Inspection·September 24, 2025

F 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: On 09/24/2025 at 8:15 a.m., an interview was conducted with the Nursing Home Administrator (NHA), he stated the facility had no Personal Care Assistant (PCA) program, nor did the facility use Personal Care Assistants (PCAs). A review of the facility's employee list obtained on 09/24/2025, listed Staff E with a job title of Certified Nursing Assistant (CNA) with a position start date of 01/19/2025. On 09/24/2025 a review of Staff E's personnel file was conducted. The file revealed no evidence of the staff member being a licensed CNA. On 09/24/25 at 10:51 a.m., a Background Screening for Staff E was reviewed on the Clearinghouse Screening Management system. The screening revealed Staff E's Level II eligibility determination was a status of Agency Review Required. The licensure status revealed Staff E had no professional license. On 09/24/2025 at 12:12 p.m., an interview was conducted with the NHA and the Regional Nurse Consultant (RNC). The NHA and RNC reported the Human Resource Manager (HRM) had run an audit that morning (09/24/2025) because of the request for personnel files by the surveyors and discovered Staff E did not have a CNA license. A review of Staff E's personnel file was conducted with the NHA and RNC. The NHA reported the date of hire for Staff E had been 01/07/2025, then, after further review, he stated the original hire date was 08/23/2023, and the employment terminated in 02/08/2024. The NHA stated he assumed Staff E was re-hired as a dietary aide on 03/17/2024. The NHA stated Staff E had a department transfer on 01/19/2025 from dietary to a CNA position. The NHA confirmed Staff E had been performing CNA job duties for resident care and services from the transition date of 01/19/2025 through the present date, 09/24/2025. When asked how Staff E had come to be put on the schedule as a CNA, the NHA stated the Director of Nursing (DON) and the HRM person were not here at the time of the transition of the employee. The NHA stated he could only assume it was a lack of process. At 12:36 p.m., the RNC stated the former Human Resource person was terminated on 05/01/2025 for falsification of time for other staff and other reasons. The RNC was observed speaking on the phone. The RNC reported she had spoken with the former NHA. The RNC confirmed Staff E had been transferred from dietary to the CNA position. The RNC stated, being honest, it appears the HR person and Staff E were in a relationship. The former HR person was just doing her own thing. On 09/24/2025 at 12:58 p.m., an interview was conducted with the current HRM. She confirmed she had been in her position since the last week in May 2025. She stated she was unaware Staff E did not have a CNA license. On 09/24/2025 at 1:27 p.m., an interview was conducted with the Staffing Coordinator. She confirmed her responsibility was to complete the staffing schedule. She reported she completed her staffing assignments from a handwritten list of employees she compiled. A request for a review of the list was conducted, which subsequently, she stated she could not find the handwritten list. The staffing coordinator provided staffing assignment sheets for (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 2 Event ID: 106150 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 106150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Pruitthealth-North Tampa, LLC 18940 Sunlake Blvd Lutz, FL 33558 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)