Pruitthealth-North Tampa, LLC

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure Certified Nursing Assistant (CNA) registry verification and competency evaluation for one staff member (Staff E) of five staff reviewed.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure wound care was done in a timely manner and dressings were dated for three residents (#182, #277, #51) out of four residents reviewed for non-pressure skin conditions.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure pain was controlled for three residents (#185, #379, #182) out of three reviewed for pain management.

Inspectors wrote2. During an interview on 06/16/25 at 11:42 a.m. Resident #29 stated she was getting weaker due to no one at the facility assists her with walking. She stated therapy instructed her to ensure someone was supervising her while walking. During a follow up interview on 06/18/25 at 09:41 a.m. Resident #29 stated having lost endurance since discharging from therapy as no one was available to supervise except when family visits. During an interview on 06/17/25 at 12:13 p.m. Staff V, CNA stated, it is hard sometimes we don't have as many CNAs as needed. Many of the residents are total care and the distance from room to room. Staff V, stated having to cover around corners makes the job tasks even harder to get basic care completed, but certainly at meal times. She stated they did not have time for the extras if asked. [...]

Inspectors wroteBased on interviews and record review the facility did not ensure medications for new admissions were available timely for four residents (#182, #185, #379, #228) out of four sampled for admission orders.

Inspectors wroteBased on interviews and record review the facility did not ensure residents who entered arbitration agreements understood the contract contents for three residents (#228, #51 and #29) of three residents sampled.

Inspectors wroteDuring an initial on 06/16/25 at 10:21 a.m. Resident #229's door had an 8 ½ by 11 (letter size) CDC Contact Isolation Precautions sign printed in color showing two large fonts STOP signs in all capital letters and the following Contact Precautions written between the two signs. The next line revealed in all capital letters Everyone Must: Clean their hands, including before entering and when leaving the room. The following line in all capital letters showed: Providers and Staff Must Also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to implement an antibiotic stewardship program including developing a system to monitor use of antibiotic-resistant organisms for one resident (#378) out of two residents reviewed for antibiotic stewardship with potential to impact the entire facility.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure dignity was maintained for residents during dining in one dining room (between 400 & 500 halls) out of three dining rooms.

Inspectors wroteBased on interviews, observations and record review the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one resident (#5) of one resident reviewed.

Inspectors wroteBased on observation, interviews, and record review the facility failed to revise an Activity of Daily Living (ADL) care plan to reflect a resident's condition for one resident (#29) out of eight residents reviewed.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide meal assistance for one resident (#43) out of two residents sampled. Findings Included: During an interview and observation on 06/16/2025 at 12:20 p.m. Resident #53 was observed scooping mashed potatoes onto a spoon feeding Resident #43. Resident #53 stated I am feeding my [family member] (Resident #43). I feed her and try to eat my food in-between. If I don't feed, her then no one helps her. Review of Resident #43's admission record revealed an admission date of 09/21/2023. Resident #43 was admitted to the facility with diagnosis to include need for assistance with personal care, Muscle weakness (generalized), Mild protein-calorie malnutrition, Other specified joint disorders, right hand, other lack of coordination, Aphasia, Aphasia following cerebral infarction, Dysphagia, oropharyngeal phase. [...]

Inspectors wroteBased on interviews, observations and record reviews, the facility failed to provide nephrostomy care and services consistent with professional standards of practice for one resident (#328) out of one sampled resident.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Twenty-five medication opportunities were observed, and two errors were identified resulting in an error rate of 8.0%. Findings Included: During a medication administration observation on 6/17/25 at 8:41 A.M. for Resident #6, Staff F, Registered Nurse (RN), prepared vitamin B-12 (1 tablet), multiple vitamin with minerals (1 tablet), and Gabapentin 300 mg (milligram) capsule (1 capsule) by crushing the medications and administering with applesauce. Review of the facility's list titled, Oral Dosage Forms that Should Not be Crushed 2016, published by the Institute of Safe Medication Practices (ISMP) showed Gabapentin tablet should not be crushed. On 6/17/25 at 8:48 A.M. [...]

Inspectors wroteBased on observations and interviews facility failed to ensure medication was stored appropriately on three halls (100, 200, 500) out of five halls related to unlocked medication/treatment carts, unattended medication, dirty medication carts, and controlled drugs not stored in a permanently affixed compartment.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective Action Plan to improve findings of deficient practice on the annual survey conducted 6/19/25 regarding a medication error rate of greater than 5.0% and infection control during medication administration.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure surgical wounds were monitored for signs of infection and surgical sutures were removed per physician orders for two residents (#1 and #7) of three residents sampled for wound care.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide sufficient nursing staff to meet the needs of three residents (#8, #9, & #13) out of seven sampled residents related to answering call lights timely and provide activities of daily living.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain a functioning nurse call system to respond to resident needs during two days (10/17/24, 10/18/24) of two days observed during survey.

Inspectors wroteBased on interviews and record review, the facility failed to complete an investigation for a fracture of unknown origin for one resident (#1) out of thirteen sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure competent nursing care staff, related to care of one unresponsive Resident (#10), and wound monitoring for two Residents (#1 and #7) was provided out of thirteen resident sampled.