Health inspection·February 27, 2025

F 0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Residents Affected - Few On 2/26/25 at 10:53 a.m., an interview was conducted with Resident #25, while seated in the main dining room. He said he was supposed to get double portions with his food items but has not been getting double portions. Resident #25 revealed he used to get four pieces of toast, then he got three, then two, and now he gets no toast at breakfast at all. He continued to say he only gets one scoop of eggs for breakfast as well and he is continually hungry and he keeps losing weight and is not getting double portions like he is supposed to. On 2/26/2025 at 11:30 a.m. the main dining room was observed for the lunch meal service. During the observation, there were approximately twenty residents seated at various tables, all being assisted by six staff members with their meal trays. Staff were observed removing meal trays from tray carts and placing the trays on tables in front of the residents. Staff were identified lifting lids to the trays and setting up the meal per resident choice and the need for assistance. At 11:38 a.m., Resident #25 was observed seated at a table and already received his lunch tray. Observations of his lunch tray included what appeared to be one small Salisbury steak patty covered with brown gravy, a small scoop of what appeared to be cheese potatoes, and six small carrot slices. Resident #25 also received two small plastic cups of red liquid juice and one plastic wrapped cookie. It appeared all the food items were a Regular texture base. Resident #25 did not receive double portions with any of the food items. Review of the lunch meal ticket positioned next to the resident's tray revealed, Double Protein, which was highlighted in yellow, and regular diet No Added Salt (NAS). The ticket did not have any dislikes noted. (Photographic Evidence Obtained) An interview was conducted on 2/26/25 at 11:42 a.m. with the CDM. She reviewed Resident #25's lunch meal ticket and plate of food and confirmed he should have received two pieces of the Salisbury steak and he did not. A review of Resident #25's medical record revealed he was admitted to the facility on [DATE]. Review of the admission diagnosis sheet revealed diagnoses to include but not limited to dementia and need for assistance with personal care. Review of Resident #25's February 2025 physician orders revealed the following: 1. Heart Healthy Diet, Regular Texture, Regular/thin consistency - Double Portion meat/entrée at each meal for diet, order date 1/9/25. Page 1 of 5 105350 105350 02/27/2025 Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698

F 0808 2. Med Pass 2.0 TID [three times a day] 120 ml [milliliters] record % consumed, order date 1/15/25. Level of Harm - Minimal harm or potential for actual harm Review of Resident #25's Progress Notes and Registered Dietician Assessment/Notes, with look back period from 11/27/24, revealed: Residents Affected - Few - A Weight Change Note dated 1/15/25 at 5:00 p.m., weight loss of 17% in 30 days. Diet is NAS regular, thin liquid. Will add Med Pass 2.0 supplements, 120 ml TID and also double portion meat/entre each meal. Will follow as need. - A Weight Change Note dated 2/24/205 at 2:15 p.m., weight has become more stabilized and is 186 lbs. Diet is NAS, regular, thin liquid. Double portion entree was added last month when he had weight loss. His BMI [body mass index] 25. - 7.5% lost. Med Pass 2.0 PO [by mouth] 120 ml TID was put in place due to weight loss he had last month. Will follow as need. On 2/26/25 at 2:20 p.m., an interview with the facility's Registered Dietician (RD), who has been employed as the RD for about 6 months. She revealed she was aware Resident #25's weight loss upon his readmission from the hospital on 1/8/25. She also revealed she had interventions to include double portions for protein as well as Med Pass three times a day to increase weight. She noted Resident #25 generally consumes 75 to 100% of meals and although Resident #25 has had some weight loss, she continues to monitor his weights and he is stable and within his BMI range. She continued to say she will keep Med Pass and Double Portions for him. The RD reviewed the photo of the resident's lunch meal and she confirmed he did not receive double portion for meat. She revealed he should have received two patties instead of one and the meal ticket also revealed, double portion. The RD confirmed the CDM and the tray line staff should have caught that today and followed the meal ticket/order. She revealed there are times she is at the tray line and she supervises and reviews tickets as to what is served on tray line. Review of Resident #25's current care plans, with a next review date 4/9/25, revealed the following: Resident has nutritional problem or potential nutrition problem of having unplanned weight loss with interventions in place to include but not limited to: Provide and serve supplement as ordered; Provide and serve diet as ordered (double portions entrée each meal); Monitor and record each meal; RD to evaluate and make diet changes as recommended and as need; Weigh per protocol. On 2/27/25 at 7:15 a.m. an interview and observation was conducted with the CDM in the facility kitchen, where she demonstrated the meal service process in the kitchen. Staff A, Cook, Staff B, [NAME] in training, Staff C, Dietary Aide, and the CDM, all were getting ready to plate and send out breakfast meal trays to residents. The CDM revealed either the day before or a couple of days prior, Staff A, [NAME] will receive paper meal tickets and place them in a pile on the steam table counter area. The CDM also revealed Staff A, [NAME] or whoever is the cook for the day will review each ticket one a time as the plate is being prepared. The CDM revealed the Staff A, [NAME] reads meal ticket and looks out for things to include the type of diet, type of texture, allergies, likes and dislikes, adaptive eating equipment, and also if double portions are ordered. She revealed if the meal ticket says double portions, the cook for the day will honor the meal ticket and plate as read. She revealed double portions would be defined as two times the normal scoop for soft food items and double portions of other items such as steak or chicken. For the breakfast meal, the double portion would be two 105350 Page 2 of 5 105350 02/27/2025 Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hard boiled eggs instead of one, a scoop size of six ounces of hot cereal instead of two, and double cups of liquid. Staff A, [NAME] confirmed the process the CDM explained and is the process he follows. The CDM further revealed when the meal tray is plated, the Dietary Aide, in this case Staff C, Dietary Aide, will review the meal ticket and plated food items for accuracy. Staff C, Dietary Aide confirmed she looks at all the food items on the meal tray and the meal ticket to determine if the cook provided the right diet and menu items. The CDM also revealed that she monitors the tray line for the breakfast and lunch meal service, many of the dinner meal services, and at times during the weekends. The CDM revealed the cook on assignment when she is not at the facility is the person who is responsible for reviewing the meal tickets and following them for accuracy. Further interview with Staff A, [NAME] and Staff C, Dietary Aide, who both worked on 2/26/25 in the kitchen, confirmed they did not know how several plates of food got out to residents that did not follow the meal ticket. Staff A, [NAME] and Staff C, Dietary Aide also confirmed they found out Resident #25 and a couple of other residents did not receive double portions as per their meal ticket order for the lunch meal service. The CDM also confirmed that should not have happened and she was not sure how the meal tickets were not followed. On 2/27/25, the Nursing Home Administrator, Director of Nursing, and the CDM all confirmed the facility did not have a Following/honoring meal tickets/diets policy and procedure for review. Based on observations, interviews, and record review, the facility failed to provide a therapeutic diet according to physician orders for two residents (#1 and #25) out of four residents reviewed. Findings included: 1. Review of Resident #1's admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of cerebral infarction due to embolism of left posterior cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, dysphagia following cerebral infarction, and altered mental status. An interview was conducted on 2/26/25 at 10:30 a.m. with Resident #1. He was observed sitting in the main dining room at a table watching television. He raised his hand and told Staff D, Certified Nursing Assistant (CNA) he wanted coffee and a snack. Staff D, CNA said I am going to get him a snack because he was in therapy during snack time. She was observed going to another room off the main dining area and obtained a soft cookie and placed it on the coffee cart. Staff D, CNA was overheard asking another staff member what Resident #1's diet was and the other staff member said he needed thickened liquids. Staff D, CNA prepared Resident #1s' coffee with nectar thickener and provided it to Resident #1. He did not receive a snack. An interview was conducted on 2/26/25 at 10:54 a.m. with Resident #1. Resident #1 was observed with no snack in front of him. He said, I haven't gotten my snack. She's giving me the run around. It's my snack and I want it, I'm hungry. 105350 Page 3 of 5 105350 02/27/2025 Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's February 2025 physician orders revealed an order with a start date of 2/25/25 and no stop date, NAS/CCD [no added salt/carb-controlled diet], pureed texture, Nectar/Mildly thick consistency. Double portion protein/entrée each meal. An interview was conducted on 2/26/25 at 11:26 a.m. with Staff D, CNA. She said for residents who are on pureed diets, they can have pudding for a snack. She said Resident #1 asked her for a snack a while ago but she was not sure what his diet order was. She said she could ask his nurse but she didn't want to leave all the residents in the dining area unsupervised. She said she could wait until he gets his lunch tray to see what kind of diet he has and then give him a snack at that time. She said to the resident's lunch will arrive at 11:30 a.m. A lunch observation was conducted on 2/26/25 at 11:35 a.m. Resident #1 was observed sitting in the main dining room with a plate of sliced carrots, a scoop of scalloped potatoes, and ground beef with gravy on it. An interview was conducted on 2/26/25 at 11:36 a.m. with Staff E, Registered Nurse (RN). She said she is in the dining room helping out because the other nurse was on break. She confirmed she gave Resident #1 his meal tray and she observed his lunch plate and said he received mechanical soft food, and she was not sure if it was double portions of protein or not. She obtained his meal ticket and confirmed the meal ticket said, Double protein mechanical soft with nectar thick liquids. An interview was conducted on 2/26/25 at 11:50 a.m. with the Director of Nursing (DON). She said speech therapy will assess a resident and make recommendations for their diet order and, I have to approve it, then nursing will put the order into the medical record and a dietary communication form is competed and given to someone in the kitchen, then we follow up with the Dietary Manager to ensure they are aware of the change in the diet order. An interview was conducted on 2/26/25 at 11:52 a.m. with the Dietary Manager. She said when a diet is changed a dietary communication form is filled out and given, to me, and I make sure the order is changed in the system. She said she also reviews residents' medical records every day, and sometimes twice a day, for any dietary changes. The Dietary Manager confirmed Resident #1 received a mechanical soft diet for lunch and confirmed she provided him with an extra portion of mechanically soft textured meat. She said she was not here yesterday (2/25/25) and was not aware Resident #1's diet changed to puree and said that was a problem. She asked Staff F, Corporate Traveling RN, if Resident #1 was on a puree diet and she said, yes, his diet was downgraded yesterday and Staff F, Corporate Traveling RN told the dietary manger to get the Speech Therapist to sit with the resident. An interview was conducted on 2/26/25 at 11:59 a.m. with the Speech Therapist. She said Resident #1 was at high risk for aspiration and he was on a mechanical soft diet with thickened liquids, but she trialed him with a peanut butter and jelly sandwich yesterday (2/25/25) and he immediately started coughing, so she downgraded his diet to puree because she didn't want him on a mechanical soft diet and someone giving him a sandwich because of his risk for aspiration. She said when she changed his diet, she filled out the diet change slip and gave it to, a guy in the kitchen. She said Resident #1 does well when his food is all mixed together and when he eats, he automatically mixes it all together. She said he is a resident who will eat anything and everything and you have to watch out for him because he is on a pureed diet but he will eat anything. Review of Resident #1's physician notes dated 2/24/25 revealed .Dysphagia following cerebral 105350 Page 4 of 5 105350 02/27/2025 Lake Haven Nursing and Rehab Center 1351 San Christopher Dr Dunedin, FL 34698

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few infarction ST [speech therapy] to following - discussed with ST, will maintain puree diet at this time on pureed diet with moderately thick liquid Nursing to assist with feeds as needed. A follow up interview was conducted on 2/26/25 3:38 p.m. with the Dietary Manager. She said the dietary electronic system is different from the medical record, so in order for diets to get updated on the meal tickets she relies on the dietary change forms, and she did not receive a dietary change form for Resident #1. She said someone handed the dietary change form to the dishwasher yesterday and from there the form is missing and the dietary system did not get updated. 105350 Page 5 of 5