Inspection Reports for Tampa Lakes Health And Rehabilitation Center
750 Hayes Rd, Lutz, FL 33549, FL, 33549
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
3.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
26% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Census: 67
Deficiencies: 5
Date: Jan 9, 2025
Visit Reason
Routine inspection of Tampa Lakes Health and Rehabilitation Center to assess compliance with regulatory requirements including PASRR screening, medication administration, food safety, resident privacy, and infection control.
Findings
The facility failed to ensure completion of PASRR Level II screenings for residents with mental illness or suspected mental illness, failed to monitor blood pressure before administering medication for one resident, failed to follow professional food safety standards in multiple areas, failed to safeguard resident privacy, and failed to implement proper infection prevention and control practices including hand hygiene and respiratory mask storage.
Deficiencies (5)
Failed to ensure the Preadmission Screening and Resident Review (PASRR) Level II were completed for residents with mental illness or suspected mental illness.
Failed to monitor blood pressure before administering medication ordered for increased blood pressure for one resident.
Failed to follow professional standards for food service safety in the facility kitchen, dining areas, and nourishment rooms.
Failed to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Failed to provide and implement an infection prevention and control program ensuring proper hand hygiene, respiratory mask storage, and offering hand hygiene to residents during meal service.
Report Facts
Residents sampled: 67
Residents reviewed for medication regimens: 6
Dining areas observed: 6
Nourishment rooms observed: 6
Units observed for privacy issues: 6
Units observed for infection control: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff O | Registered Nurse (RN), Unit Manager (UM) | Named in medication monitoring deficiency |
| Staff P | Licensed Practical Nurse (LPN) | Named in medication monitoring deficiency |
| Director of Nursing | Director of Nursing (DON) | Named in medication monitoring and privacy deficiencies |
| Staff E | Dietary Aide | Named in food safety deficiencies |
| Assistant Food Service Director | Assistant Food Service Director | Named in food safety deficiencies |
| Staff H | Dietary Aide | Named in food safety deficiencies |
| Staff D | Dietary Aide | Named in food safety deficiencies |
| Staff R | Dietary Aide | Named in food safety deficiencies |
| Staff S | Dietary Aide | Named in food safety deficiencies |
| Staff J | Registered Nurse (RN) | Named in privacy and infection control deficiencies |
| Staff M | Licensed Practical Nurse (LPN) | Named in privacy deficiency |
| Staff F | Certified Nursing Assistant (CNA) | Named in infection control deficiency |
| Staff L | Certified Nursing Assistant (CNA) | Named in infection control deficiency |
| Staff G | Certified Nursing Assistant (CNA) | Named in infection control deficiency |
| Staff C | Certified Nursing Assistant (CNA) | Named in infection control deficiency |
| Staff B | Registered Nurse (RN) | Named in infection control deficiency |
| Staff Q | Licensed Practical Nurse (LPN) | Named in infection control deficiency |
| Respiratory Therapist | Respiratory Therapist (RT) | Named in infection control deficiency |
| Staff A | Unit Manager (UM) | Named in infection control deficiency |
| Infection Preventionist | Infection Preventionist (IP) | Named in infection control deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 15, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to reasonably accommodate the needs related to wheelchair use for Resident #3.
Complaint Details
The complaint investigation found that Resident #3 was without his wheelchair for two days after staff borrowed it for assessment of another resident and did not return it in a timely manner. Resident #3 was unable to get out of bed and expressed feeling picked on. Staff interviews confirmed the wheelchair was borrowed with permission but not returned promptly. The Director of Nursing agreed this was unacceptable.
Findings
The facility failed to ensure Resident #3 had access to his wheelchair for two days after it was borrowed by staff for assessment purposes and not returned in a timely manner, limiting his ability to get out of bed and ambulate. Interviews with staff and review of records confirmed the wheelchair was taken without proper communication and was not returned promptly, which was deemed unacceptable.
Deficiencies (1)
Failure to reasonably accommodate the needs and preferences of Resident #3 related to wheelchair use, resulting in lack of access to the wheelchair for two days.
Report Facts
Residents Affected: 4
Residents Affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Unit Manager (UM)/Registered Nurse (RN) | Asked Resident #3 for permission to borrow the wheelchair and confirmed it was therapy's role to evaluate the wheelchair fit. |
| Director of Therapy | Physical Therapist (PT) | Confirmed the wheelchair was borrowed for assessment and was not returned promptly; was unaware of the early removal by Staff D. |
| Director of Nursing | DON | Acknowledged the wheelchair was not returned timely and agreed it was unacceptable that Resident #3 did not have access to his wheelchair. |
Inspection Report
Deficiencies: 1
Date: Mar 13, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety and sanitation standards, specifically focusing on the maintenance and cleanliness of kitchen equipment including ice machines and ice/water dispensers across the facility.
Findings
The facility failed to maintain kitchen equipment in a clean manner, with observations of white and brown substances (lime scale) on ice machines and ice/water dispensers in the main kitchen and six living unit kitchens. The Dietary Manager and Maintenance Director confirmed maintenance responsibilities and cleaning schedules, but contamination was still present.
Deficiencies (1)
Failure to ensure kitchen equipment was maintained in a clean manner for 1 of 1 ice machines and related ice/water dispensers on 6 living units, with visible lime scale and other substances.
Report Facts
Number of ice machines inspected: 1
Number of ice/water dispensers inspected: 6
Cleaning frequency: 1
Cleaning frequency: 7
Scoop cleaning frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding ice machine and ice/water dispenser conditions and maintenance responsibilities | |
| Maintenance Director | Interviewed regarding maintenance and cleaning schedules for ice machines and dispensers |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 31, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide a requested medical record for one resident (#2).
Complaint Details
The complaint investigation found that the facility did not provide the requested medical records to Resident #2's family. The family paid $20.22 for copies, but the facility could not provide proof that the records were sent. Interviews with the Medical Records Coordinator, Business Office Manager, Director of Nursing, and family members confirmed the records were not received. The facility attorney confirmed sending the records but could not provide proof. The facility policy requires attorney review and authorization before release, but the process was not properly documented or completed.
Findings
The facility failed to provide proof that Resident #2's family received the requested medical records despite payment being made. Interviews with staff and family confirmed the records were not received, and the facility could not locate documentation of the release. The facility's policies require authorization and attorney review before releasing records, but communication and documentation were incomplete.
Deficiencies (1)
Failure to provide requested medical records to Resident #2's family despite payment and authorization.
Report Facts
Payment amount: 20.22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Records Coordinator | Interviewed regarding the procedure for releasing medical records and inability to provide proof that records were sent | |
| Business Office Manager | Interviewed about documentation of payment for medical record copies | |
| Director of Nursing | Interviewed about knowledge of whether Resident #2's family received the medical records | |
| Facility Administrator | Stated no proof was found that Resident #2's family received the requested medical records |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 31, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide a requested medical record for one resident (#2).
Complaint Details
The complaint investigation found that the facility did not provide the requested medical records to Resident #2's family despite payment. The family confirmed non-receipt, and the facility lacked documentation proving the records were sent. The facility attorney confirmed sending the records but could not provide proof.
Findings
The facility failed to provide proof that Resident #2's family received the requested medical records despite payment being made. Interviews with staff and family confirmed the records were not received, and the facility could not locate documentation of the release of records to the family.
Deficiencies (1)
Failure to provide requested medical record to resident or legal representative.
Report Facts
Payment amount: 20.22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Records Coordinator | Interviewed regarding the procedure for releasing medical records and inability to provide proof that records were sent to Resident #2's family | |
| Business Office Manager | Interviewed regarding documentation of payment for medical record copies | |
| Director of Nursing | Interviewed about knowledge of whether Resident #2's family received the medical records | |
| Facility Administrator | Stated no proof was found that Resident #2's family received the requested medical records |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 27, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, hospice communication, and COVID-19 reporting at Tampa Lakes Health and Rehabilitation Center.
Findings
The facility failed to revise the care plan for a resident with aggressive behaviors, failed to ensure collaborative communication with hospice services for a resident under hospice care, and failed to notify residents, families, and representatives following the admission of residents with COVID-19.
Deficiencies (3)
Failed to review and revise the care plan related to behaviors for one resident (Resident #98) who was on 1:1 due to aggressive behavior.
Failed to ensure collaborative communication with Hospice Services for one resident (#60) under hospice care, with no hospice notes or care plans found in the resident's record.
Failed to notify residents, families, and representatives following the admission of two residents (#61 and #100) who tested positive and were cared for with COVID-19 precautions.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Certified Nursing Assistant (CNA) | Reported Resident #98 was on 1:1 due to an altercation |
| Staff J | Certified Nursing Assistant (CNA) | Observed Resident #98 and reported aggressive behaviors |
| Staff H | Licensed Practical Nurse (LPN) | Reported Resident #98 was aggressive and on 1:1 |
| Staff I | Licensed Practical Nurse (LPN), Unit Manager | Confirmed Resident #98 was on 1:1 due to aggression |
| Risk Manager | Confirmed Resident #98 had been on 1:1 since July incident | |
| Director of Nursing | Director of Nursing (DON) | Reported care plan expectations and hospice communication |
| Staff E | Medical Records | Confirmed absence of hospice notes for Resident #60 |
| Staff F | Licensed Practical Nurse (LPN) | Unaware of hospice visits for Resident #60 |
| Infection Preventionist | Infection Preventionist (IP) | Reported on COVID-19 positive residents and notification practices |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Responsible for COVID-19 notification calls and policy interpretation |
Inspection Report
Routine
Deficiencies: 5
Date: May 7, 2021
Visit Reason
The inspection was conducted as a routine regulatory survey of Tampa Lakes Health and Rehabilitation Center to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during medication administration, failure to provide ordered adaptive eating equipment, failure to provide showers as scheduled, failure to provide restorative therapy and splint application as ordered, and failure to maintain kitchen dishwashing equipment at required temperatures.
Deficiencies (5)
Failure to ensure dignity was maintained during dining when medications were administered to a resident while dining, requiring the resident to stop eating.
Failure to provide eight residents with ordered adaptive eating and drinking equipment during multiple meal services over four days.
Failure to ensure one resident received showers according to the shower schedule for the last 30 days.
Failure to provide restorative therapy and apply splints as ordered for three residents, resulting in missed restorative care and splint application.
Failure to maintain the kitchen's mechanical dishwashing machine at required wash and rinse temperatures, with documented temperatures below minimum requirements and missing temperature logs.
Report Facts
Residents affected: 1
Residents affected: 8
Residents affected: 1
Residents affected: 3
Days: 4
Temperature degrees F: 147
Temperature degrees F: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee J | Registered Nurse | Named in medication administration during dining room observation |
| Employee G | Certified Nursing Assistant | Named in meal service and adaptive equipment provision observation |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration policies and adaptive equipment |
| Occupational Therapist employee M | Occupational Therapist | Interviewed regarding adaptive equipment use and restorative therapy |
| Certified Dietary Manager (CDM) | Certified Dietary Manager | Interviewed regarding dishwashing machine operation and adaptive equipment availability |
| Staff member W | Certified Nurse Assistant (CNA) restorative | Interviewed regarding restorative care and splint application |
| Staff member U | Registered Nurse | Interviewed regarding restorative care program and documentation |
| Staff member X | Registered Nurse unit manager | Interviewed regarding restorative care and splint application |
| Staff member V | Certified Nurse Assistant | Interviewed regarding splint use for Resident #85 |
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