility's staff. The resident's care plan included interventions for behavioral issues and psychotropic medication management, but the oversight in PASRR evaluation meant that the necessary Level II PASRR was not completed, as confirmed by Staff A during an interview. Similarly, Resident #75 was admitted with multiple diagnoses, including mood disorder, dementia, schizophrenia, and anxiety disorder. The Level I PASRR for this resident also failed to trigger a Level II evaluation, despite the presence of serious mental illness and dementia. Interviews with the Social Services Director and Assistant confirmed that a Level II evaluation was required but not completed. The facility's policy mandates a review of PASRR forms for serious mental illness and intellectual disability, which was not adhered to in these cases, resulting in the deficiency.
Deficiency in Qualified Care Provision for Resident
Penalty
Summary
The facility failed to ensure that services provided to a resident were performed by individuals with the necessary skills, experience, knowledge, and licensure. This deficiency was observed in the care of a resident who was dependent on staff for all activities of daily living (ADL) due to multiple health conditions, including a tracheostomy, dementia, and chronic kidney disease. The resident's care plan required assistance from two staff members for ADLs, yet observations revealed that private sitters hired by the family were performing these tasks without the involvement of certified nursing assistants (CNAs) as required by the care plan. Interviews with the private sitters indicated that they were responsible for the resident's ADL care, including turning the resident, providing incontinence care, and performing range of motion exercises. The sitters were not consistently monitored or supported by facility staff, and the Nursing Home Administrator was unaware of the extent of care being provided by these sitters. The facility's policy on visitation and essential caregivers did not require these sitters to provide necessary care, highlighting a gap in ensuring that care was delivered by qualified personnel as per the resident's care plan.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing activity program that met the individual interests and needs of two residents, leading to a deficiency in enhancing their quality of life. Resident #154, who preferred to stay in bed due to weakness from recent cancer treatments, expressed a desire to participate in activities but was not offered bedside activities by the facility staff. Despite having a care plan that included participation in activities of choice and requiring staff assistance, there was no documentation of Resident #154's participation in group or individual activities throughout the month. The Activities Director admitted that one-on-one activities were not documented in the resident's medical record, and the weekly activity log did not include Resident #154's name. Resident #472, who only spoke Creole, was observed lying in bed throughout the day without being provided activities, with the television on an English-speaking program. The resident's care plan indicated a need for assistance with activities due to cognitive deficits and required physical assistance. However, the Activities Director was unaware of the resident's language needs and had not implemented a process to ensure that room visits were conducted or that activity interventions were followed. The resident's representative confirmed that the resident only understood Creole and expressed a desire for the resident to be more involved in activities. The Director of Nursing stated that all residents should be offered the opportunity to participate in activities, and if a resident refused, it should be documented with follow-up to encourage involvement. The facility's policy on activities emphasized the need for sensitivity and understanding of each resident's individual needs, including medical, emotional, spiritual, therapeutic, and recreational needs. However, the facility failed to adhere to this policy, resulting in a deficiency in providing appropriate activities for the residents.
Deficiency in Respiratory Care Due to Lack of Supplies
Penalty
Summary
The facility failed to provide necessary emergency tracheostomy supplies for three residents, leading to deficiencies in respiratory care. Resident #142 did not have the required tracheostomy set of the same size and a smaller size in their room, as confirmed by Staff E, RN/UM. The resident's care plan and physician orders specified the need for an ambu bag and replacement trach at the bedside, which were not present during the observation. Resident #25's room was found lacking essential respiratory care equipment, including a dry humidifier bottle and missing suction catheters. The resident's physician orders required continuous humidified oxygen, which was not being administered as prescribed. Staff O, RN, was unable to locate the necessary equipment, indicating a failure to adhere to the care plan and physician orders. Resident #156's suction canister was observed to be nearly full with a dark pink liquid, and no replacement canister was available in the room. Staff P, RN, had to leave the floor to obtain a new canister, highlighting a lack of readily available supplies. The facility's policy required changing the suction canister every 72 hours or when 3/4 full, which was not followed. Additionally, the supply closet on the floor was found to be lacking extra canisters and suction catheters, further demonstrating the facility's failure to maintain adequate respiratory supplies for residents with tracheostomy needs.
Resident Fall Due to Inadequate Assistance
Penalty
Summary
The facility failed to prevent a fall resulting in injury to a resident who had severe cognitive impairment and required substantial assistance with activities of daily living. The resident, who had been admitted to the facility in 2017, had a history of dementia, muscle wasting, and lack of coordination, among other conditions. The care plan for the resident indicated the need for a total mechanical lift with two-person assistance for transfers and two-person assistance for bed mobility. However, during an incident on 07/16/2024, a CNA attempted to provide care alone, which led to the resident rolling out of bed and sustaining injuries. On the day of the incident, the CNA was providing evening care and noticed the resident had a large bowel movement. The CNA rolled the resident onto her side to clean her, but the resident rolled out of bed before the CNA could stop her. The CNA had called out for assistance but did not receive help in time. The resident fell to the floor, resulting in a scalp hematoma and a clavicle fracture. The CNA reported that the resident had never rolled out of bed before, and the bed was raised to an ergonomic height for care. Interviews with staff revealed that the resident was known to require two-person assistance for care, especially when being cleaned. The Nursing Home Administrator confirmed that the CNA initially thought she could manage the care alone but called for help when realizing the extent of the task. The incident was investigated, and it was determined that the fall was unsubstantiated for neglect, although staff received education on abuse, neglect, exploitation, and misappropriation following the event.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents on the 3rd and 4th floors. Observations revealed that the flooring in room 409 was lifting and could be freely moved, posing a potential hazard. Additionally, the wall behind bed B in room 409 had several deep scratch marks with missing paint and visible debris on the floor. Despite the facility's electronic maintenance system and concierge rounds, these issues were not reported or addressed in a timely manner. Interviews with staff, including the Nursing Home Administrator (NHA), Registered Nurse (RN) Unit Manager (UM), and Maintenance Assistant (MA), indicated a lack of awareness and communication regarding the maintenance concerns in room 409. The NHA and RN UM were unsure if the maintenance staff were aware of the issues, and the MA only became aware of the flooring concern on 5/16/2024. The Director of Nursing (DON) confirmed that environmental or maintenance concerns should be documented in the facility's electronic maintenance log, but this process was not effectively followed. Further observations in room 311-B revealed damaged walls with patches of paint coming off and deep scratches. Staff interviews indicated that daily inspections by Certified Nursing Assistants (CNAs) and Unit Managers were supposed to identify such concerns, but the damaged walls in room 311-B were not noticed or reported. The facility's policy on maintaining a safe, clean, and comfortable environment was not adhered to, as evidenced by the unaddressed maintenance issues in the resident rooms.
Inaccurate Resident Assessments and Discharge Documentation
Penalty
Summary
The facility failed to ensure the accuracy of resident comprehensive assessments for three residents. Resident #64 was observed with bilateral, one-quarter length bed rails up, despite the quarterly Minimum Data Set (MDS) assessment indicating that bed rails were not used. This discrepancy was confirmed through multiple observations and interviews with the resident's representative. Similarly, Resident #81 was observed with bed rails up, although the annual MDS assessment also indicated that bed rails were not used. These observations were made on different days, confirming the inconsistency in the documentation and actual use of bed rails for both residents. Additionally, the facility failed to accurately document the discharge status of Resident #158. The medical record indicated that the resident was discharged to a short-term general hospital, while progress notes and physician orders confirmed that the resident was discharged home. This inconsistency was verified through an interview with a Licensed Practical Nurse (LPN) and Clinical Reimbursement Specialist (CRS). The facility's policies and procedures for discharge management and resident assessment were reviewed, highlighting the need for accurate documentation and coordination by the interdisciplinary team (IDT) and nursing staff.
Failure to Obtain Informed Consent and Properly Assess Bedrail Use
Penalty
Summary
The facility failed to ensure informed consent for the use of bedrails was obtained prior to their installation and did not properly assess residents for bedrail use. This deficiency was identified for three residents who had bedrails installed without documented informed consent or proper assessment. Resident #64, who had diagnoses including dementia and anxiety disorder, was observed with bedrails up, but there was no documentation of alternative methods tried or informed consent obtained. The resident's care plan and MDS assessment did not reflect the use of bedrails, and the resident's representative confirmed that they were not informed of the risks or asked to provide consent. Similarly, Resident #81, with diagnoses including psychosis and hemiplegia, was observed with bedrails up without any documentation of alternative methods or informed consent. The resident's care plan and MDS assessment did not address the use of bedrails, and the Occupational Therapy Plan of Care did not mention bedrails either. Staff interviews revealed uncertainty about the assessment process and the necessity of bedrails for this resident. Resident #311, who had multiple fractures and dementia, was also observed with bedrails up without proper assessment or informed consent. The resident's care plan and medical record did not document the use of bedrails or alternative methods tried. Staff interviews indicated that the bedrails were already installed when the resident was admitted, and there was no clear understanding of the assessment process for bedrail use. The facility's policy required thorough assessment and informed consent, which were not followed in these cases.
Failure to Provide Necessary Mobility Device
Penalty
Summary
The facility failed to accommodate the needs of Resident #39, who was diagnosed with Multiple Sclerosis (MS), obesity, and Lupus Erythematosus, by not providing a necessary mobility device. During an interview, Resident #39 expressed a desire to plan outings for the summer but stated that the facility had taken her wheelchair, leaving her without one. Observations confirmed that a wheelchair was not present in her room, despite her care plan indicating the need for a high back wheelchair due to her medical conditions. The care plan also specified the use of a wheelchair for locomotion and a total mechanical lift with two staff members for transferring. The resident's quarterly MDS assessment indicated she was cognitively intact and had used a wheelchair for mobility within the last seven days. Interviews with facility staff revealed inconsistencies and a lack of clarity regarding the provision of the wheelchair. The Occupational Therapist (OT) mentioned that residents are assessed for the type of chair they need but did not provide a clear reason why Resident #39 did not have a wheelchair. The Director of Nursing (DON) stated that assistive devices are provided based on therapy assessments and should remain with the resident for their entire stay, even if not used frequently. However, the DON could not explain why Resident #39 did not have a wheelchair available for her use, despite her documented need and the facility's policy.
Failure to Resolve Resident Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to resolve a resident grievance regarding missing clothing in a timely manner. Resident #143, who was admitted with a primary diagnosis of muscle wasting and atrophy and had intact cognition, reported missing clothes to the staff on multiple occasions. Despite the resident's repeated complaints and a detailed list of missing items, the facility did not locate the clothing or provide a satisfactory resolution. The resident expressed frustration over the ongoing issue and reluctance to send more clothes to the laundry due to fear of further losses. The grievance was officially filed on 04/29/24, and the facility's records indicated it was resolved by 05/08/24. However, the resident continued to report missing items and dissatisfaction with the facility's response. The facility offered items from the lost and found, which the resident declined, and there was a lack of clear communication regarding reimbursement or reordering of the missing items. The resident stated that the facility had not mentioned anything about helping him reorder the missing clothes. Interviews with staff, including the Unit Manager, Social Services Director, and Administrator, confirmed the resident's grievances and the facility's attempts to address the issue. However, the facility's efforts, including searching the laundry and lost and found, were unsuccessful, and the resident remained dissatisfied. The facility's grievance policy outlined the process for handling such concerns, but in this case, the resolution was not achieved to the resident's satisfaction.
Inaccurate PASRR Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Level I Pre-Admission Screening and Resident Review (PASRR) assessments for three residents. Resident #24 was admitted with diagnoses including Alzheimer's disease, bipolar disorder, and schizoaffective disorder. The Level I PASRR form incorrectly indicated that the resident did not have a secondary diagnosis of dementia or Alzheimer's, and no request for a Level II PASRR evaluation was made. The Director of Nursing and the Social Service Director acknowledged the error, attributing it to confusion during the PASRR completion process with assistance from an outside vendor. Resident #81 was admitted with diagnoses including unspecified psychosis, dementia, anxiety disorder, depressive episodes, and insomnia. The Level I PASRR assessment did not trigger a Level II PASRR evaluation despite the presence of serious mental illness diagnoses. Similarly, Resident #38, who had major depressive disorder, bipolar disorder, vascular dementia, and schizoaffective disorder, had an incorrectly completed Level I PASRR form. The Social Services Director confirmed the error and submitted a Level II screening after the oversight was identified. The facility's PASRR policy mandates a Level II PASRR for residents with serious mental illness and dementia, which was not followed in these cases.
Failure to Update Care Plan After Discontinuation of Physician's Order
Penalty
Summary
The facility failed to review and revise the care plan for a resident who was admitted with multiple diagnoses, including hemiplegia, hemiparesis, and multiple sclerosis. The resident was observed without a foot brace, which was previously ordered but later discontinued. Despite the discontinuation of the physician's order for the foot brace, the care plan was not updated to reflect this change. The resident, who was cognitively intact, confirmed that she did not want to wear the shoe at the time of the interview. However, the care plan still included interventions related to the use of the foot brace, which was no longer applicable. Interviews with staff, including an LPN and the Director of Nursing (DON), revealed that the care plan should have been revised when the physician's order for the foot brace was discontinued. The facility's policy mandates that care plans be reviewed and revised periodically to reflect the resident's current health status. The failure to update the care plan resulted in outdated and irrelevant interventions being listed, which could potentially impact the resident's care and well-being.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to provide necessary nail care for a resident who was unable to perform Activities of Daily Living (ADLs) independently. On 05/13/24, the resident expressed the need for her nails to be cut, stating that staff did not offer to cut her nails. On 05/15/24, the resident was observed with elongated, uneven, and jagged nails with visible dirt underneath. Despite the resident's request to a Certified Nursing Assistant (CNA) to cut her nails, the CNA stated she did not have a nail clipper and did not follow up on the resident's offer to use her own clippers. The resident's care plan indicated that she required assistance with personal hygiene, including nail care during bathing and as necessary, but this was not adhered to by the staff. Further investigation revealed that the CNAs were not responsible for cutting nails, as stated by the Director of Nursing (DON). Instead, the responsibility fell on the nurse or nurse manager. However, this protocol was not communicated effectively to the staff, leading to the resident's unmet need for nail care. The facility did not provide a policy related to nail care, indicating a lack of clear guidelines and procedures for staff to follow in such situations.
Failure to Ensure Communication with Hospice Providers
Penalty
Summary
The facility failed to ensure active and ongoing communication between the facility and hospice providers for two residents receiving hospice services. Resident #18, who has a history of malignant neoplasm of the lung, cognitive communication deficit, and other conditions, reported that hospice assists with her care. However, a review of her medical record revealed no hospice notes or communication forms. Staff interviews confirmed the absence of hospice documentation, and the Director of Nursing (DON) acknowledged that hospice notes should be part of the resident's medical record or placed in a hospice binder. The facility's Hospice Agreement mandates ongoing communication and documentation, which was not adhered to in this case. Resident #24, diagnosed with Alzheimer's Disease, reported severe pain levels of 10 during interviews. Despite having physician orders for multiple pain medications, the resident's pain was not adequately managed. Staff interviews revealed that the hospice nurse did not leave visit reports at the facility, and the Unit Manager was unaware of a hospice book. Additionally, a nurse was observed struggling to administer a Tylenol pill to the resident, who had difficulty swallowing. The DON stated that hospice staff should communicate with facility staff and leave visit notes, and that residents should be comfortable at all times with appropriate pain management. The lack of proper communication and documentation between the facility and hospice providers led to deficiencies in the care of both residents. The facility did not maintain hospice notes in the medical records, and there was inadequate pain management for Resident #24. These failures indicate a breach of the facility's Hospice Agreement and a lack of adherence to expected protocols for coordinating care with hospice services.
Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a medication administration error rate of 7.41%. During the observation of 27 medication administration opportunities, two errors were identified involving two residents. Resident #56 received an incorrect dose of folic acid, being administered 400 mcg instead of the prescribed 1 mg. Resident #4 was given Ferrous sulfate 325 mg instead of the prescribed Polysaccharide iron complex 150 mg. These errors were observed during medication administration by Staff K, RN, who did not verify the correct medications and dosages as per the physician's orders. Resident #56 was admitted with diagnoses of muscle wasting, atrophy, and polyosteoarthritis. The medication error for this resident involved the administration of folic acid at an incorrect dosage. Similarly, Resident #4, who was admitted with diagnoses of atrial fibrillation and cognitive communication deficit, received the wrong type of iron supplement. Staff K, RN, failed to follow the facility's policy of verifying the right dose, right medication, right route, right time, and right resident before administering the medications. The Director of Nursing (DON) confirmed that nursing staff are expected to verify the five rights of medication administration and compare the medication with the resident's medication administration record and physician's orders. The facility's policy on medication administration, effective since November 2018, mandates that medications be administered as prescribed and verified three times before administration. The failure to adhere to these procedures led to the identified medication errors.
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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) |
|---|---|---|---|---|
| Aviata At The Bay | 0.3 mi | ★★★★★ | 3 | 2 |
| Ybor City Center For Rehabilitation And Healing | 2.7 mi | ★★★★★ | 3 | 0 |
| Elon Manor Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 10 | 0 |
| Whispering Oaks | 2.8 mi | ★★★★★ | 11 | 0 |
| Canterbury Towers Inc | 4.8 mi | ★★★★★ | 0 | 0 |
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