Inspection Reports for Fairway Oaks Center
13806 N 46th St, Tampa, FL 33613, FL, 33613
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 3
Date: Nov 20, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notification prior to transfer, provision of activities of daily living (ADLs) care, and maintenance of complete clinical records.
Findings
The facility failed to notify a resident's representative prior to transfer, did not provide adequate grooming and personal hygiene care including nail trimming for dependent residents, and failed to maintain complete, accurate, and accessible clinical records for a resident, including timely notification of family after falls.
Deficiencies (3)
Failed to ensure the resident representative was notified prior to the resident's transfer for one resident.
Failed to provide activities of daily living (ADLs) related to grooming and personal hygiene care, including nail trimming, for three dependent residents.
Failed to maintain complete clinical records for one resident which were accurately documented, readily accessible, and systematically organized.
Report Facts
Residents affected: 1
Residents affected: 3
Residents affected: 1
Falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nursing Assistant (CNA) | Interviewed regarding nail care practices and documentation |
| Staff C | Certified Nursing Assistant (CNA) | Interviewed regarding nail trimming frequency and showering |
| Staff D | Certified Nursing Assistant (CNA) | Interviewed regarding nail care concerns and bathing |
| Staff A | Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding nail trimming procedures and diabetic residents |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding clinical record keeping and fall notifications |
| Nursing Home Administrator (NHA) | Nursing Home Administrator | Interviewed regarding clinical records office and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 11, 2024
Visit Reason
The inspection was conducted following a complaint alleging neglect and abuse of Resident #100, including allegations of double briefing, physical restraint, and improper care.
Complaint Details
The complaint involved Resident #100 being found with hands tied behind her back, double briefed, call light out of reach, and TV not working. The Resident Representative reported these concerns. The facility suspended the CNA involved pending investigation. The complaint was not substantiated by the facility, and the Resident Representative was not contacted after the report. The facility did not include the restraint allegation in federal reports.
Findings
The facility failed to provide Abuse/Neglect training to one staff member and did not report all alleged violations of abuse, including physical restraints, to the State Survey Agency. Resident #100 was found with hands bound behind her back, double briefed, and with a call light out of reach. The facility investigated but did not substantiate the complaint and failed to include all details in federal reports.
Deficiencies (2)
Failed to provide Abuse/Neglect training to one staff member.
Failed to timely report all alleged violations of abuse including physical restraints to the State Survey Agency.
Report Facts
Employees reviewed: 10
Residents sampled: 23
Suspension duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff X | Certified Nursing Assistant (CNA) | Failed to receive Abuse/Neglect training and was suspended pending investigation for alleged inappropriate touching and double briefing |
| Director of Nursing (DON) | Provided statements regarding Resident #100's condition and complaint investigation | |
| Nursing Home Administrator (NHA) | Reported allegations to abuse hotline and police, suspended CNA, and provided statements about investigation and reporting | |
| Staff G | Licensed Practical Nurse (LPN) | Unit Manager who notified DON of complaint |
| Staff Y | Licensed Practical Nurse (LPN) | Attempted to fix TV and involved in complaint investigation |
| Assistant Director of Nursing (ADON) | Notified DON of complaint |
Inspection Report
Routine
Deficiencies: 12
Date: Sep 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, facility cleanliness, privacy, and other aspects of nursing home operations.
Findings
The facility was found deficient in multiple areas including failure to provide wheelchair mobility to a resident, privacy violations for residents, unclean shower rooms, incomplete PASRR screening, incomplete and inconsistent care plans for residents, failure to provide adequate activities of daily living care including nail care and showers, medication administration errors, improper catheter care, failure to provide trauma-informed care, and failure to post accurate daily nurse staffing information.
Deficiencies (12)
Failed to ensure wheelchair mobility was provided for one resident (#7) of eight sampled.
Failed to provide two residents (#76 and #82) with privacy during observed days.
Failed to ensure two community shower rooms were cleaned and maintained.
Failed to ensure timely and accurate PASRR screening for one resident (#73) of 23 sampled.
Failed to develop and implement complete care plans for skin conditions and activities of daily living for residents (#44, #45, #51).
Failed to provide activities of daily living care including fingernail care and showers for two residents (#44 and #51).
Failed to provide quality care and services related to medication administration and skin care treatment for one resident (#45).
Failed to provide appropriate care for residents with indwelling urinary catheters to prevent leakage and tubing breaks for two residents (#82 and #13).
Failed to provide trauma-informed care and ensure staff training for one resident (#39) with PTSD.
Failed to post up-to-date and accurate daily nurse staffing information for three days.
Medication error rate was 20% with seven errors from 35 medication administration opportunities for three residents (#14, #93, #498).
Failed to maintain accurate and complete medical record documentation for bathing and medication administration for four residents (#498, #93, #14, #51).
Report Facts
Medication error rate: 20
Days staffing sheet not updated: 3
Medication administration opportunities: 35
Medications observed administered: 9
Residents sampled: 46
Residents affected: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff Z | Certified Nursing Assistant (CNA) | Named in wheelchair mobility deficiency for Resident #7 |
| Staff W | Registered Nurse (RN) | Named in wheelchair mobility deficiency for Resident #7 and medication administration |
| Staff AA | Certified Nursing Assistant (CNA) | Named in wheelchair mobility deficiency for Resident #7 |
| Staff BB | Licensed Practical Nurse/Unit Manager (LPN/Unit Manager) | Named in wheelchair mobility deficiency for Resident #7 |
| Rehab Director | Named in wheelchair mobility deficiency for Resident #7 | |
| Staff H | Certified Nursing Assistant (CNA) | Named in privacy deficiency for Resident #76 |
| Staff C | Personal Care Attendant (PCA) | Named in privacy deficiency for Resident #82 |
| Staff G | 100/200 Unit Manager | Named in privacy and catheter care deficiencies for Resident #82 |
| Staff P | Housekeeper | Named in shower room cleanliness deficiency |
| Staff M | Housekeeping Supervisor | Named in shower room cleanliness deficiency |
| Staff N | Environmental Services Director | Named in shower room cleanliness deficiency |
| Staff S | Registered Nurse (RN) Minimum Data Set (MDS) Director | Named in PASRR screening deficiency |
| Staff V | Registered Nurse (RN) | Named in medication administration and skin care treatment deficiency |
| Staff EE | Licensed Practical Nurse/Wound Care Nurse | Named in medication administration and skin care treatment deficiency |
| Assistant Director of Nursing (ADON) | Named in medication administration and skin care treatment deficiency | |
| Director of Nursing (DON) | Named in multiple deficiencies including ADL care, medication administration, shower sheets, staffing posting | |
| Staff K | Certified Nursing Assistant (CNA) | Named in catheter care deficiency for Resident #13 |
| Staff L | Licensed Practical Nurse (LPN) | Named in catheter care deficiency for Resident #13 |
| Staff O | Licensed Practical Nurse (LPN) | Named in trauma informed care deficiency for Resident #39 |
| Staff I | Licensed Practical Nurse (LPN) | Named in trauma informed care deficiency for Resident #39 |
| Staff B | Staffing Coordinator | Named in nurse staffing posting deficiency |
| Staff U | Licensed Practical Nurse (LPN) | Named in medication administration deficiency for Resident #498 |
| Staff W | Registered Nurse (RN) | Named in medication administration deficiency for Resident #14 |
Inspection Report
Routine
Deficiencies: 7
Date: Sep 1, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, medication administration, dental services, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to resolve resident concerns about meal condiments, inadequate care planning for weight loss, failure to provide assistance with activities of daily living such as nail care, failure to assess and document skin scratches, inadequate monitoring of psychotropic medication behaviors, a high medication error rate, and failure to provide dental services to a resident.
Deficiencies (7)
Failed to resolve resident concerns related to receiving condiments at meals as voiced at the Food Committee meeting.
Failed to develop and implement a complete care plan relevant to weight loss and failed to implement the care plan for one resident.
Failed to provide activities of daily living assistance for soiled fingernails for one resident.
Failed to assess scratches on a resident's shins and document the findings.
Did not identify specific behaviors to monitor related to psychotropic medication administration for two residents.
Medication error rate was 25.81% due to errors including omitted medications, crushing medications not to be crushed, and failure to follow blood pressure parameters.
Failed to provide dental services to one resident who was edentulous and had not been asked about dentures.
Report Facts
Medication error rate: 25.81
Weight loss: 16.5
Weight loss: 9
BIMS score: 5
BIMS score: 6
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Registered Dietitian | Confirmed resident weight loss and lack of nutrition recommendations |
| Staff F | Registered Nurse (RN) | Confirmed resident's fingernails were dirty during observation |
| Staff G | Certified Nursing Assistant (CNA) | Confirmed resident's fingernails were dirty and described nail care practices |
| Staff D | Registered Nurse (RN) | Observed medication administration with errors |
| Staff B | Registered Nurse (RN) | Observed medication administration with errors |
| Staff C | Licensed Practical Nurse (LPN) | Observed medication administration with errors and behavior monitoring |
| Director of Nursing | Director of Nursing (DON) | Provided interviews regarding behavior monitoring, medication errors, and skin assessments |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding resident dental needs and dental visit report |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Apr 15, 2021
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements including PASRR screening, provision of care and assistance with activities of daily living, accident prevention, bed rail use, and antibiotic stewardship.
Findings
The facility was found deficient in multiple areas including inaccurate PASRR screening for one resident, failure to provide adequate grooming and personal hygiene services to two residents, failure to ensure an accident-free environment related to oxygen tubing for one resident, failure to properly assess, obtain consent, and document use of bed rails for eight residents, and failure to implement an effective antibiotic stewardship program related to monitoring antibiotic use for one resident.
Deficiencies (5)
Failed to ensure accurate PASRR screening and referral for one resident.
Failed to provide necessary grooming and personal hygiene services including showers, nail care, and shaves for two residents.
Failed to ensure an accident-free environment related to oxygen tubing placement for one resident.
Failed to assess, obtain consent, obtain physician orders, and include in care plans the use of bed rails for eight residents.
Failed to implement an effective antibiotic stewardship program related to monitoring antibiotic use for one resident.
Report Facts
Residents sampled: 40
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 8
Residents affected: 1
Antibiotic days: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff F | Unit Manager | Confirmed grooming and bathing deficiencies and documentation issues for Resident #6 and #28 |
| Staff G | Registered Nurse (RN) | Reported CNAs notify her of resident bathing refusals |
| Staff I | Licensed Practical Nurse (LPN) | Reported CNAs mostly agency staff do not inform her of resident bathing refusals |
| Staff A | Certified Nursing Aide (CNA) | Responsible for ensuring oxygen tubing is not on the floor and notifying nurse if tubing is on floor |
| Staff B | Registered Nurse (RN) | Educates resident on oxygen safety and concerned about tubing sanitation |
| Director of Nursing (DON) | Director of Nursing | Provided bed rail evaluations, acknowledged lack of signed consents for bed rails, and discussed antibiotic stewardship program deficiencies |
| Infection Control Preventionist (ICP) | Infection Control Preventionist | Reviewed antibiotic orders and line listings, identified monitoring deficiencies for Resident #27 |
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