Inspection visit
Inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0571
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Limit the charges against residents' personal funds for items or services for which payment is made under
Medicare or Medicaid.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility charged costs for transportation not specifically
requested by 1 of 1 resident reviewed for allocation of personal funds out of a total sample of 37 residents,
(#54).
Findings:
Review of resident #54's medical record revealed she was admitted to the facility on [DATE], and
readmitted from an acute care hospital on 3/24/2022. Her diagnoses included diabetic retinopathy,
cataracts in both eyes, diabetes mellitus with complications, left above the knee amputation, depression,
and anxiety.
The Minimum Data Set quarterly assessment with Assessment Reference Date 5/12/2023 noted the
resident required corrective lenses for sight and scored 12 out of 15 on the Brief Interview for Mental
Status, that indicated the resident had mild cognitive impairment. The assessment noted the resident
required extensive staff assistance for Activities of Daily living, and she depended on staff to assist with
locomotion off the unit.
Review of the Order Summary Report showed medication orders for Cyclopentolate eye drops to the right
eye for eye surgery, ordered 11/08/2022, Ketorolac eye drops to the left eye for eye surgery, ordered
11/08/2022, Prednisolone eye drops to the left eye for cataracts, ordered 4/17/2023, and orders for
ophthalmology appointments scheduled outside the facility on 2/22/2023, 4/03/2023, 4/17/2023, 4/18/2023,
and 5/15/2023.
The comprehensive care plan included focus for impaired vision related to diabetic retinopathy, dependence
on glasses, and cataracts in both eyes. The care plan noted the resident required staff assistance with
mobility, transfers, and dressing, related to impaired cognitive functioning, anxiety, and depression,
On 5/22/2023 at 11:46 AM, resident #54 stated she had been having difficulty with the facility assisting her
with transportation so she could get to her eye doctor appointments. She explained she recently had
surgery and was very concerned because she had blurry vision and discomfort. She said she had
transportation benefits included in her Medicaid plan at no cost to her, but the facility wanted her to use the
community bus service and she had to pay for it. She said she was worried as it's very expensive.
On 5/25/2023 at 9:30 AM, the [NAME] Unit Manager said residents were transported by various service
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
105872
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105872
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tuskawilla Nursing and Rehab Center
1024 Willa Springs Dr
Winter Springs, FL 32708
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0571
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
providers to medical appointments outside the facility. She explained some residents had Medicaid benefits
for it, and those who didn't have family available to take them often used the community bus service that
required, money in their account.
On 5/25/2023 at 10:00 AM, the Social Services Director explained she assisted residents with
transportation arrangements to medical appointments outside of the facility. She said it was a tedious
process to make transport appointments through many of the Medicaid benefits providers. She explained
resident #54 sometimes became distressed about getting to her eye doctor appointments and the facility
had enrolled her in the community bus service a few months prior.
On 5/26/2023 at 11:39 AM, the Business Office Manager explained fees for the community bus service
were withdrawn from the resident's trust account when they have one. She said the facility paid for the
service if residents did not have a trust account. She recalled resident #54's son had recently set up an
account for her. She provided a, Resident Statement Landscape form that showed debits for bus fare.
During a telephone interview on 5/26/2023 at 12:25 PM, resident #54's son said there had been several
times in the past his mother was distressed about her transportation. He said he reached out to the Social
Services Director multiple times for help over the past months, but he never received any responses. He
explained he was concerned because his mother told him she needed money for the bus, and she was very
distressed because she didn't have the cash for the fare. He said he reached out to the Medicaid case
worker who assured him there was no cost transportation benefits available, and recalled the resident often
had difficulty with being assisted by staff to get to the pickup location on time. He stated he set up an
account for his mother to help her with her distress over the [NAME].
On 5/26/2023 at 11:50 AM, the Social Services Director recalled enrolling resident #54 in the community
bus service program. She said she did not offer other choices, and she did not have a list. She checked the
medical record and acknowledged there were no notes or care plan to note resident #54 or her family
representative specifically chose to use the bus. She said all resident preferences and choices should be
included in the plan of care, and she would make sure she included them in the future. She explained the
facility uses the bus service because oftentimes the transportation benefit service provider, doesn't work
out.
The facility's admission packet included information titled, Nursing Home Resident Rights and
Responsibilities, that read, (a) 5. The facility may not impose a charge against the personal funds of a
resident for any item or service for which payment is made under Title XVII or Title XIX of the Social
Security Act. (i) The right to be fully informed, in writing and orally, . during his or her stay, of services
available in the facility and or charges for such services, including any charges for services not covered
under Title XVII or Title XIX of the Social Security Act or not covered by the basic per diem rates .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105872
If continuation sheet
Page 2 of 3
Printed: 05/28/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
105872
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/26/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Tuskawilla Nursing and Rehab Center
1024 Willa Springs Dr
Winter Springs, FL 32708
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to refer a resident with a newly evident mental disorder for
Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 1
resident reviewed for PASARR, out of a total sample of 37 residents, (#67).
Findings:
Resident #67 was admitted to the facility on [DATE] with active diagnoses including bipolar disorder,
metabolic encephalopathy, major depressive disorder, anxiety disorder and unspecified dementia.
Review of the Minimum Data Set (MDS) admission assessment with assessment reference date (ARD) of
4/26/23 revealed resident #67 had a Brief Interview for Mental Status (BIMS) score of 03 which indicated
she was severely cognitively impaired. The document indicated her active diagnoses included anxiety
disorder, depression (other than bipolar) and bipolar disorder.
Review of resident #67's electronic medical record (EMR) revealed a care plan initiated 4/25/23 for use of
psychotropic medications related to anxiety disorder, behavior management, depression and bipolar
disorder. The interventions included to identify common behavioral expressions and expected responses to
interventions and implement appropriate, individualized person-centered interventions and to describe how
the behaviors impact the resident and others (e.g., increases resident distress, dangerous to the resident or
others).
Resident #67's EMR contained a Level I PASARR dated 4/24/23 which did not indicate she had a mental
illness (MI) diagnosis. The Medical Certification for Medicaid Long-Term Care Services and Patient Transfer
Form (3008) sent from the hospital at time of admission indicated resident #67 had a diagnosis of bipolar
disorder.
Resident #67's EMR contained a progress noted dated 4/26/23 which read, Resident was admitted with DX
(diagnosis) of Bipolar Disorder.
On 5/26/23 at 11:04 AM, the Social Services Director (SSD) stated the admissions department usually
obtained a resident's PASARR prior to admission. She explained the clinical team then reviewed the
PASARR upon admission. The SSD stated she was responsible for completing a new PASARR if one was
not sent upon admission or contained incorrect information. She reviewed resident #67's Level I PASARR
and acknowledged the screening did not indicate resident #67 had a MI diagnosis. The SSD reviewed the
3008 transfer form sent from the hospital upon admission and verified it indicated resident #67 had a
diagnosis of bipolar disorder. She acknowledged the PASARR was inaccurate. The SSD explained she was
on vacation at the time of resident #67's admission. She was unsure if a new PASARR had been completed
or if resident #67 had been referred for a Level II screening.
On 5/26/23 at 1:02 PM, the Director of Nursing (DON) stated resident #67's PASARR was reviewed upon
admission and was identified as inaccurate. She explained she did not have access to complete a new
PASARR screening and the SSD was on vacation. The DON stated she reached out to a sister facility for
assistance in completing a new PASARR. The sister facility agreed but did not send one over. The DON
acknowledged the Level I PASARR screening for resident #67 was inaccurate upon admission and she was
not referred for a Level II PASARR evaluation and determination.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105872
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F571 - The facility must not impose a charge against the personal funds of a
Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
FAQ · About this visit
Common questions about this visit
What happened during the May 26, 2023 survey of TUSKAWILLA NURSING AND REHAB CENTER?
This was a inspection survey of TUSKAWILLA NURSING AND REHAB CENTER on May 26, 2023. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TUSKAWILLA NURSING AND REHAB CENTER on May 26, 2023?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Me..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.