Inspection·June 4, 2021

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 record review, interviews, observation, and policy review the facility did not ensure a care plan was developed for wandering for one (#65) of 40 sampled residents, and the facility failed to implement the plan of care for seizure precautions for one (#49) of 40 sampled residents. Findings included: 1. On 6/02/21 at 8:55 AM, an interview was conducted with Resident #7. Resident #7 reported that Resident #65 goes in everybody's rooms, takes things, puts the items in her room, and the staff get the items back. Resident #7 said he has found Resident #65 laying in his bed. The staff just let her do whatever she wants. Resident #7 had not talked to anyone in the facility about it because he didn't know who to talk to. Resident #7 stated the staff all know about it, but he thinks they don't watch Resident #65 good enough because there is not enough staff. A review of Resident #65's admission record revealed a diagnosis of Alzheimer's disease. A review of the quarterly Minimum Data Set Assessment (MDS) dated [DATE] revealed a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment. Further review of the MDS, section E, behaviors, revealed wandering behaviors had occurred one to three days in the 7 day look back period. A review of Resident #65's care plan dated 3/15/21 revealed no evidence that a care plan for wandering behaviors had been developed. On 6/03/21 at 9:32 AM, Staff D, LPN (licensed practical nurse) MDS coordinator said, I don't see a wandering care plan. Social Services does the wandering care plans. I am not sure they do a care plan for the locked unit. On 6/03/21 at 9:42 AM, an observation was conducted on the Happy Trails secure unit. Resident #65 was not found in her room and could not be found anywhere in the hallway or common areas. Further observation revealed Resident #65 was in Resident #82's bed covered in blankets wearing her pajamas. On 6/03/21 at 9:47 AM, an observation and interview was conducted with Staff C, CNA (certified nursing assistant). Staff C, CNA said she has worked on the secure unit for five years. Staff C, CNA indicated Resident #65's room was not where Resident #65 was found by the surveyor. Staff C, CNA confirmed Resident #65 does wander. She said Resident #65 does have a wandering care plan, but she doesn't know what it is. Staff C, CNA also confirmed Resident #65 was in Resident #82's room in Resident #82's bed. Staff C, CNA said Resident #65 does it all the time. She wanders. Resident #65 also takes other residents' things sometimes. Staff C, CNA said, we try to redirect her. She takes shoes or blankets. None of the other residents have complained that she knows of. Staff redirect Resident #65 out (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 8 Event ID: 105455 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 105455 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/04/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Placid Health and Rehabilitation Center 125 Tomoka Blvd S Lake Placid, FL 33852 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)