Tamarac Center for Rehabilitation and Healing

In the surveyor’s words

From the most serious findings on record at Tamarac Center for Rehabilitation and Healing, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Sep 18, 2025

  Based on observations, interviews and record reviews, the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP), during a perineal care observation for I of 1 sampled resident, Resident #7, reviewed for perineal care, for 1 of 4 sampled residents reviewed for PEG tube, Resident #7, during a percutaneous endoscopic gastrostomy (PEG) tube care observation; failed to perform hand hygiene, and failed to change damaged PPE gloves during a bolus feeding observation for 1 of 4 sampled residents reviewed for tube feeding, Resident #9; failed to follow their policy for hand hygiene during a medication administration for 1 of 6 medication administration observations, Resident # 16; failed to initiate an EBP nursing care plan… […]

• No harm, potential for more than minimal, isolatedF584Sep 18, 2025

  Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 10 of 60 rooms (room [ROOM NUMBER]-B, #102-B, 105-B, #110, #116, #120, #206, #210, #212, and #214). The findings included:The findings included: 1. On 09/15/25 at 10:25 AM, observation revealed a telephone on top of the nightstand of an occupied resident room [ROOM NUMBER]-B with accumulation of residue on the dialing pad and the handset. 2. On 09/15/25 at 10:40 AM, observation revealed a telephone on top of the nightstand of an occupied resident room [ROOM NUMBER]-B with accumulation of residue on the dialing pad and a loose Air Conditioning cover. 3. […]

• No harm, potential for more than minimal, isolatedF609Sep 18, 2025

  Based on observations, interviews, record review and the review of the facility policy, the facility failed to report a resident's unwitnessed fall with an injury of unknown source for 1 of 1 sAMPLED resident reviewed for Falls, Resident #77.The findings included:Review of the facility's policy titled Fall Prevention Program revised on 05/2025 documented .when any resident experience a fall, the facility will:.obtain witness statements in the case of injury.Review of the facility's policy titled Unexplained Injures revised on 05/2025 documented all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated.if the injury is of unknown source, reporting and investigation procedures shall be implemented in accordance with the facility's abuse… […]

• No harm, potential for more than minimal, isolatedF610Sep 18, 2025

  Based on observation, interviews and the facility policy review, the facility failed to initiate and conduct a complete and thorough investigation to an unwitnessed fall resulting in an injury of unknown source of origin for 1 of 1 sampled resident for Falls (Resident #77). The findings included:Review of the facility's policy titled Fall Prevention Program revised on 05/2025 documented .when any resident experiences a fall, the facility will.obtain witness statements in the case of injury.Review of the facility's policy titled Unexplained Injures revised on 05/2025 documented all unexplained injuries, including bruises, abrasions, and injuries of unknown source will be investigated.if the injury is of unknown source, reporting and investigation procedures shall be implemented in… […]

• No harm, potential for more than minimal, isolatedF684Sep 18, 2025

  Based on observations, interviews and record reviews, the facility failed to follow physician orders for weekly weight monitoring for 1 of 5 sampled residents reviewed for respiratory care, Resident #34. Based on observations, interviews, and record reviews, the facility failed to follow the professional standards of nursing practice for not following physician orders by ensuring that blood pressure and heart rate were monitored before the administration of a beta blocker medication for 1 of 6 medication administration reviews, affecting Resident #100; and failed to follow their own policy by ensuring the right dosage and right route based on the six rights of medication administration were followed for 1 of 5 unnecessary medication reviews, affecting Resident #7. The findings included: 1. […]