Lakeland Health Care Ctr

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for 1 of 1 (R1) resident reviewed for catheter care. R1's catheter collection bag was observed during to be attached to a garbage receptacle and the bottom of the collection bag was observed resting directly on the floor.

Inspectors wroteBased on interview and record review, the facility did not ensure residents were free from physical and verbal abuse for 1 (R1) of 3 residents reviewed for abuse. R1, who is diagnosed with dementia, started displaying aggressive behaviors and being resistive to cares within the first 2 weeks of being admitted to the facility. The facility did not develop or implement a behavior care plan with resident specific interventions to help guide staff in how to care for R1. On 8/11/25, R1 was being cared for by Certified Nursing Assistant (CNA)-C and Registered Nurse (RN)-D. R1 was agitated, aggressive and resistive to cares. CNA-C was working to calm R1. RN-D entered R1's room and was yelling at R1 to let them take care of R1. While R1 was sitting at the edge of R1's bed, RN-D grabbed R1's legs and threw them in R1's bed, making R1 lay down in bed. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure residents with dementia received the appropriate treatment and services to attain their highest practical physical, mental and psychological well-being for 1 (R1) of 1 resident reviewed with dementia.*R1 has a diagnosis of dementia. R1 started displaying aggressive behaviors and being resistive to cares within the first 2 weeks of being admitted to the facility. The facility did not develop or implement a behavior care plan with resident specific interventions to help guide staff in how to care for R1. The facility did not document that R1's Medical Doctor (MD) was made aware of R1's increase in aggressive and resistive care behaviors. [...]

Inspectors wroteBased on interview and record review the facility did not ensure that 1 (R1) of 1 allegations of potential abuse/neglect were reported immediately, but not later than 2 hours after the allegation is made.*On 6/23/2025, R1 received medication that was not prescribed to R1, which resulted in R1 going to the emergency room. Facility staff did not report the incident in a timely manner and did not report the potential neglect/abuse to the administrator and/or law enforcement.

Inspectors wroteBased on interview and record review the facility did not ensure 2 (R3 & R1) of 3 residents were free of significant medication errors.* On 6/30/25, R3 received R2's medication which consisted of Hydralazine 50 mg (milligrams) and Ropinirole 0.5 mg.* On 6/23/25, R1 received another resident's medication.

Inspectors wroteBased on observation and interviews, the facility did not ensure each resident is treated with dignity and respect that promoted maintenance or enhancement of quality of life. This occurred for 2 (R30 and R55) of 10 Residents reviewed for dignity. *On 8/29/24, Surveyor observed R30 and R55 being fed breakfast at the same time by Recreation Therapy Leader (RTL)-E who was standing during the entire meal. Further, RTL-E was referring to R30 by a nickname Bob-O that is not documented in the care plan as an approved nickname. Findings Include: The facility's policy and procedure Assisting Residents With Meals last revised 3/2024 documents: Purpose .The facility will ensure that Residents that need assistance with meals will receive assistance for the consumption of a meal. Meals are to be an enjoyable experience for Residents. [...]

Inspectors wroteBased on record review and staff interviews, the facility did ensure 1( R61) out of 18 residents were free from neglect. R61 needed extensive assistance from staff to use the toilet and to transfer on and off the toilet. When R61 would become fatigued, often in the evening, staff would use an EZ stand to transfer R61 on and off the toilet. On 12/24/24, 2nd shift staff member left R61 attached to the sling for the EZ stand, seated on the toilet at approximately 9:30 p.m The 2nd shift CNA left the facility at the end of her shift without providing cares to R61 and transferring R61 back to bed. A night shift nurse found R61,at approximately 12:45 a.m., still seated on the toilet and was visibly upset. R61 is unable to make her needs known and has a diagnosis of dementia. This is evidenced by: Policy Review: Freedom from Abuse, Neglect and Exploitation origination date : 04/2013. [...]

Inspectors wroteBased on record review and staff interviews, the facility did not ensure that 2 allegations of abuse involving 5 Residents (R32, R12, R62, R27, and R39) were reported immediately to the Nursing Home Administrator (NHA)-A and the State Survey Agency. *On 2/3/24, and 2/4/24, Registered Nurse (RN)-Q documented R32 was verbally abusing R12, R62, and R27 and did not report this to NHA-A. *On 6/10/24, R39 reported an allegation of mistreatment by a CNA on 6/9/24. The allegation was not reported to NHA-A until 6/17/24. The facility's policy entitled, Freedom From Abuse, Neglect and Exploitation, last revised 2/2024 documents: BACKGROUND . Residents will not be subjected to abuse by anyone, including but not limited to, facility staff, other Residents, consultants or volunteers, staff of other agencies serving the Resident, family members or legal guardians, friends or other individuals. G. [...]

Inspectors wroteBased on record review and interview, the facility did not implement fall prevention interventions to prevent falls and did not consult with a physician post fall 2 (R72, R32) of 9 residents reviewed for accidents. *R72 sustained an injury of unknown origin to their scalp that was not properly assessed or reported to physician until 3 days later. * R32 sustained an unwitnessed fall from the toilet due to being unsupervised in the bathroom. R32's comprehensive care plan indicates that they are not to be left alone on the toilet.

Inspectors wroteBased on observation, record review and interview, the facility did not provide adequate nutritional support to 1 (R72) of 4 residents reviewed for Nutrition. *R72 had physician's orders in place to monitor weights twice weekly. The facility did not consistently monitor R72's weight in accordance with physician orders. R72 sustained a 7.6 pound weight loss from 5/22/24-6/1/24 with no physician notification documented until 6/5/24.

Inspectors wroteBased on observation and interview, the facility did not ensure the cleaning and disinfecting of R30's glucometer after each use. Facility Glucometers are being disinfected with a 70% isopropyl alcohol wipe daily rather than with a disinfectant bleach wipe in order to kill bloo- bourne pathogens. *On 8/29/24 Surveyor observed LPN (Licensed Practical Nurse)-M administer blood glucose testing for R30. RN-G did not clean and disinfect R30's Glucometer with a disinfectant wipe which kills blood borne pathogens. This deficient practice had the potential to affect 1 of 1 residents reviewed for blood glucose monitoring.

Inspectors wroteBased on interview and record review, the facility failed to prevent 5 (R3, R4, R6, R1, and R5) of 6 residents reviewed for abuse to be free from sexual abuse from R2. The facility failed to prevent 3 (R4, R1, and R8) of 6 residents reviewed to be free from sexual or physical abuse from R7. R2 had an identified history of inappropriate sexual behaviors with peers and staff. The facility did not have effective interventions in place to prevent sexual abuse of peers. When sexual abuse of peers did occur, the interventions were not revised, new interventions were not put in place, and monitoring was not increased; R2 continued to sexually abuse his peers. R2 attempted to enter R3's room multiple times uninvited (6/27/23, 8/8/23.) On 8/8/23, R2 entered R3's room while she was undressed. The facility did not assess R3 for any psychosocial harm or mental anguish after the sexual abuse. [...]

Inspectors wroteBased on record review and interview, the facility did not provide appropriate treatment and services for 2 (R2 and R7) of 2 resident reviewed with a diagnosis of dementia with behavioral symptoms to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. R2 was admitted to the facility with a diagnosis of dementia with behaviors. Shortly after admission, R2 started exhibiting behavior symptoms included wandering into female peers' rooms and making sexual comments, propositioning and gesturing to staff and peers. The R2 was seen by psych services to assist with behavior concerns and pharmacological interventions which were not effective. R2's care plan was not person centered and did not address R2's sexual and wandering behaviors exhibited towards others resulting in sexual abuse of 5 female peers. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring all alleged violations involving resident-to-resident abuse, were reported immediately, (but not later than 2 hours if the allegation involves abuse or result in serious bodily injury or not later than 24 hours if the events do not involve abuse and do not result in serious bodily injury) to the Administrator and to the State Agency for 6 of 6 allegations of abuse involving 5 residents, R7, R8, R4, R2, and R1. In addition, the facility did not report the results of all investigations, within 5 working days of the incident to the state agency. * On 7/28/23, 8/21/23, 9/10/23, 9/21/23, R7 was documented to have been involved in a resident-to-resident physical altercation that was not reported to the state agency. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, mistreatment, or resident to resident altercations were thoroughly investigated for 6 out of 6 reportable incidents reviewed involving 5 residents (R7, R4, R8, R1 and R2.) On 7/28/23 and 9/10/23, R7 and R4 were involved in resident-to-resident physical altercations. On 7/28/23, R7 was pushing R4's wheelchair. R4's feet were dragging, and she was yelling out in pain. On 9/10/23, R7 was squeezing R4's shoulders so hard that she was yelling out in pain. Per facility policy and federal regulation allegations of abuse are to be reported to the Nursing Home Administrator (NHA)-A. NHA-A and DON-B were not made aware of these allegations of abuse. There were no interviews completed and no investigation done into the abuse allegations. [...]

Inspectors wroteBased on observation and interview the Facility did not serve food in accordance with professional standards for food service safety. The thermometer was not sanitized between food items during the breakfast meal on 6/6/23 observed in the two serving kitchens on Unit A. This has the potential to affect 30 Residents residing on the A unit.

Inspectors wroteBased on observation, interview, and record review, the Facility did not ensure that Residents at risk for pressure injuries received necessary treatment and services to prevent the development of pressure injuries for 1 (R64) of 5 Residents reviewed for pressure injuries. * On 6/5 and 6/6/23, R64 was observed in bed without the heels being offloaded per plan of care initiated on 7/22/22 and revised on 3/22/23.

Inspectors wroteBased on observation, interview and record review the facility did not provide supervision to prevent accidents for 1 (R8) of 7 residents reviewed for accidents. *R8's call light was not observed clipped to R8's clothing per R8's care plan. *R8 had a fall on 02/03/2023. The facility did not thoroughly investigate the fall in order to implement an appropriate intervention.

Inspectors wroteBased on observation, interview, and record review the Facility did not promptly refer a resident to the dentist for 1 (R65) of 1 Residents reviewed for dental services. On 3/23/23 R65's family member informed Facility staff R65 has a loose tooth and requested R65 be seen by a dentist. R65 is not scheduled to be seen by a dentist until 6/8/23.

Inspectors wroteBased on observation, interview, and record review the Facility did not have an effective infection control program for 3 (R64, R38, & R33) of 4 Residents observed during personal cares. * R64, R38, & R33 were observed to not have appropriate hand hygiene during personal care observations. * The mechanical lift was not disinfected after being used for R38, who is on enhanced barrier precautions.