Tuskawilla Nursing and Rehab Center

In the surveyor’s words

From the most serious findings on record at Tuskawilla Nursing and Rehab Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 5, 2022

  Based on observation, interview, and record review, the facility failed to provide the appropriate level of assistance during bed mobility and bathing tasks to prevent a fall and left [CONDITION(S)] for 1 of 3 residents reviewed for falls (#1) and failed to implement the plan of care regarding activities of daily living (ADLs) to ensure the safety of 2 of 4 residents reviewed for ADL care (#2 & #3), of a total sample of 7 residents. After resident #1 fell from her bed, she experienced excruciating pain, extreme confusion, and disorientation. Resident #1 suffered significant decline in her physical health, and functional and cognitive status which ultimately led to admission to hospice services. […]

• Immediate jeopardy, isolatedF726Aug 5, 2022

  Based on observation, interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skills to comprehend and implement the plan of care related to appropriate level of assistance required during bed mobility and bathing tasks to prevent a fall with fracture for 1 of 3 residents reviewed for falls (#1), and ensure the safety of 2 of 4 residents reviewed for activities of daily living (ADL) care (#2 & #3), of a total sample of 7 residents. After resident #1 fell from her bed, she experienced excruciating pain, extreme confusion, and disorientation. Resident #1 suffered significant decline in her physical health, and functional and cognitive status which ultimately led to admission to hospice services. […]

• Actual harm, isolatedF604May 12, 2023

  Based on interview, and record review, the facility failed to ensure a vulnerable, cognitively impaired resident was free of physical restraint for 1 resident reviewed for restraint and seclusion, of a total of 5 sampled residents (#1). This failure could have resulted in the potential for multiple types of injuries, and even death. Using the reasonable person concept there was potential for psychosocial harm such as agitation, aggression, anxiety, development of delirium, feelings of imprisonment or restriction of freedom of movement. Findings Resident #1, a 95- year-old male, was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, isolatedF585May 21, 2026

  Based on observation, interview, and record review, the facility failed to support the resident's right to voice a grievance concerning missing property for 1 of 2 residents reviewed for personal property, of a total sample of 32 residents, (#3).Findings:Resident # 3 was admitted to the facility on [DATE] with diagnoses that included encephalopathy (brain dysfunction), chronic respiratory failure, chronic obstructive pulmonary disease and unspecified obstructive sleep apnea. A review of the Quarterly Minimum Data Set assessment with reference date 5/07/26 revealed resident #3 had a Brief Interview for Mental Status Score of 15 out of 15, which meant her cognition was intact.On 5/18/26 at 10:38 AM, resident #3 said she was missing about three blankets, including an electric blanket and her… […]

• No harm, potential for more than minimal, isolatedF694May 21, 2026

  Based on observation, interview, and record review, the facility failed to ensure the intravenous (IV) dressing was changed as ordered for 1 of 2 residents, (#5), and failed to obtain orders for IV dressing changes for 2 of 2 residents, (#5 & #13), reviewed for IV therapy, of a total sample of 32 residents. Findings: 1.Resident #5 was admitted to the facility on [DATE] with diagnoses of end stage renal disease, endocarditis (infection of the heart), type 2 diabetes, & bacteremia (bacteria in the blood). A care plan for IV medication use was initiated on 5/04/26 that instructed staff to monitor the central line IV to his right chest, to receive antibiotics and fluids. […]