F 0699
Provide care or services that was trauma informed and/or culturally competent.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to implement a care plan for residents with a diagnosis of Post
Traumatic Stress Disorder (PTSD) for 2 of 2 sampled residents (Resident #4 and #91).The findings
included:
Residents Affected - Few
A review of the facility's Behavioral Health Services policy, last reviewed on 09/02/25, documented the
facility will provide behavioral health care and services that create an environment that promotes emotional
and psychosocial well-being, meets each resident's needs, and includes individualized approaches to care.
Under procedure it was documented to complete the nursing assessment and social services assessment
upon admission/readmission, quarterly, and as needed with changing condition. Through this assessment
the facility should identify residents to ensure an accurate diagnosis of a mental disorder or psychosocial
adjustment difficulty, or PTSD was made by a qualified professional. Initiate behavior monitoring, behavior
management care plan, and kardex as indicated by assessment findings, use of psychoactive medications,
resident/responsible party conversations, and observations. The social worker is primarily responsible for
initiation of the behavior management care plan.
1. Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses that included
PTSD. A comprehensive assessment dated [DATE] documented the resident had moderate cognitive
impairment, was independent for activities of daily, and had a primary medical condition of PTSD.
A review of Resident #4's care plan did not address the resident's diagnosis of PTSD, including the cause
and triggers the resident may exhibit.
An interview was conducted with the Social Service Director (SSD) on 12/17/25 at 12:00 PM. The SSD
acknowledged the findings.
2) Record review revealed Resident #91 was admitted to the facility on [DATE]. Further review of the record
revealed that Resident #91's diagnosis included in part, Chronic Obstructive Pulmonary Disease (COPD),
Bipolar Disorder and Post Traumatic Stress Disorder (PTSD).
A review of Resident #91's care plan did not address the resident's diagnosis of PTSD, including the cause
and triggers the resident may exhibit.
An interview was conducted with the Social Service Director (SSD) on 12/17/25 at 3:40 PM. The SSD
acknowledged the findgs.
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:
105268
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
105268
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/18/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakeside Health Center
2501 N Australian Avenue
West Palm Beach, FL 33407
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and interview, the facility failed to document a change in a resident's condition for 1 of 1
sampled resident reviewed for respiratory infection (Resident #74). The findings included: A review of the
facility's policy titled, Changes in Resident's Condition or Status, last reviewed 08/29/25, documented in
part: Documentation associated with identifying and communicating a change in a resident's status
includes: date and time of procedure, acute change in status, behavioral changes, vital signs, oxygen
saturation level, other assessment findings in the appropriate areas in the residence medical record,
nursing interventions, and communication with healthcare team members.Record review revealed Resident
#74 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the
resident had severe cognitive impairment and required partial A moderate assistance with activities of daily
living. A review of Resident #74's care plan revealed a care plans, dated 12/15/25, that documented the
resident is on antibiotic therapy related to an Upper Respiratory Infection (URI).A review of Resident #74's
physician orders revealed an order dated 12/12/25 for Amoxicillin, (an antibiotic), 500 milligrams by mouth
every 12 hours for URI for 7 days.A review of Resident #74's progress notes dated 12/05/25-12/13/25 did
not reveal any indications or symptoms of the resident having an URI. A review of residence #74's vital
signs revealed no indication of the Resident having an infection.A review of Resident #74's progress notes
revealed a progress note dated 12/14/25 that documented the resident was receiving Amoxicillin 500
milligrams by mouth every 12 hours for URI for 7 days and was tolerating well.An interview was conducted
with the Director of Nursing (DON) on 12/18/25 at 12:00 PM. The DON acknowledged the above and stated
she would look into it. A follow up interview was conducted with the DON on 12/18/25 at 1:00 PM. The
[NAME] stated that Resident #74 was seen by the Nurse Practitioner (NP) on 12/12/25 and provided
documentation of such visit (not in resident's record). A review of the NP's progress note dated 12/12/25 at
9:30 AM documented: Patient (Resident #74) was seen today for ongoing issues with upper respiratory
signs and symptoms. Staff reported increased nasal drainage and cough a few days ago and due to patient
history of allergies he was started on Zyrtec (allergy medication). Today patient has ongoing worsening
signs and symptoms and has some complaints of nasal congestion with the drainage along with not much
improvement in cough. Patient has no fevers, has history of recurrent sinus infections. Plan: Amoxicillin 500
milligrams two times a day for 7 days, continue allergy medications, follow up any non- resolved signs and
symptoms.
Event ID:
Facility ID:
105268
If continuation sheet
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