Lakeland Community Care Center

Based on staff interview and record review, the facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident who was coded as discharged to the hospital but was discharged to home instead of the hospital for one (1) of 18 sampled residents. (Residents #83) Findings included: A record review of the Discharge MDS with an Assessment Reference Date (ARD) of 11/09/24 revealed the Resident #83 was discharged to a short-term general hospital. A record review of a Physician's Telephone Orders, dated 11/09/24, revealed Resident #83 had an order to be discharged home. On 01/29/25 at 08:07 AM, an interview with the Social Services Director (SSD), revealed Resident #83 was admitted for a brief time as she was there for skilled care and had planned to return home. The SSD stated she prepared the discharge summary based on the physician orders on the day Resident #83 left the facility. On 01/29/25 at 08:45 AM, in an interview with Registered Nurse (RN) #1/MDS, she acknowledged the MDS was coded incorrectly as being discharged to the hospital because he went back home…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and facility policy review, the facility failed to develop a person-centered care plan regarding a resident's impaired vision for one (1) of (18) care plans reviewed. Resident #68. Findings included: A review of the facility's policy titled Comprehensive Care Plan Policy, revised on 01//2025, revealed, Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. All disciplines work together to develop a plan of care that meets the resident's needs, preferences, and goals. A record review of the Comprehensive Care Plan revealed Resident #68 did not have a care plan regarding impaired vision. A record review of the admission Record revealed the facility admitted Resident #68 on 6/23/23 and he had current diagnoses including Paralytic Ptosis of Left Eyelid. A record review of the Eye Examination, dated 09/19/2024, revealed Resident #68 was seen by a local optometrist and was diagnosed with Dry Eye Syndrome of bilateral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were secured and inaccessible to unauthorized residents and staff one (1) of four (4) days of survey observations. Findings included: A review of the facility's policy titled Medication Storage, dated 01/2015, revealed, .All drugs, treatments, and biologicals must be stored securely . Resident #5 A record review of the admission Record revealed the facility admitted Resident #5 on 04/21/2017 with diagnoses including Spinal Stenosis. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/2024 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of eight (8), which indicated the resident's cognition was moderately impaired. On 01/28/2025 at 4:40 PM, during an observation and interview with the Administrator, an unattended medicine cup was observed on Resident #5's bedside table alongside a glass of water. The resident was lying flat in bed, and no staff were present to monitor the resident taking…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to maintain complete and accurate medical records by failing to document that residents were informed of their rights regarding Advance Directives for three (3) of (18) resident records reviewed, Residents #22, #27, and #61. Findings included: A record review of the admission Record revealed the facility admitted Resident #22 on 06/10/2024 with diagnoses including Unspecified Dementia, Resident #27 on 06/14/2024 with diagnoses including Atherosclerotic Heart Disease, and Resident #61 on 9/20/2024 with diagnoses including Vascular Dementia. A record review of the Resident Rights/Advance Directive revealed the Advance Directive was not initialed by the residents or Resident Representatives that confirmed they were informed of information regarding formulating an Advance Directive for Residents #22, #27, and #61. A record review of the Resident Rights/Advance Directive revealed the Advance Directive was not initialed by the residents to confirm being informed of information regarding formulating an Advance Directive for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff and Resident Representative (RR) interviews, record review, facility investigation, and policy review the facility failed to ensure nursing staff treated residents with respect and dignity during procedures and medication administration for two (2) of eight (8) residents sampled. Residents #5 and Resident #6. Findings Include: Record review of the facility's policy titled, Resident [NAME] of Rights, reviewed/revised on 1/23, revealed, Each resident has a right to a dignified existence . and communication with and access to persons and services inside and outside the facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life .10. Reside and receive services in the facility with reasonable accommodation or resident needs and preferences . Resident #5 During an interview with Resident #5 on 5/19/24 at 1:22 PM, she stated Licensed Practical Nurse (LPN) #1 was disrespectful and demanding when she entered her room to collect a urine sample. She explained that this conduct was nothing new. This nurse had frequently…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record reviews the facility failed to ensure call lights were within reach for three (3) of five (5) sampled residents. Resident #3, Resident #4 and Resident #5 Findings Include: Resident #3 On 1/25/24 at 11:15 AM, an observation revealed the call light for Resident #3 was draped over the back of a bedside chair at the end of the resident's bed. The resident was seated on the end of the bed with the call light out of reach. On 1/25/24 at 4:14 PM, an observation revealed the call light for Resident #3 was draped over the back of a bedside chair. The resident was seated in her wheelchair with her call light out of reach. Resident #3 was observed looking for her call light, attempted to reach it, however, the call light was out of reach. On 1/26/24 at 11:18 AM, observation revealed that Resident #3 was seated in her wheelchair in her room with her call light out of her reach, draped over the back of the bedside chair at the end of her bed. She was coughing and sneezing. The resident needed a tissue, but there were none in her room. The resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, and facility policy review the facility failed to implement interventions included in the individualized care plans for four (4) of five (5) sampled residents. Residents #1, #3, #4 and #5. Findings Include: Record review of the facility policy titled, COMPREHENSIVE PERSON-CENTERED CARE PLANS, with revision date 3/18, revealed, Policy: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . Procedure: .6. Staff approaches are to be developed for each problem/strength/need . Assigned disciplines will be identified to carry out the intervention Resident #1 Record review of the Care Plan for Resident #1 with a problem onset date of 1/5/2024 revealed Total urinary incontinence related to impaired mobility and diuretic med use .Approaches Toilet checks on me q2h (every 2 hours) and prn .Keep call light within easy reach of me . Record review of the Care Plan for Resident #1 with a problem onset date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure that dependent residents received the necessary services to maintain good grooming and personal hygiene for one (1) of five (5) residents reviewed for activities of daily living (ADLs). Resident #1 Findings include: Record review of the facility policy titled, INCONTINENT CARE, with a review date of 7/12, revealed, Policy: To provide routine, preventive skin, perineal care to residents after an incontinent episode. Responsibility: All Nursing Personnel . Record review of a statement signed by the Executive Director and dated 1/26/24, revealed that the facility did not have a specific policy for ADL (Activities of Daily Living) care. On 1/25/24 at 2:37 PM, an interview with Resident #1 revealed that she received morning care, including incontinent care and a bed bath prior to breakfast on 1/25/24 and received incontinent care following breakfast. She stated that she went to the Therapy Department prior to lunch at approximately 11:45 AM, returned to her room for lunch and then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide Activities of Daily Living (ADL) care regarding fingernail care for residents who are dependent upon staff for two (2) of four (4) sampled residents. Resident #1 and Resident #2 Findings Include: Record review of the facility's policy, Fingernails/Toenails Care, reviewed 10/09, POLICY:The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. Responsibility: Nursing Assistant or Licensed Nurse .1. Nails can be partially cleaned during bath care .3. Nail care includes daily cleaning and regular trimming . Resident #1 On 12/04/23 at 4:00 PM, an observation and interview with Resident #1 revealed she had contractures of both hands, and all of her fingernails were long. There was a black substance caked under her right thumbnail. Resident #1 stated that she did not prefer to have long fingernails and wanted her fingernails trimmed. The resident said she could not recall the last time her fingernails were trimmed. On 12/05/23 at 10:30…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, policy review, record review, and interviews, the facility failed to ensure secure storage of medication included limited of access, for one (1) of four (4) sampled residents reviewed for pressure sores as evidenced by skin protectant ointment left unattended at resident's bedside. Resident #1. Findings Include: Record review of the facility policy titled Medication Storage ,reviewed 11/10 revealed POLICY: Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologicals must be stored securely and following the manufacturer's labeled recommendations, or per facility policy . Record review of a handwritten statement dated 11/14/23 and signed by Certified Nursing Assistant (CNA) #2 revealed that she fed some of a white substance she noticed next to the resident's supper tray to the resident. Record review of the Resident Incident Report dated 11/14/23 at 6:00 PM revealed that CNA #1 reported that Resident #1 had ingested approximately five (5) cubic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and facility policy review, the facility failed to provide an environment free of urine odor for two (2) of three (3) facility halls. Central Hall and North Hall. Findings include: A review of the facility document, Resident [NAME] of Rights, dated 01/2023, revealed, Each resident has a right to a dignified existence .in an environment that promotes maintenance or enhancement of (his or her) quality of life .A. Facility residents shall have the right to .32. A safe clean, comfortable home like environment . An observation of the Central and North halls, on 09/12/23 at 10:05 AM, revealed there was a strong urine odor along both hallways. An observation of the Central and North hallways, on 09/12/23 at 01:30 PM, revealed both hallways had a strong urine odor. An observation, on 09/13/23 at 09:32 AM, revealed the Central and North hallways had a urine odor. On 9/14/23 at 9:10 AM, an observation of the North Hall and Central Hall biohazard rooms revealed strong urine odors coming from the rooms. The barrels were full but covered. No debris was observed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a resident was without physical restraints related to the use of full-length bed rails for one (1) of 21 sampled residents. Resident #22 Findings include: A review of the facility document, Resident [NAME] of Rights, dated 01/2023, revealed, Each resident has a right to a dignified existence .in an environment that promotes maintenance or enhancement of (his or her) quality of life .A. Facility residents shall have the right to .37. be free of physical .restraints . A record review of the facility's policy Restraint Evaluation and Restraint Reduction, dated 8/2013 revealed . all residents have the right to be unrestrained. Restraints should be used only as a last alternative and only when other less restrictive measures have been tried and rejected .Definition: 'Physical restraints' are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and the facility policy review the facility failed to provide respiratory services in a manner to prevent the possibility of complications for two (2) of two (2) residents reviewed for respiratory conditions. Resident #3 and Resident #15. Findings include: A record review of the facility's policy, Standard Precautions, dated 09/2019, revealed, .Procedure .5. Handle soiled patient care equipment in a manner that prevents transfer of microorganisms to others and to the environment . Resident #3 On 09/12/23 at 9:00 AM, during an observation, Resident #3 had a Continuous Positive Airway Pressure (CPAP) device in his room and the tubing was on the floor of the room. There was no bag or designated container to store the tubing. On 09/12/23 at 11:50 AM, in an observation of Resident #3, his CPAP tubing remained on the floor on the right side of bed. There was a face mask for the CPAP located in a plastic bag on the resident's windowsill in his room. On 09/13/23 at 08:30 AM, in an observation of Resident #3, he was lying in bed and the CPAP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews, and the facility policy review the facility failed to prevent the possibility spread of infections by placing soiled dressings in the resident's trash for (1) out of 21 sampled residents. Resident #11 Findings include: Review of the facility's Standard Precautions policy, dated 09/2019, revealed, .Standard Precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated (HAI) agents among patients and healthcare personnel .Procedure .10. Follow procedures for disposal of regulated/infections waste when items are saturated with blood . On 09/13/23 at 03:07 PM, in an observation and interview with Licensed Practical Nurse (LPN) #2 she performed wound care on Resident #11 with the assistance of Registered Nurse #2/Nurse Manager. LPN #2 removed the soiled dressings from the wounds to the buttocks and sacrum and discarded the bloody dressings in a clear bag in the resident's garbage can. During the interview, LPN #2 confirmed that placing soiled dressings in the resident's garbage, and not in red…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, the facility failed to honor residents' rights by not providing showers per choice for five (5) of 18 residents sampled. Residents #1, #15,#25, #29, #38. Findings Include: A review of the facility's policy, Resident [NAME] Of Rights, dated 11/17, revealed, Each resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancement of (his or her) quality of life, regardless of diagnosis, severity of condition or payment source and to exercise those rights as a citizen of the Unites (United) States without interference, coercion. including those rights specified herein .15. Self determination, which the facility must promote and facilitate through support of resident choice, consistent with his or her interests, assessments and plan of care and make other choices about aspects of his or her life in the facility that are significant to the resident.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident, staff and family interviews, and facility policy reviews, the facility failed to honor the residents rights for visitation for four (4) of seven (7) family interviews. Resident #15, #17,#38, #77. Findings Include: A review of the facility's visitation policy, titled Visitation Guidance, dated May 2021 revealed .Indoor visitation for unvaccinated residents in a facility that has less than 70 % of the residents vaccinated and county positivity rate greater than 10 % visitation should be compassionate only. Any resident with active COVID, regardless of vaccination status, will have no visitation until they meet criteria to discontinue isolation . A review of the facility's, Resident [NAME] of Rights, dated 11/17 revealed Each resident has a right to a dignified existence, self-determination, and communaiton with and access to persons and services inside and outside the Facility in a manner and in an environment that promotes maintenance or enhancemento of (his or her) quality of life,regardless…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews, and facility policy review, the facility failed to notify the resident or resident representative in writing of residents' hospitalization for four (4) of 21 records reviewed. Resident #34, #46, #83, #57 Findings Include: A record review of the facility's policy, Discharge and Transfer Policies-Involuntary, with a revision date of 1/2015, revealed before a facility transfers a resident to a hospital or allows a resident to go on therapeutic leave, the nursing facility must provide written information to the resident and a family member or legal representative that specifies the duration of the bed-hold policy and the facility's policies regarding bed-hold policies. Resident #34 On 8/09/21 at 11:56 AM, in an interview and observation of Resident #34 sitting in his wheelchair, he stated he has been to the hospital a couple of times due to his leg being amputated. A record review of the Face Sheet revealed Resident #34's initial admission was on 5/10/21. A record review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record review, and facility policy review, the facility failed to follow the comprehensive care plan by not providing showers per residents' request for five (5) of 18 sampled residents. Resident #1, #29, #38, #25, #15 Findings include: A review of the facility's Care Plan Policy, titled Comprehensive Person Centered Care Plans, dated 3/18 revealed,Policy Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care .Interdisciplinary: All disciplines work together to develop a plan of care that meets the residents' needs, preferences, and goals. Resident #1 During an interview on 08/11/21 at 03:49 PM, with Resident #1, revealed he prefers to have showers rather than bed baths. Resident #1 said bed baths do not clean as good as a shower. Resident #1 said he asked the Certified Nursing Assistants (CNA's) when the shower room will be open again and he did not get an answer. Record review of the bathing report for July and August 2021 revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and facility policy review, the facility failed to prevent the possible spread of food-borne illness for one (1) of four (4) observations. Findings include: A record review of the facility's Monitoring Food Temperatures for Meal Service policy, 2016 Edition, revealed Guideline: Food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures.Procedure: 1. Prior to serving a meal, food temperatures will be taken and documented for cold and hot foods to ensure proper serving temperatures. Any food not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action On 08/11/21 at 11:50 AM, the Dietary Manager (DM) brought a meal tray into the conference room for the State Survey Agency (SSA) to taste and observe per the SSA request. After the DM brought the meal tray, he left the room. The meal was served in a hinged Styrofoam divided plate with a lid. The meal included fried chicken, sweet potato casserole, greens, cornbread and a piece…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record reviews, and facility policy review, the facility failed to prevent the possible spread of infection for one (1) of three (3) meals observed. Resident #34. Findings Include: A record review of the facility's policy, Standard Precautions, reviewed date 1/15, revealed, POLICY: Standard Precautions will be utilized to provide a primary strategy for the prevention of healthcare-associated infectious (HAI) agents among patients and healthcare personnel. A review of the facility's policy, Contact Precautions, dated 9/19, revealed, POLICY: Contact Precautions are a transmission based precaution that will be utilized to reduce the risk of epidemiologically important micro-organisms by direct or indirect contact. On 8/11/21 at 12:26 PM during an observation and interview with Resident #34 revealed he had not been served a lunch tray although Resident #34's roommate had been served a meal tray. Resident # 34's roommate confirmed the meal tray, which was observed on his bedside table, was his lunch tray. Resident # 34 stated they (staff) had not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.