Health inspection·July 18, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review the facility failed to provide care and services for bathing and toileting, supervision, and monitoring for one resident (#1) of nine sampled residents. Residents Affected - Few Findings include: A review of Resident #1's clinical chart, the admission Record, reflected an admission of 02/2019, with a readmission of 02/11/2023. The diagnosis information included: acute and chronic respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease, need for assistance with personal care, metabolic encephalopathy, and repeated falls. On 07/17/2023 at 9:40 a.m., in the middle of the hall outside of Resident #1's room, a strong old urine smell was observed. Resident #1 was observed in bed, her head of bed was raised approximately 45 degrees. A strong urine smell was noticeable while standing at the end of the bed. Resident #1's sheets at the bottom of her bed, the bottom sheet was observed to have light, dried yellow staining. The bed had a disposable chuck pad under her bottom, which could be seen at the edge of the mattress. She stated she had not been up, and that she was waiting on her medication. She said she sometimes had help to go to the bathroom. A wheelchair (w/c) was observed at bedside. Resident #1 indicated she drank a lot of water. Four (4) Styrofoam cups were observed on the bedside table and bedside nightstand. She lifted one of the cups with effort. She reported she had water. On 07/17/2023 at 10:22 a.m., Staff A, Licensed Practical Nurse (LPN), was observed outside of Resident #1's room. She indicated sometimes Resident #1 would self-propel her w/c into the bathroom for use. The resident wears a brief. Sometimes staff will assist as necessary. On 07/18/2023 at 9:05 a.m., an observation was conducted in the middle of the hall, outside of Resident #1's room. The odor in the hall was a light, old urine odor. Resident #1 was observed in her bed. On 07/18/2023 at 11:15 a.m., an interview was conducted with the Housekeeping Manager. Resident #1's bed was observed with the Housekeeping Manager. Resident #1's bed was observed to have a saturated and yellowed disposable chuck present on the bed with the bed control on the chuck. Photographic evidence was obtained. Resident #1 was observed to be sitting in her wheelchair (w/c) at bedside. On 07/18/2023 at 11:20 a.m., an interview was conducted with Staff A, LPN, she was standing outside of Resident #1's room at her medication cart. Staff A, LPN indicated Resident #1 needed assistance to get herself out of bed. She stated, She does not transfer herself. An observation of Resident #1's bed was conducted with Staff A, LPN. The top sheet and blanket were pulled back to see a 2nd (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 3 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 07/18/2023 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)