Health inspection·November 22, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Resident and staff interview, Resident Record review and review of facility policy and procedure, it was determined that the facility did not ensure that one of thirty four residents ( # 81) was treated in a dignified manner. Findings Included: An observation and interview was conducted with Resident # 81, on 11/19/19 at 12: 45 p.m. He was observed seated on his bed, wearing light colored sweat pants. The front of the sweat pants in the groin area were observed to be wet. There was an odor of urine noted. Resident # 81 indicated he felt like he needed a blood test because I keep peeing all over myself. Resident # 81 ambulated out into the hallway and was observed walking down the hall past three staff members who were in the hall. At approximately 1: 05 p.m. on 11/19/19, twenty minutes after the observation in Resident # 81's room. Resident # 81 was observed in the facility conference room in the front left hall of the facility. Resident # 81 resides in a back hall of the facility. Resident # 81 would have had to ambulate from the back of the facility to the front of the facility , past both nursing stations and through the facility open dining room/ activity area to reach the conference room. Resident # 81 was observed to be dressed in the same wet sweat pants and continued to have an odor of urine. On 11/20/19 at 10: 00 a.m. Resident # 81 was observed dressed and lying on top of the made bed in his room. His sweat pants were visibly wet in the groin area. and thee was an odor of urine. Review of the CNA ADL (Certified Nurses Aide Activity of Daily Living) task documentation for Bladder Continence, revealed documentation that Resident # 81 was continent of bladder on all three shifts on 11/19/19 and 11/20/19. Review of a Minimum Data Set ( MDS) quarterly assessment, dated 10/20/19 revealed a score of 13 on the Brief Interview for Mental Status which indicated cognitively intact. The MDS indicated he was occasional incontinent of bladder and bowel. Review of Diagnosis Information on the Resident admission Record sheet revealed that Resident # 81 does have mental health related diagnoses. Review of a care plan for ADLs initiated 1/15/19 and revised 10/8/19, revealed under Toilet Use: 1 staff assist ; Toilet/ Check and change upon arising, before and after meal, at bedtime and as needed with routine care. Review of the CNA [NAME] revealed : Toilet Use: Supervision and Toilet/ Check and change upon arising, before and after meal, at bedtime and as needed with routine care. (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 6 Event ID: 105283 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 105283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lakeland Hills Center 610 E Bella Vista Dr Lakeland, FL 33805 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)