Health inspection·August 10, 2022

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and record review, the facility failed to ensure resident rooms with fall floor mats, were maintained and free from trip hazards during four of four days observed (8/7/2022, 8/8/2022, 8/9/2022, and 8/10/2022), affecting three (101, 104, and 105) of three resident rooms where fall mats were observed. Findings include: On 8/7/2022 at 10:30 a.m., 1:00 p.m. on 8/8/2022 at 7:30 a.m., 9:45 a.m. on 8/9/2022 at 1:00 p.m.; and on 8/10/2022 at 9:40 a.m. the following was observed: 1. Resident room [ROOM NUMBER] (window bed) was observed with two thin grey colored fall floor mats. The mats were observed placed on the floor on either side of the bed and with the resident in bed. Both mats were observed tattered, ripped, torn, and gouged, leaving non cleanable surfaces, and with corners and edges sticking up, creating a fall/trip hazard. 2. Resident room [ROOM NUMBER] (window bed) was observed with one grey colored fall floor mat on the floor with ripped and torn edges, and areas that were not cleanable. Three corners of the mat were observed sticking up and creating a fall/trip hazard. There was another fall floor mat placed on the floor that was blue in color. The blue floor mat had staining and with cracks, leaving a non-cleanable surface. The resident was observed in bed while the mats were on the floor. 3. Resident room [ROOM NUMBER] (door bed) was observed with one grey colored fall floor mat. The resident was observed in bed at the time of the observations. The corners of the fall floor mat was ripped and torn and leaving edges that stuck up creating a trip/fall hazard. During the survey timeframe to include 8/7/2022 through 8/10/2022 the facility was noted with sixty (60) resident rooms. Of the sixty (60) resident rooms, thirty-seven (37) were occupied by residents. Of the thirty-seven (37) occupied resident rooms, three (3) rooms were observed with residents who utilized fall floor mats; all three (3) rooms had fall floor mats that were severe with disrepair and with surfaces that were not cleanable. Photographic evidence was obtained. On 8/10/2022 at 10:00 a.m. Staff B, Certified Nursing Assistant (CNA) confirmed the floor mat in room [ROOM NUMBER] was not maintained and created a trip hazard. She revealed it should be reported to the maintenance director in order for him to repair and or replace. On 8/10/2022 at 12:36 p.m. an interview with a Staff E, Housekeeper, she confirmed she does not Page 1 of 5 105350 105350 08/10/2022 Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few move the mats and sweeps and mops over them and around them. She was asked if she has noticed the condition of some of the mats and replied, I tell them. Staff E confirmed them' referred to the Maintenance Director. On 8/10/2022 at 12:44 p.m. an interview with the Director of Nursing (DON), Maintenance Director (MD), and the Regional Administrator (RA) revealed they were made aware of the non-maintained fall floor mats prior to the interview. The MD confirmed the fall mats are under his department and it is his responsibility to either maintain or replace mats that are no longer useable or cleanable. The MD, along with the DON, explained that all staff who enter resident rooms would be responsible for the reporting of unmaintained and broken equipment to the MD by way of documenting in the Maintenance Log books, which were located at the nursing stations. The MD stated he reviews those logs daily and will work to repair and or replace equipment that was noted. The DON and the RA said they had noticed the unmaintained fall floor mats previously, approximately a month ago and had made requests to replace the ripped/torn, soiled mats. The RA indicated they had tried to place orders to various equipment companies but fall mats were hard to obtain. The DON and RA were unable to provide documentation of an order for new floor mats at the time of the interview. Further, the DON indicated the floor staff, who are in rooms daily, confirmed they have never reported these fall floor mats being in disrepair and with non-cleanable surfaces. The MD confirmed he did not have any documentation in the Maintenance Logs with relation to fall floor mats in disrepair. A follow up interview with the facility's Nursing Home Administrator on 8/10/2022 at 1:30 p.m. revealed he did not have any documentation to support fall floor mats were order recently. An e-mail communication provided by the DON on 08/10/2022 revealed follow-up for an order from one company, which included fall mats and was dated 06/23/2022. No additional attempts to obtain fall mats were provided. 105350 Page 2 of 5 105350 08/10/2022 Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to assess and develop care plan interventions for two (#64 and #26) of two residents who smoke. Findings include: During the entrance conference with the nursing home administrator (NHA) and the director of nursing (DON) on 08/07/22 at 09:36 a.m., the NHA stated the facility was non-smoking. The NHA stated there was only one resident [Resident #64] who only smokes when his family visits. During the facility entrance on 8/7/2022 at 8:55 a.m., an observation was made of the front covered patio and entrance to the building with three plastic chairs, a plastic table and a large [NAME]-[NAME] pot placed on the ground. The observations revealed numerous cigarette butts in the [NAME]-[NAME] pot. Further, there were several cigarette butts observed on the rocks and near a plant/bush, at and around the [NAME]-[NAME] pot. This pot with cigarette butts was still observed in the same place at 1:00 p.m. and again on 8/8/2022 at 7:40 a.m. Photographic evidence was obtained. On 08/07/22 at 11:17 a.m., Resident #64 was observed at the west nurse's station sitting on his walker. Resident #64 said to surveyor, are you the one who is taking me out to smoke? Staff F, licensed practical nurse (LPN) said to Resident #64, No, she is not the one. You will go, just wait. On 08/07/22 at 12:29 p.m., Resident #64 was observed with a cigarette in his left pocket at the west nurse's station. Resident #64 was heard asking if he can go out to smoke. Staff H, registered dietician (RD) said, you have to wait for your family. The NHA also said to the resident, I know you forget. Review of a resident face sheet for Resident #64 dated 08/09/22 showed the resident was admitted to the facility on [DATE] with diagnosis to include unspecified dementia without behavioral disturbance, and resided in the west wing, a secured unit which required staff to enter a pin code to exit / enter the secured unit. Review of a minimum data set (MDS) for Resident #64 dated 07/22/22, showed Resident #64 has a brief interview for mental status (BIMS) score of 11, indicating the resident is moderately impaired. On 08/08/22 at 12:08 p.m., Resident #64 was observed in his room having lunch. A cigarette was observed on the resident's nightstand. Resident #64 asked surveyor, are you taking me out to smoke? Resident #64 stated he hoped to smoke after lunch. On 08/09/22 at 02:04 p.m., Resident #64 was observed in his room napping. A cigarette was observed on the resident's nightstand. On 8/8/2022 at 3:00 p.m. Resident #26 was observed out in the front covered patio area, seated in his wheelchair and with his family member seated next to him. Resident #26 was observed positioned in his wheelchair facing the [NAME]-[NAME] pot, with the cigarette butts in it. He was observed smoking a cigarette and conversing with his family member. Resident was noted on facility property while smoking, and the [NAME]-[NAME] pot with the cigarette butts was also on the facility property. This 105350 Page 3 of 5 105350 08/10/2022 Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698

F 0656 was verified with interview with the maintenance director on 8/9/2022 at 8:00 a.m. Level of Harm - Minimal harm or potential for actual harm Review of a history and physical for Resident #26 dated 5/10/21 showed Resident #26 is a resident of this facility and smokes two cigars a day. A care coordination document dated 5/18/21 showed Resident #26 is identified as a smoker who smokes 1-5 cigarettes per day. Residents Affected - Few Review of a care plan for Resident #26 under smoking assessment showed a blank care plan without checkmarks documented to indicate Resident #26 was assessed for smoking abilities. On 08/09/22 at 02:18 p.m., an interview was conducted with the facility's receptionist. The receptionist stated she supervises the door all the time. Stated she does not know that any of the residents go out to smoke. The receptionist stated she does not remember the family members taking residents out and if they do, she does not know. On 08/09/22 at 04:25 p.m., Resident #64 wandered to the nurse's station and stated he would like a cigarette. Resident asked Staff G, registered nurse (RN) to take him out for a quick smoke. Staff G stated to the resident, you can only smoke with your family. Resident #64 appeared frustrated with the response and frowned his face. Resident #64 said, my family will not be here until Thursday, that won't work. Review of an admission nursing evaluation dated 6/2/22 showed Resident #64's speech is clear, speaks English, is always understood, and usually understands others. The cognitive assessment showed Resident #64 is alert and oriented. Under preferences / routines, Resident #64's smoking preferences were not checked. The Yes, No or need for smoking safety evaluation was not documented. An interview was conducted on 08/09/22 at 02:03 p.m., with Staff H, RD. Staff H stated she is familiar with the Resident #64 and works closely with him. Staff H said, the resident [#64] is a smoker, he goes out to smoke with his sister. They sit out in the front. On 08/09/22 at 04:39 p.m., an interview was conducted with Resident #64's assigned nurse, Staff I, LPN. When asked if Resident #64 smokes, Staff I stated, Yes. He is a smoker. Review of a psych health progress record dated 7/13/22 showed Resident #64 was evaluated as an active smoker. A physician visit record dated 7/6/22 under social history, tobacco use, showed Resident #64's smoking status identified as current, every day smoker. An activity progress note for Resident #64 dated 7/12/22 showed a new admit note indicating resident is a [AGE] year-old Caucasian male. He is alert and oriented with periods of confusion. He is ambulatory, pleasant, and cooperative . He enjoys sitting outside during the day and smoking. Review of the care plan for Resident #64 initiated 6/24/22 did not show any interventions in place related to smoking. The care plan review showed the facility did not have a plan in place or interventions to address the resident's desire to smoke or interventions for the frequent requests to smoke. On 08/10/22 at 08:50 a.m., an interview was conducted with the DON. The DON stated the admissions team member who screened the resident [#64] at the hospital did not report to the facility he was a 105350 Page 4 of 5 105350 08/10/2022 Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few smoker. Stated she is aware records indicated the resident is a smoker. Stated the first few weeks the resident was very sick and was not seeking tobacco. Stated after he cleared out, he started asking to smoke. Stated a family member was notified and they come and take him outside to have his cigarette. The DON stated she does not like the residents smoking upfront. The DON said, we do not want that. The DON agreed it was not fair to the resident who comes in and out of confusion, has a dementia diagnosis, not to have his tobacco or to wait until a family member can take him outside. The DON stated they will have a care plan meeting to address his [Resident #64] smoking needs. On 08/09/22 at 04:06 p.m., an interview was conducted with the NHA. The NHA stated the facility was non-smoking and they do not have a policy. NHA was notified of a large [NAME]-[NAME] pot full of cigarette butts that was observed on the front area. The NHA stated the cigarette butts belonged to the families or visitors. The NHA stated some families chose to have a cigarette with their residents. The NHA stated there were two residents who smoke in the facility premises under the supervision of their families, Resident #64 and #26. The NHA was asked if these residents were care planned to smoke within the premises. The NHA stated the family members are violating their policy. The NHA stated he has a designated smoking area for staff who smoke. The NHA stated facility smoking areas should have approved fire receptacles for disposal of cigarette butts. The NHA said, I get it. The resident [#64] should not be keeping cigarettes in his room. I guess I have to give them a 30-day notice. NHA stated if anyone was to be smoking cigarettes, they should be at a designated area with approved receptacles. The NHA re-stated the facility was non-smoking. Review of an undated facility policy titled, [name of facility] care center smoking policy showed it is the policy of the center to ensure residents who smoke do so in the safest manner. In order to ensure residents safety, the following procedures must be met: 1. Residents who smoke will be assessed for safety regularly by center staff. Review of a facility policy titled, care - planning - interdisciplinary team, revised February 2014, showed the facility's care planning / interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. 105350 Page 5 of 5