Inspection Reports for Tampa Lakes Health And Rehabilitation Center

750 Hayes Rd, Lutz, FL 33549, FL, 33549

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Deficiencies (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/year

Deficiencies per year

8 6 4 2 0
2021
2022
2023
2024
2025

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
NameTitleContext
Staff ORegistered Nurse (RN), Unit Manager (UM)Named in medication monitoring deficiency
Staff PLicensed Practical Nurse (LPN)Named in medication monitoring deficiency
Director of NursingDirector of Nursing (DON)Named in medication monitoring and privacy deficiencies
Staff EDietary AideNamed in food safety deficiencies
Assistant Food Service DirectorAssistant Food Service DirectorNamed in food safety deficiencies
Staff HDietary AideNamed in food safety deficiencies
Staff DDietary AideNamed in food safety deficiencies
Staff RDietary AideNamed in food safety deficiencies
Staff SDietary AideNamed in food safety deficiencies
Staff JRegistered Nurse (RN)Named in privacy and infection control deficiencies
Staff MLicensed Practical Nurse (LPN)Named in privacy deficiency
Staff FCertified Nursing Assistant (CNA)Named in infection control deficiency
Staff LCertified Nursing Assistant (CNA)Named in infection control deficiency
Staff GCertified Nursing Assistant (CNA)Named in infection control deficiency
Staff CCertified Nursing Assistant (CNA)Named in infection control deficiency
Staff BRegistered Nurse (RN)Named in infection control deficiency
Staff QLicensed Practical Nurse (LPN)Named in infection control deficiency
Respiratory TherapistRespiratory Therapist (RT)Named in infection control deficiency
Staff AUnit Manager (UM)Named in infection control deficiency
Infection PreventionistInfection 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
NameTitleContext
Staff DUnit 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 TherapyPhysical 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 NursingDONAcknowledged 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
NameTitleContext
Dietary ManagerInterviewed regarding ice machine and ice/water dispenser conditions and maintenance responsibilities
Maintenance DirectorInterviewed 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
NameTitleContext
Medical Records CoordinatorInterviewed regarding the procedure for releasing medical records and inability to provide proof that records were sent
Business Office ManagerInterviewed about documentation of payment for medical record copies
Director of NursingInterviewed about knowledge of whether Resident #2's family received the medical records
Facility AdministratorStated 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
NameTitleContext
Medical Records CoordinatorInterviewed regarding the procedure for releasing medical records and inability to provide proof that records were sent to Resident #2's family
Business Office ManagerInterviewed regarding documentation of payment for medical record copies
Director of NursingInterviewed about knowledge of whether Resident #2's family received the medical records
Facility AdministratorStated 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
NameTitleContext
Staff GCertified Nursing Assistant (CNA)Reported Resident #98 was on 1:1 due to an altercation
Staff JCertified Nursing Assistant (CNA)Observed Resident #98 and reported aggressive behaviors
Staff HLicensed Practical Nurse (LPN)Reported Resident #98 was aggressive and on 1:1
Staff ILicensed Practical Nurse (LPN), Unit ManagerConfirmed Resident #98 was on 1:1 due to aggression
Risk ManagerConfirmed Resident #98 had been on 1:1 since July incident
Director of NursingDirector of Nursing (DON)Reported care plan expectations and hospice communication
Staff EMedical RecordsConfirmed absence of hospice notes for Resident #60
Staff FLicensed Practical Nurse (LPN)Unaware of hospice visits for Resident #60
Infection PreventionistInfection Preventionist (IP)Reported on COVID-19 positive residents and notification practices
Nursing Home AdministratorNursing 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
NameTitleContext
Employee JRegistered NurseNamed in medication administration during dining room observation
Employee GCertified Nursing AssistantNamed in meal service and adaptive equipment provision observation
Director of NursingDirector of NursingInterviewed regarding medication administration policies and adaptive equipment
Occupational Therapist employee MOccupational TherapistInterviewed regarding adaptive equipment use and restorative therapy
Certified Dietary Manager (CDM)Certified Dietary ManagerInterviewed regarding dishwashing machine operation and adaptive equipment availability
Staff member WCertified Nurse Assistant (CNA) restorativeInterviewed regarding restorative care and splint application
Staff member URegistered NurseInterviewed regarding restorative care program and documentation
Staff member XRegistered Nurse unit managerInterviewed regarding restorative care and splint application
Staff member VCertified Nurse AssistantInterviewed regarding splint use for Resident #85

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