Rehabilitation and Healthcare Center of Tampa

Inspectors wroteBased on observation, record review and interview, the facility failed to provide social services supports for one resident (#6) of fourteen sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents on two of three floors (2nd and 3rd floors) had an environment free from heavy foul and offensive odors during four of four days observed (3/30/25, 3/31/25, 4/1/25, and 4/2/25). It was found heavy odors emitted from two of thirty-four sampled residents (#163 and #80) and their rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1. Call light cords and buttons were placed within reach while residents were in bed in five of ninety-six resident rooms, on two of three floors, (Rooms 214a, 216p, 234a, 302a 310a, and 310b, ; and 2. Did not ensure bathroom call light cords were free hanging and not tied to hand rails for resident bathrooms 220, 226, 228, 234, and 310, during three of four days observed (3/30/25, 3/31/25, 4/1/25).

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide two of thirty-four sampled residents, (#107, and #36) with a homelike eating experience during two of three meals observed on 3/30/2025 and 3/31/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plan interventions were implemented related to call light placement when residents were in bed for three (#163, #80, and #113) of thirty-four sampled residents.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice related to physician orders for pain parameters and administration of pain medications for one (Resident #147), and nebulizer treatments for one (Resident #132) of 34 residents reviewed for physician orders.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide suctioning for one (Resident #70) with a Tracheostomy out of 34 residents sampled. Findings Included: During an observation on 03/30/2025 at 10:12 a.m., Resident #70 was observed sitting in bed dressed in a hospital gown and was observed to have a Tracheostomy with no suction. During an observation on 03/30/2025 at 12:15 p.m., the Risk Manager was observed bring a Suctioning machine onto the 3rd floor and putting into resident #70's room. During an observation on 03/30/2025 at 12:26 p.m., a suctioning machine was observed on the dresser in Resident #70's room. Review of Resident #70's admission record revealed a re-admission date of 03/29/2025 and initial admission date of 11/25/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure 1) availability of personal protective equipment (PPE) for four out of five bins on hallway 4 Long, 2) proper storage of respiratory equipment for one (Resident #132) of two residents, and 3) proper Contact Precautions were followed for one (Resident #155) of two residents on transmission-based precautions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a process was in place for smoking safety for three (#8, #29, #164) out of 19 residents sampled. Findings Included: 1. During an interview on 10/28/2024 at 10:00 a.m., Resident #8 was observed lying in bed dressed for the day. To the right of her bed was a bedside table with a green and white box of cigarettes. Next to the box was a lighter. Resident #8 stated she was a smoker but only smoked occasionally when she was having a bad day. She stated she usually signed out at the front desk and went in front of the building to smoke. She stated she did not use the facilities smoking section because the smoking area was disgusting and the times available were not convenient for her. She stated, no one cleans the smoking area, and it smells out there. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure a accurate comprehensive care plan for one (#141) of eight sampled residents.

Inspectors wroteBased on observation, record review, and interviews, the facility did not ensure accuracy of Preadmission Screening and Resident Review (PASRR) for two (#67 and #75) of 16 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure services provided/arranged by an individual had the skills, experience, knowledge and licensure to perform tasks for one resident (#142) out of eight residents observed.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to provide an ongoing activity program that provided one on one activities as scheduled and met the individual interests and needs to enhance the quality of life for two (#154 and #472) of two sampled residents. Findings Included: During an interview on 10/28/24 at 11:00 A.M., Resident #154 said he preferred to stay in bed, he felt weak due to recent cancer treatments. He wanted to participate in activities but the facility staff had not offered or provided bedside activities. Review of Resident #154's admission record, showed admission date of 6/28/24. Review of Resident #154's order summary report active orders as of 10/28/24, showed monitor and record pain every shift, restorative nursing as needed, Tramadol 50 mg every 6 hours as needed for pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide emergency tracheostomy supplies for three residents (#142, #25, and #156) of three residents observed.

Inspectors wroteBased on record reviews and interviews, the facility failed to prevent falls/accidents resulting in an injury to one resident (#1) out of three residents sampled for falls. Resident #1 sustained a scalp hematoma and clavicle fracture with a transfer to a higher level of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment for two patient floors (3rd and 4th) out of three patient floors in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure accuracy of resident comprehensive assessment for three residents (#64, #81, and #158) out of fifty-two sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure informed consent for the use of bedrails was obtained prior to installation of bedrails and failed to ensure residents were assessed properly for the use of bedrails prior to installation for three residents (64, #81, and #311) of three residents sampled for bedrail use.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an accommodation of resident needs related to mobility devices for one resident (#39) out of fifty-two sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to resolve a resident grievance, to their satisfaction, in a timely manner for one resident (#143) out of the fifty-one sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the accuracy of Level I Pre-admission Screening and Resident Review (PASRR) assessments for three residents (#24, #38, and #81) out of eight residents sampled for PASRR's.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to review and revise the care plan for one resident (#63) out of two residents reviewed for rehabilitation and restorative services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide nail care for one resident (#100), who was unable to carry out Activities of Daily Living (ADLs), out of one sampled resident.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure active and ongoing communication was received between the facility and hospice providers for two residents (#18 and #24) out of four residents reviewed for hospice services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%. A total of 27 medication administration opportunities were observed with two medication errors for two residents (#56 and #4) of four residents sampled for medication administration, which resulted in a medication administration error rate of 7.41%.

Inspectors wroteBased on observations and interview, the facility failed to ensure sufficient staff with the appropriate competencies and skills-sets to perform the functions of the food and nutrition service, taking into consideration resident assessments and individual plans of care related to dietary staff not properly implementing adequate kitchen hygiene, proper sanitation practices, proper food labeling and storage, and appropriate serving of meals affecting 158 out of 168 residents in the facility. The likelihood of serious injury and/or death to 158 residents as a result of the facility's failure to prepare, store and serve food in accordance with professional standards for food service safety resulted in the determination of Immediate Jeopardy on 12/13/23. The findings of Immediate Jeopardy were determined to be removed on 12/14/23 and the severity and scope was reduced to a D.

Inspectors wroteBased on observations, interviews, record review and policy review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in one of one kitchens observed, and three of three nutrition rooms observed, as evidenced by improper dish washing, unsanitary kitchen area, undated food, expired food, inappropriate food temperatures, unlabeled food, unsanitary preparation of food, food with evidence of bio-growth, and residents not being served according to their prescribed diet orders. This failure created a situation that resulted in the likelihood of serious injury and/or death to 158 residents and resulted in the determination of Immediate Jeopardy on 12/13/23. The findings of Immediate Jeopardy were determined to be removed on 12/14/23 and the severity and scope was reduced to a D. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to utilize the Quality Assurance and Performance Improvement (QAPI) process to investigate, develop, and implement an effective Performance Improvement Plan (PIP) to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in one of one kitchen observed, and three of three nutrition rooms observed. The facility failed to ensure the safety of 158 residents in the facility as a result of the failure. The likelihood of serious injury and/or death to 158 residents as a result of the facility's failure to prepare, store and serve food in accordance with professional standards for food service safety resulted in the determination of Immediate Jeopardy on 12/13/23. [...]

Inspectors wroteBased on observations, interviews, record review and policy review, the facility failed to ensure pain medication was administered and pain was managed for three residents (#20, #14, and #9) of four reviewed for pain management.

Inspectors wroteBased on interviews and record review, the facility did not ensure grievances were addressed in a timely manner for resident council members with potential to affect a census of 168.

Inspectors wroteBased on observations, interviews, record review and review of facility policies, the facility failed to: 1) ensure dialysis residents received a meal to go during dialysis for three residents (#15, #16 and #17) out of eight residents on dialysis; 2) failed to ensure residents were provided with snacks between meals for three residents (#15, #16 and #17) out of eight residents; and 3) failed to ensure one resident (#19) out of ten with a food allergy received an appropriate meal.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure infection control practices we utilized on one of three units, related to hand washing and the use of personal protective equipment (PPE) in contact isolation rooms.