Inspection Reports for Tuskawilla Nursing and Rehab Center
1024 Willa Springs Dr, Winter Springs, FL 32708, FL, 32708
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 20, 2024
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to thoroughly investigate a possible elopement incident involving resident #22.
Complaint Details
The complaint investigation focused on a possible elopement incident on 6/05/24 involving resident #22. The facility did not complete required documentation or investigation steps. The Administrator acknowledged deficiencies in the investigation and documentation process.
Findings
The facility failed to properly investigate a possible elopement on 6/05/24, including lack of incident report, progress notes, and updated elopement risk evaluation. The Administrator acknowledged incomplete documentation and investigation despite viewing video evidence and interviewing staff.
Deficiencies (1)
Facility failed to thoroughly investigate a possible elopement for resident #22, including lack of incident report, progress notes, and updated elopement risk evaluation.
Report Facts
Residents reviewed: 32
Date of elopement drill: Jun 5, 2024
Date of incident: Jun 5, 2024
Date of Administrator verbal/written statements collection: Jun 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Worked the night resident #22 set off the front door alarm; involved in responding to the incident |
| CNA F | Certified Nursing Assistant | Sent to front door during alarm; observed resident #22 outside the door; provided verbal statement |
| CNA A | Certified Nursing Assistant | Worked the night resident #22 set off the alarm; remained on unit |
| LPN B | Licensed Practical Nurse | Worked the night resident #22 pushed the front door and got outside; checked residents per policy |
| LPN D | Licensed Practical Nurse | Worked the night of 6/05/24; heard overhead announcement and checked residents |
| Administrator | Responded to incident; conducted investigation; acknowledged incomplete documentation |
Inspection Report
Deficiencies: 2
Date: May 26, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding residents' personal funds charges and the coordination of pre-admission screening and resident review (PASARR) evaluations.
Findings
The facility was found to have charged a resident for transportation costs not specifically requested and failed to refer a resident with a newly evident mental disorder for a Level II PASARR evaluation. Both deficiencies were noted with minimal harm and affected few residents.
Deficiencies (2)
Facility charged costs for transportation not specifically requested by a resident, contrary to regulations limiting charges against residents' personal funds for items or services paid under Medicare or Medicaid.
Facility failed to refer a resident with a newly evident mental disorder for Level II PASARR evaluation and determination.
Report Facts
Residents reviewed: 37
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Provided information about transportation services and Medicaid benefits | |
| Social Services Director | Explained transportation arrangements, enrollment in community bus service, and PASARR screening responsibilities | |
| Business Office Manager | Explained fees for community bus service and resident trust account debits | |
| Director of Nursing | Acknowledged inaccurate PASARR screening and efforts to complete new PASARR |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the use of physical restraints on a vulnerable, cognitively impaired resident (#1) at Tuskawilla Nursing and Rehab Center.
Complaint Details
The complaint involved an incident where resident #1 was found physically restrained with a sheet tied to the bed frame. The restraint was discovered between 1:30 AM and 2:00 AM on 5/06/23 but was not reported until approximately 7:15 AM. The Administrator confirmed the incident was not reported to relevant State agencies within the required timeframe. Law enforcement was contacted and investigated the incident. Staff interviews revealed denial of knowledge about who tied the resident. The resident had no injuries but was cognitively impaired and unable to recall the event.
Findings
The facility failed to ensure resident #1 was free from physical restraints, as a sheet was found tied across the resident's midsection to the bed frame, restricting movement. The incident was not reported timely to the appropriate authorities. Additionally, the facility failed to consistently implement care plan interventions requiring two-person mechanical lift transfers for residents #1 and #2.
Deficiencies (3)
Failure to ensure resident was free from physical restraints; a sheet was tied to the bed frame restricting resident's movement.
Failure to timely report suspected abuse and neglect to proper authorities.
Failure to consistently implement care plan interventions for mechanical lift transfers requiring two persons.
Report Facts
Fall Risk Evaluation score: 14
BIMS score: 8
BIMS score: 13
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Assigned nurse who discovered the sheet tied to resident #1 and cut it off; did not immediately report the incident. |
| CNA B | Certified Nursing Assistant | Discovered the sheet tied to resident #1 and alerted LPN A; reported the incident to the Administrator. |
| CNA E | Certified Nursing Assistant | Assigned CNA on 3 PM to 11 PM shift on 5/05/23; transferred resident #1 alone with mechanical lift despite two-person requirement; denied knowledge of tying the sheet. |
| LPN D | Licensed Practical Nurse | Worked on 3 PM to 11 PM shift; denied knowledge of the sheet tied to resident #1. |
| CNA C | Certified Nursing Assistant | Reported the incident to the Administrator on 5/06/23 after being informed by CNA B. |
| Administrator | Received report of the incident, reviewed video surveillance, contacted law enforcement, and confirmed failure to timely report abuse. | |
| Director of Nursing | Director of Nursing (DON) | Notified of the incident; confirmed facility was restraint free; stated incident should have been reported immediately. |
| Psych ARNP | Advanced Registered Nurse Practitioner | Assessed resident #1 post-incident; noted no injuries and resident unable to recall event due to confusion. |
| RN Weekend Supervisor | Registered Nurse | Conducted skin assessment on resident #1 after incident; found no injuries. |
| CNA F | Certified Nursing Assistant | Reported resident #1 required two-person mechanical lift transfers. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 2, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to meet discharge requirements prior to issuing a discharge notice for one resident.
Complaint Details
The complaint investigation found that Resident #1 was issued a Nursing Home Transfer and Discharge Notice for non-payment while Medicaid approval was pending and estimated patient liability payments were being made. An appeal was filed and the resident remained in the facility.
Findings
The facility failed to provide adequate documentation and justification before issuing a Nursing Home Transfer and Discharge Notice to Resident #1, who was Medicaid pending and had an appeal filed. The discharge notice was issued due to non-payment despite the resident's sister sending estimated patient liability payments and ongoing Medicaid application efforts.
Deficiencies (1)
Failed to meet the requirements for discharge prior to issuing a discharge notice for 1 of 3 residents reviewed for discharge.
Report Facts
Past due balance: 50000
Residents reviewed for discharge: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Signed the Nursing Home Transfer and Discharge Notice and involved in discussions about the discharge notice. |
| Business Office Manager | Business Office Manager | Provided information about Medicaid application status and resident's account balance. |
| Administrator | Administrator | Acknowledged awareness of the discharge notice and involvement in Medicaid approval efforts. |
Inspection Report
Routine
Deficiencies: 2
Date: Jul 15, 2021
Visit Reason
The inspection was conducted to assess compliance with standards of care related to intravenous (IV) therapy and respiratory therapy for residents at the facility.
Findings
The facility failed to provide appropriate IV care for one resident by not changing the PICC line dressing as ordered, and failed to ensure respiratory therapy was provided as per physician orders for two residents, including incorrect oxygen flow rates and lack of proper monitoring.
Deficiencies (2)
Failure to provide intravenous (IV) care and services according to standards of practice and plan of care for one resident, including not changing PICC line dressing as ordered.
Failure to ensure respiratory therapy was provided as per physician orders for two residents, including incorrect oxygen flow rates and inadequate monitoring.
Report Facts
Residents reviewed for IV care: 40
Residents reviewed for respiratory therapy: 40
Residents affected by IV care deficiency: 1
Residents affected by respiratory therapy deficiency: 2
PICC line dressing change frequency: 7
Oxygen flow rate ordered for residents: 2
Oxygen flow rate observed: 4.25
Oxygen flow rate observed: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN C | Registered Nurse | Noted resident's outdated and soiled IV dressing and could not explain standard of practice |
| Director of Nursing | Director of Nursing (DON) | Explained standard of practice for PICC line dressing changes and nursing responsibilities |
| RN D | Registered Nurse | Worked 7-3 shift, documented resident refused medication but did not document refusal of IV dressing change |
| RN B | Registered Nurse | Assigned to resident #66, flushed PICC line but did not document education on infection risk |
| RN E | Registered Nurse | Worked night shift, did not notice dirty IV dressing or recall prior refusals |
| East Wing Unit Manager | Unit Manager | Checked oxygen settings for residents #23 and #136 and identified incorrect flow rates |
| RN B | Registered Nurse | Checked physician orders and oxygen flow rate for resident #23 |
| RN A | Registered Nurse | Assigned nurse for resident #136, checked oxygen flow rate but was unaware of correct order |
| LPN A | Licensed Practical Nurse | Commented on oxygen flow rate for resident #136 and lack of knowledge of physician order |
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