Dade City Health and Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility failed to honor a resident's decision to formulate an advance directive and did not ensure a residents' end-of-life wishes for Do Not Resuscitate (DNR) was honored for one (#3) of three residents sampled. On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. The facility's failure to honor Resident #'s DNR status deprived her of a dignified death and likely resulted in severe pain and organ damage. Additionally, Resident #3 could not express her reaction to this event. Applying the reasonable person concept, Resident #3 would likely experience serious psychosocial harm by being resuscitated against her wishes. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the resident's right to be free from neglect for one resident (#3) out of three residents sampled. On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. The facility's failure to honor Resident #3's DNR status deprived her of a dignified death and likely resulted in severe pain and organ damage. Additionally, Resident #3 could not express her reaction to this event. Applying the reasonable person concept, Resident #3 would likely experience serious psychosocial harm by being resuscitated against her wishes. This failure resulted in the determination of Immediate Jeopardy occurring on [DATE]. [...]

Inspectors wroteBased on review of the facility policy, interviews and record review, the facility failed to ensure the residents' wishes were honored related to Do Not Resuscitate (DNR) orders for one (#3) of three residents sampled. On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. This failure resulted in the determination of Immediate Jeopardy occurring on [DATE]. During the survey, the survey team verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy, and the Immediate Jeopardy was removed as of [DATE]. [...]

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure nursing staff were competent in identifying and honoring cardiopulmonary resuscitation wishes for one (#3) of three residents sampled On [DATE], when staff failed to verify Resident #3's resuscitation code status and performed Cardiopulmonary Resuscitation (CPR) against the documented resident's wishes. Resident #3 had a fully executed Do Not Resuscitate (DNR) order in the medical record dated [DATE]. This failure resulted in the determination of Immediate Jeopardy occurring on [DATE]. During the survey, the survey team verified the implementation of the facility's immediate actions to remove the Immediate Jeopardy, and the Immediate Jeopardy was removed as of [DATE]. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to provide adequate supervision to prevent falls for three (#3, #8, and #9) of three residents sampled for fall events out of a total of nine sampled residents, related to lack of an IDT (Interdisciplinary Team) assessment post fall and identifying and / or implementing appropriate post fall interventions for Resident #3, #8 & #9, and accurate neuro check monitoring for Resident #3.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accurate generally accepted accounting principles were implemented for two residents (#3 and #7) of three residents reviewed for Resident Trust Fund monies out of nine sampled residents. Resident #3 was not being charged the correct patient liability (cost of care) or allocated his personal needs allowance of $160.00 per month; Resident #7, a Supplemental Security Income (SSI) recipient, was not being charged the correct patient liability and the facility had not safeguarded his funds by ensuring the Social Security office had been notified of his residence in the Nursing Home.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a prompt effort to resolve a grievance for one resident (#3) of three residents sampled for grievances of a total of nine sampled residents. Resident #3's family member had voiced a concern on 02/24/2025 regarding Resident #3's patient trust monies, an accounting of the withdrawals, an inquiry of a $400.00 deposit, an $1800.00 refund, and a concern regarding the posting of Resident #3's $160.00 monthly patient allowance. The concern was still outstanding as of 07/15/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident documentation was accurate and complete for four (#1, #2, #3, #4) of four sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain wound care orders and perform wound care timely for one (#3) of four sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain pressure ulcer wound care orders and provide pressure ulcer wound care in a timely manner for one (#2) of four sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for ten residents (#19, #48, #13, #17, #34, #33, #16, #97, 78, and #73) out of 24 residents sampled for PASRR review.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to store, prepare and appropriately document food temperatures in accordance with professional standards for food service safety in the facility kitchen area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to: 1.) failing to ensure a medication administration error rate of less than five percent. A total of ten medication administration opportunities were observed with two errors for one (Resident #8) of three residents observed. This resulted in a medication administration error rate of 20% (F759) and 2.) failed to ensure proper storage, labeling and dating of food and beverages in accordance with professional standards for food service safety in one pantry (East) of two pantries and one of one facility kitchen (F812) during the revisit survey conducted 6/10/2024 to 6/11/2024.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement facility wide procedures to maintain a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. 1) The facility failed to ensure hand hygiene was provided to five residents (#416, #102, #100, #97, and #22) prior to meal service out of five residents sampled. 2) The facility failed to ensure two residents (#214 and #416) was identified as isolation precautions at the room entrance out of two residents sampled. 3) The facility failed to ensure nebulizer masks were stored in appropriate storage bags for two residents (#16 and #48) of three residents reviewed for appropriate storage of nebulizer masks. 4) The facility failed to ensure reusable equipment was cleaned for two residents (#67 and #93) out of six residents sampled during medication pass. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to adhere to the smoking assessment of one resident (#79) out of the twenty smoking residents, and allowed three residents (#79, #9, and #213) to possess unsecured smoking paraphernalia outside of the supervised smoking times.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed and six (6) errors were identified for four residents (#67, #48, #415, and #24) of six residents observed. These errors constituted a 20% medication error rate.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure two residents (#79 and #213) were assessed for self-administration of treatments and medications out of forty sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to complete the smoking assessment for one resident (#364) out of four residents sampled.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assess, obtain physician orders, and provide treatments for one resident (#79) out of one resident sampled for skin conditions unrelated to pressure injuries.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one resident (#416) out of two residents sampled for pressure ulcers, received necessary care and services to promote healing, prevent infection, and prevent new ulcers from developing.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to provide medications ordered by the physician at the time of admission for one resident (#212) out of one resident sampled for new admissions and failed to notify the physician of the unavailability of the those medications.

Inspectors wroteBased on interviews and record review, the facility failed to ensure physician ordered lab work was completed accurately and in a timely manner for one resident (#33) out of five sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the accuracy of documentation presented for two of two pantry refrigerator temperature logs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to formulate an advance directive was honored for two residents (#109 and #212) out of three residents sampled for Advanced Directives related to a resident receiving CPR (cardiopulmonary resuscitation) for 3 minutes when they had wished to not be resuscitated and a resident without an advance directive order who wished to have one. Findings Included: 1) Resident #109 was admitted to the facility on [DATE] for rehabilitation services after a hospitalization, with diagnoses including chronic kidney disease Stage 3B, acute respiratory failure with hypoxia, and chronic diastolic Congestive Heart Failure. Review of Resident #109's medical record revealed the following: -A State of Florida Do Not Resuscitate form was signed by a physician and a family member of Resident #109 on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the residents' right to be free from neglect to ensure two residents (#10, #12) out of 11 residents at risk, with known neurocognitive disorders and/or dementia and a history of wandering and exit seeking, was provided supervision and services to prevent elopement. The facility neglected to maintain an exit door alarm system in proper operation or implement alternate methods to prevent elopements since 08/02/2023. The facility nursing staff neglected to ensure the safety of Resident #10, from approximately 12:40 p.m. until 1:37 p.m. or approximately 57 minutes on 09/02/2023. Resident #10 exited the front door unobserved by staff. She traveled down a steep drive, across a street to an apartment building parking lot which was approximately 600 feet away. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure two residents (#10, #12) out of 11 residents at risk, with known neurocognitive disorders and / or dementia and a history of wandering and exit seeking, was provided supervision and services to prevent elopement. The facility failed to maintain an exit door alarm system in proper operation to prevent elopements since 08/02/2023. The facility nursing staff failed to ensure the safety of Resident #10, from approximately 12:40 p.m. until 1:37 p.m. or approximately 57 minutes on 09/02/2023. Resident #10 exited the front door unobserved by staff. She traveled down a steep drive, across a street to an apartment building parking lot which was approximately 600 feet away. She was discovered and returned to the facility by a male resident of the apartment complex. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all grievances were tracked through to their conclusion for 1) voiced concerns by residents from the Resident Council and the Food Committee Council meetings between April 2023 and September 2023, and 2) voiced concerns from three residents (#11, #14, and #17) related to their specific diet out of seventeen residents sampled during survey.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents were free from unnecessary medications by 1) not ensuring proper behavioral and side effect monitoring for psychotropic medications for four residents (#2, #5, #6, and #14) of four residents sampled and, 2) not ensuring use of as needed (PRN) psychotropic medications were limited to 14 days for one resident (#5) of four residents sampled.

Inspectors wroteBased on observations, interviews, and record review the facility 1) failed to ensure the planned menu was followed for three of three observed meals during lunch, 2) failed to ensure residents received an alternate meal when they were absent from the facility for three residents (#11, #14, and #17) out of seventeen sampled, and 3) failed to ensure residents were provided their preferences at meals for four residents (#11, #17, #13, and #6) of seventeen residents sampled during survey.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the Patient-Centered Care Plan was followed for one resident (#10) out of 16 residents sampled.

Inspectors wroteBased interviews and record review, the facility failed to ensure one resident (# 11) received an antibiotic ordered for a urinary tract infection out of 17 residents sampled during the survey.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the medical records included completed documentation for one resident (#10) out of 16 residents sampled.

Inspectors wroteBased on observations, interviews, and record review it was determined the facility failed to provide Quality Assessment and Assurance (QAA) practices that demonstrated identification, monitoring, and implementation of an effective Action Plan regarding assessing and ensuring two residents (#10 and #12) out of 11 sampled residents with wandering and exit-seeking behaviors was provided supervision and services to prevent elopement.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to notify five (#22, #32, #41, #85, and #186) out of five sampled residents and their representatives in a timely manner of the positive COVID-19 results within the facility.

Inspectors wroteBased on review of test results, review of the staff schedule for 2/8/22, and interviews, the facility failed to test 26 out of 65 staff members twice weekly for COVID-19 per the community transmission rate (high) for the period of 2/3 - 2/9/22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate three (Residents #49, #56 and #74) of 96 residents by failing to provide beds that were long enough so their feet could extend without hanging over the footboard. Findings Included: 1. Observation and interview of Resident #49 on 2/08/22 at 10:38 a.m., revealed the resident sitting up at the top of his air mattress with his right knee up toward the ceiling, under the covers. The resident straightened his right leg and his foot was observed over the foot board of the bed. The resident stated he was 6 foot 5 inches tall and he had to keep his legs bent or they rub over the footboard and hurt. The footboard of the bed was observed peeling. Observation of the resident on 2/8/22 at 12:00 p.m., revealed the resident lying toward the top of the bed with his right foot hanging over the footboard. [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to 1. ensure privacy of resident medical information for seven (Residents #4, #11, #50, #54, #55, #74, and #336) of 45 residents and 2. ensure privacy during a shower for one (Resident #37) of 45 residents.

Inspectors wroteBased on interviews and record review the facility failed to response to a grievance in a timely manner for one (Resident #61) of forty five sampled residents. Finding Included: An interview on 02/08/22 at 10:37 a.m. with Resident #61 revealed that when she went to the hospital back in December, came back to the facility, and was in isolation for 2 weeks, she wrote a check for $450. She reported that she gave the check to social services in December 2021, and had been given multiple excuses like because of COVID they were not going to the bank. She stated she had been relying on her friend to get things for her because she had not been able to get her money. The resident reported that she spoke with the Business Office Manager (BOM) about her money in January 2022 who stated that she had no money. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide Activities of daily Living (ADL) tasks for one (Resident #41) of 45 sampled residents related to unwanted facial hair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident #74) of 45 residents observed received care and services related to a brace and dry flaky feet. Findings Included: During observation and an interview with Resident #74 on 2/9/22 at 1:00 p.m., he stated he had not had a shower in a couple of weeks and no one took his socks off or checked his skin under his brace. Resident #74 stated that the therapist put something under his brace at the bottom of his leg to assist with the rubbing he was getting from the brace, but it had not been checked since then and his feet were extremely itchy. During an interview with Staff F, CNA on 2/9/22 at 1:10 p.m., she confirmed she had not given the resident a shower and had not removed his socks to check his feet or apply lotion as he had not asked her do that. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident #49) of three sampled residents received catheter care related to a urinary catheter that was cloudy with sediment observed stuck to the tubing. Findings Included: On 2/8/22 at 12:00 p.m., an observation of Resident #49 revealed his urinary catheter tubing was cloudy, gray, and not dated. The resident stated it had not been changed for at least two months and he was currently being treated for a urinary tract infection. The resident said his catheter had not been flushed or changed and he was worried about the way the tubing looked. Observation of Resident #49's tubing on 2/10/22 at 1:10 p.m. revealed the tubing cloudy and gray with sediment. The resident stated no one had looked at the catheter or flushed it. During an interview and observation on 2/10/22 at 1:18 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident # 81) of three residents observed on oxygen, received oxygen as ordered and in a sanitary manner Findings Included: On 2/8/22 at 10:15 a.m., an observation of Resident #81 revealed her sitting in a wheel chair with her oxygen tubing stuck under her wheel chair and dragging across her bedroom floor. On 2/10/22 at 3:05 p.m., an observation of Resident #81 revealed her oxygen tubing bunched up under the wheel chair wheel and under her feet. The resident stated she was unsure why she had so much tubing and said she got stuck in the tubing with her wheel chair. The oxygen setting was observed set at three liters. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one (Resident #238) of one resident sampled for Dialysis was monitored pre and post Dialysis services.

Inspectors wroteBased on resident and staff interviews and record reviews, the facility did not act upon grievances and recommendations made by resident council. The facility did not consistently provide responses, actions and rationale regarding resident concerns. Four (#46, 151, 50, and 74) of eight residents, participating in interviews expressed concerns with meals and food service.

Inspectors wroteBased on interviews, observations and documentation and policy review, the facility did not ensure proper food storage and food service safety for 88 out of 93 residents. The facility failed to ensure the dishwashing machine was operating at the required temperatures, refrigerators were cleaned, and the kitchen and cooking equipment were maintained in a sanitary manner.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure resident rights were maintained related to not providing transportation to an outside appointment for one resident (Resident #50) out of the sampled forty residents.

Inspectors wroteBased on observations, policy review, and interviews the facility failed to ensure one (#92) of two residents reviewed was able to visit with a family member(s) in privacy and without a staff presence during the visit.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a care plan was developed for one (#38) out of 40 sampled residents regarding the application of a neck brace and failed to implement the plan of care for one (#9) out of 40 sampled residents in regards to the 1-on-1 activities.

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to revise a resident's care plan to include interventions following falls for one (Resident #33) of two residents sampled for accidents and hazards

Inspectors wroteBased on interviews, observations and record reviews, the facility did not ensure that 1:1 activity therapy was provided per the care plan for one Resident (#9) of forty sampled residents.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure that respiratory equipment was stored and maintained in accordance with professional standards for 2 (Resident #35 and #64) of 2 residents sampled for respiratory care.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure consent for use of bed rails was obtained for one (Resident #33) of one residents sampled for bed rails.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that a PRN (as needed) psychotropic medication was limited to 14 days without a rationale to extend the medication for one resident (Resident #50) and failed to ensure behavior monitoring was documented for two residents (Resident #1 and #48) out of the sampled five residents for unnecessary medications.

Inspectors wroteBased on observations and interviews the facility failed to serve a meal that conserved the flavor and appearance of the food for one of one test trays (11-16-20).