Health inspection·November 18, 2021

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to ensure that dignity was maintained related to catheter care for one resident (#374), of 10 residents sampled. Residents Affected - Few Findings Included: On 11/15/21 at 10:44 a.m., an interview was conducted with Resident #374. She was observed sitting in her wheelchair with a [urinary] catheter bag containing amber colored urine, attached to the back of the chair. The [urinary] catheter bag was observed without a privacy bag. Photographic evidence obtained. On 11/16/21 at 11:08 a.m., an observation of Resident #374 was made. Resident #374 was in bed with room door open. The [urinary] catheter bag containing amber colored urine, was observed from doorway, without a privacy bag. Photographic evidence obtained. On 11/17/21 at 9:09 a.m., an observation of Resident #374 was made. Resident #374 was sitting in her wheelchair with the room door open. The [urinary] catheter bag containing amber colored urine, was observed hanging from the back of her wheelchair. The [urinary] catheter bag was observed without a privacy bag. Photographic evidence obtained. On 11/17/21 at 9:11 a.m., an interview was conducted with Licensed Practical Nurse (LPN), Staff J. She stated the expectation was that the [urinary] catheter bag should be under the chair and in a privacy bag. Ultimately, the responsibility would be on the nurse to make sure that the [urinary] catheter bag was contained in a privacy bag. Certified Nursing Assistants (CNA)'s can put the privacy bags on. When she gave Resident #374 her medication today, she was in bed. She had not seen Resident #374 since she was up in her wheelchair, so she did not notice that she did not have a privacy bag. The privacy bags were kept in the storage area, inside the shower room and in the medication room. On 11/17/21 at 9:19 a.m., an interview was conducted with Staff H. She stated that the [urinary] catheter bag should have been covered for dignity, when a resident was in bed or in the chair. The privacy bags were stored in the central supply room, near the nurses' station. Privacy bags were also kept in the shower room. On 11/17/21 at 9:22 a.m., a follow up interview was conducted with Staff J. She stated that she fixed the tubing and placed Resident #374's [urinary] catheter bag in a privacy bag. The [urinary] catheter bag was observed inside a privacy bag underneath Resident #374's wheelchair. On 11/17/21 at 2:44 p.m., an interview was conducted with the Director of Nursing. She stated that Page 1 of 26 105620 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the [urinary] catheter bag should have been covered with a fig leaf (covering for [urinary] catheter bags). If the [urinary] catheter bag did not have a leaf, the [urinary] catheter bag should be kept inside a privacy bag. If a resident was in bed, it would be acceptable to have a [urinary] catheter bag on the window side of the bed. Although, she would prefer that the [urinary] catheter bag be placed inside a privacy bag. The privacy bags were in central supply and all staff were responsible if they noticed a resident without one. It was predominately the responsibility of the CNA. If she (The DON), noticed a resident without a privacy bag, she would put the privacy bag on herself. On 11/17/21 at 3:24 p.m., an observation was made of Resident #374. Resident #374's room door was open, she was in bed, and the [urinary] catheter bag, containing amber colored urine was observed from the door. Photographic evidence obtained. A review of Resident #374's medical record revealed an initial admission date of 11/08/21 with a diagnosis of obstructive and reflux Uropathy. A review of Resident #374's current orders revealed, [urinary] catheter care to be performed every shift. Monitor [urinary] catheter output every shift. Irrigate catheter with 30 milliliters of normal saline if clogged. Change [urinary] catheter drainage system (tubing and/or bag), change PRN (as needed) based on clinical indications such as infection, obstruction, or when the closed system is compromised. Current medications include Furosemide Tablet 20 milligrams, give 1 tablet by mouth one time a day for edema. A review of the most recent Minimum Data Set (MDS) Assessment, Section C: Cognitive Patterns dated 11/10/21, revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. A review of Resident #374's, most recent care plan dated 11/09/21, revealed a focus area for [urinary] catheter. A goal of the catheter to remain patent (unobstructed) and intact until next review. Interventions include leg bag when appropriate, provide catheter privacy bag. A review of the facility policy tiled Quality of Life-Dignity revised 02/2020, revealed, under the heading Policy Interpretation and Implementation 11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example: a) Helping the residents to keep urinary catheter bags covered. 105620 Page 2 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the Nursing Home Transfer and Discharge Notice form was provided to the appropriate parties and failed to ensure that the State Long-Term Care Ombudsman received a copy/notification of the Nursing Home Transfer and Discharge Notice for two (#95, #44) of three residents reviewed for admission, transfer, and discharge rights. Findings included: 2. A review of Resident #95's clinical record revealed she had been discharged from the facility to the hospital on [DATE] and 11/15/21. On 11/18/21 at 1:16 p.m., Staff B, Social Service Director provided the Nursing Home Transfer and Discharge Notices for 09/21/21 an 11/15/21. Review of the notices revealed no resident or representative signatures indicating receipt of the notice and no signatures in the fields at the bottom of page 2 of either notice that notices were provided to the resident or representative. An interview was conducted with Staff B on 11/18/21 at 1:43 p.m. He confirmed that they were not signed by the resident or representative and said they appeared to him as though they had not been presented or signed. He said he had not found any evidence in any facility files that the notices had been mailed to the resident or representative. An interview was conducted with the Director of Nursing (DON) on 11/18/21 at 2:20 p.m. She stated that the process for presenting transfer and discharge notice was first to present to the resident if they were cognitively alert. She said if the resident was cognitively impaired the process was for two nurses to sign the form and we should give (the form) to responsible party and if not present we would mail to them. She confirmed that the notices for Resident # 95 did not have any signatures from the resident or representative indicating receipt or indicating they had been mailed. She said there was a breakdown in the system and said, I think the breakdown is education between me to nursing and social services. She said, whenever the nurses do them (transfer and discharge notices) on the floor they were giving them directly to the patient. What the nurses had been doing was sending them in the discharge packet with the resident. The DON said the facility expectation for process with transfer discharge notices was that if it was initiated on the floor the expectation was for the nurse to give the notice to the responsible party if present. If the responsible party is not there, the nurse should put the notice in the chart and then in morning meeting we will go through the chart and give the notice to social services to mail. She said, I think the breakdown is with the social worker [Staff C]. I don't think she was understanding that when I give them [the transfer/discharge notices] to her in the morning meeting that I mean for her to mail them to the responsible party. Review of facility policy titled Transfer or Discharge Notice revised December 2016 revealed that written notice of transfer or discharge was required to be given in writing to the resident or representative as soon as practicable but before the transfer or discharge including for circumstances of immediate transfer or discharge required by a resident's urgent medical needs. 1. A review of Resident #44's Electronic Medical Record (EMR) revealed the resident was admitted to the facility on [DATE] and had an unplanned transfer to an acute care center on 10/15/21. The resident was readmitted to the facility on [DATE]. A review of the facility's Nursing Home Transfer and Discharge Notice revealed a date the notice was given as 10/15/21, the effective date was not decipherable. Page 2 of the Nursing Home Transfer 105620 Page 3 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and Discharge Notice under the section that required signatures of the physician was blank. In addition, the section indicating, Notice received by; Resident or Representative Name, were blank. Further review of the section on the page 2 of the document indicating, Notice provided to the following, Resident, Legal Guardian, and/or Representative, Long-Term Care Ombudsman Council reflected no signatures. On 11/18/21 at 2:11 p.m., a telephone interview was conducted with Resident #44's responsible party. She stated that she received a call related to the bed hold related to Resident #44's transfer to the acute care center, but she denied receiving the Nursing Home Transfer and Discharge notice. On 11/18/21 at 3:06 p.m., in an interview with the DON, she stated the facility had no evidence that Ombudsman and Resident's responsible party received the Nursing Home Transfer and Discharge Notice. She stated that there was a breakdown of communication between the social service and nursing department. 105620 Page 4 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that at the time of transfer of a resident to the hospital or therapeutic leave, the Resident/Representative was provided with a written notice that would indicate the duration of a bed-hold for one (Resident #95) of three residents reviewed for admission, transfer, and discharge rights. Findings included: A review of Resident #95's clinical record revealed she had been discharged from the facility to the hospital on [DATE] and 11/15/21. On 11/18/21 at 1:16 p.m., the Social Service Director, Staff B provided the bed hold notices for 09/21/21 and 11/15/21. Review of the notices revealed no resident or representative signatures indicating receipt of the notices. An interview was conducted with Staff B on 11/18/21 at 1:43 p.m. He confirmed the bed hold notices were not signed by the resident or representative and confirmed that the signatures that were present on the form belonged to facility staff. He said he had not found any evidence in any facility files that the notices had been mailed to the resident or representative. An interview was conducted with the Director of Nursing (DON) on 11/18/21 at 2:20 p.m. She stated that the process for presenting bed hold notices was first to present to the resident if they were cognitively alert. She said if the resident was cognitively impaired the process was for two nurses to sign the form and we should give (the form) to responsible party and if not present we would mail to them. She confirmed that the bed hold notices for Resident # 95 did not have any signatures from the resident or representative indicating receipt or documentation indicating they had been mailed. She said there was a breakdown in the system and said, I think the breakdown is education between me to nursing and social services. She said, whenever the nurses do them [bed hold notices] on the floor they are giving them directly to the patient. What the nurses have been doing is sending them in the discharge packet with the resident. The DON said the facility expectation for process with bed hold notices was if initiated on the floor, the expectation is the nurse gives to responsible party if there or if not there, they should put in the chart and then we in morning meeting go through and give to social services to mail. She said, I think the breakdown is with the social worker [Staff C]. I don't think she was understanding that when I give them [bed hold notices] to her in the morning meeting that I mean for her to mail them to responsible party. An interview was conducted with Staff B on 11/18/21 at 1:59 p.m., and he said there was no specific facility policy on bed hold notices: the notice served as the policy. 105620 Page 5 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, observations, and policy review the facility did no ensure weight loss was identified and addressed in a timely manner for two residents (#47 and #224) of six residents sampled for nutrition. Residents Affected - Few Findings included: 1. Resident #47 was admitted to the facility with a diagnosis of right femur fracture, according to the face sheet in the admission record. A review of the Minimum Data Set (MDS) assessment dated [DATE], reflected a Brief Interview for Mental Status (BIMS) score of 14, indicating his cognition was intact. A review of Section K, Swallowing/Nutritional Status, reflected a weight of 238 pounds. Review of the physician's orders in the electronic medical record reflected a diet order dated 8/13/21, Regular diet, regular texture. Review of the weight record in the medical record showed the following weights: 8/13/21 238 lbs. (pounds) 9/5/21 237 lbs. 9/16/21 216 lbs. 10/7/21 221 lbs. 10/14/21 225 lbs. A warning indicated a 5% weight loss in 30 days. 11/4/21 201 lbs. A warning indicated a 10% weight loss since the admission weight on 8/13/21, less than three months after admission. A review of the Nutrition assessment dated [DATE] revealed under 13. Assessments/comments, Appetite has improved since admission. Lab data show hypoalbuminemia and decreased Hgb (hemoglobin) level by which is recommended a supplementation of Mighty shake 4 oz (ounces) a day, plus multivitamin daily. Further review of the electronic medical record reflected no further nutrition or dietary assessments or evaluations. A review of the progress notes in the medical record revealed there were not any progress notes identifying the weight loss. A review of the care plan dated 8/13/21 revealed Resident #47 was on a therapeutic diet. The only intervention was to discuss with the resident and/or responsible party the importance of adhering to proper diet. There was also no other care plan or interventions identifying weight loss. 105620 Page 6 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 11/15/21 at 1:31 p.m., an interview was conducted with Resident #47. He said the food was not good. He had complained to staff, and a staff member told him they would send in the dietician, but no one ever came. He said the only alternative was a peanut butter and jelly sandwich. Everybody complained about the food. He had lost weight because the food was so bad. On 11/17/21 at 1:09 p.m., a follow up interview was conducted with Resident #47. He said they did not provide a menu or offer him food choices. On 11/17/21 at 2:19 p.m., an interview was conducted with the Registered Dietician (RD). She said she worked full time at the facility. The nutrition assessment was every three months, so Resident #47 would be reviewed in the quarterly care plan meeting. The RD confirmed there were no progress notes, assessments, or evaluations indicating the weight loss was identified or addressed. 2. Review of the face sheet in the admission record for Resident #224 revealed he was admitted to the facility with a diagnosis of cerebral infarction (stroke) and Type II diabetes mellitus. A review of the MDS assessment in the electronic medical record dated 10/21/21, reflected a BIMS score of 11, indicating some cognitive impairment was present. Review of Section K, Swallowing/Nutritional Status, reflected a weight of 239 pounds. Review of the physician's orders revealed a diet order dated 10/14/21, CCHO (consistent carbohydrate) diet, mechanical soft/easy to chew texture. A review of the weight record reflected the following findings: 10/15/21 240 lbs 10/17/21 239 lbs 10/21/21 239 lbs 11/7/21 226 lbs a weight change warning indicated a 5.9% weight loss since 10/15/21. 11/14/21 220 lbs a weight warning indicted an 8.3% weight loss since 10/15/21 or 30 days. Review of the Nutrition assessment dated [DATE], revealed 13. Assessment/comments, showed Resident #224 had a good appetite and was tolerating well a CCHO soft mechanical diet and eating 75-100% of the meals. It was recommended to continue with the correct diet. There were no further progress notes, assessments or evaluations that addressed the weight loss. An observation was conducted on 11/17/21 at 12:55 p.m. with the resident's CNA (Certified Nursing Assistant), Staff F. The lunch meal tray was in the room on the dresser. The apple sauce was eaten, but nothing else on the plate had been touched. An interview was conducted with Staff F, CNA during the observation. She said he did not want anything else. On 11/17/21 at 1:50 p.m., an interview was conducted with the CDM (Certified Dietary Manager) and RD. The CDM said they visit the residents and the residents let us know their dislikes and we put it 105620 Page 7 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on their meal ticket. The RD said she did a nutritional assessment within twenty-four to thirty-six hours after they were admitted . If they tell me their food preference I change it. If they tell the nurse she can change it. It is updated as necessary. The CDM said, If the residents get something they don't like on the tray like beets, then the CNA can put it on the meal ticket and we will change it in the system. There is an extension the residents can call for the menu. When we visit them we let them know. The CNAs remind them about it when they are serving the meals. The staff do angel guardian rounds in the morning. They get an update from the residents. Any concerns are noted in the rounds. The CNAs get input from the residents also. The CDM said, The CNAs let the residents know what is being served for lunch or dinner, and they take their preference and let the dietary department know what they would like. We get quite a few residents who call and let us know. The RD stated, It is a new system. We started it about three weeks ago. We are still learning the system. The CNAs tell the dietary department the residents' choices. We are not at 100% effectiveness. Residents who are disoriented get help from staff who see what they do not like and communicate that to us. The RD said she reviewed resident weights and nutritional status weekly. She stated that she documented it in progress notes. She had not reevaluated Resident #224 this month yet. They were evaluated quarterly. Weight loss would trigger in the system. The system alerted for five percent weight loss in thirty days or ten percent in six months. The weight loss triggered in the system and she could do a report. The RD said she was still in the process of evaluating Resident #224's weight. She reviewed him weekly. It was a possibility that someone put in the wrong data. It was a possibility the first weight was not correct. She said she was in the process of checking. She had not gotten to Resident #224 yet. On 11/17/21 at 3:15 p.m., an interview was conducted with the DON (Director of Nursing) who confirmed there were no progress notes for indicting the weight loss was identified for the residents. The DON said they reviewed weights monthly. The November weights were just put in so we would review them Thursday. A follow up interview was conducted with the DON on 11/17/21 at 4:43 PM. Upon admission a nutritional assessment is done, and quarterly. For weight losses, we do monthly weights or weekly weights, and discuss them in our monthly weight meeting. The dietician would monitor the alerts. The policy says the RD will review assigned unit resident weights by the fifteenth of the month for monthly weights, weekly for weekly weights, and as needed. Our monthly weights are between the first and the seventh; the first week of the month. In the monthly weight meeting the unit managers, myself, the dietician, and the ADON (assistant director of nursing) discuss the weights. Policy and Procedure: Weight and Height Measurement and Response Protocol (Created 08/2021) Policy Statement The interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss and gain for our residents. Policy Interpretation and Implementation Weight Measuring and Response 7. The Rd will review assigned unit resident weights by the 15th of the month for monthly weights, weekly for weekly weights, and as needed to follow individual weight trends overtime. 105620 Page 8 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8. Significant and/or severe weight difference is either desirable/undesirable at any given time frame including significant and/or severe weight loss and gain a 5% or more in one month, 7.5% or more in three months, and 10% or more in six months since the last weight will be remeasured the next day for confirmation by nursing. If the wait is verified nursing will immediately notify the registered dietitian (RD) verbally and/or in writing of the weight change. Nursing notification will be documented in the progress notes in the electronic medical record. 9. The RD will respond to the weight changes by completing an assessment note of the significant and/or severe weight change including desirable/undesirable and update the comprehensive care plan. The RD will also notify the resident and/or resident representative, and interdisciplinary team (physician, nursing, social services, etc.) of findings and recommendations. The RD will complete this within 48 to 72 hours upon receipt of notification from nursing regarding significant and/or severe weight change. Assessments and Analysis 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight.) b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake. c. The relationship between current medical condition or clinical situation and recent fluctuations in weight. d. Whether and to what extent weight stabilization or improvement can be anticipated. 2. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss/gain, or increasing the risk of weight loss/gain. For example: a. cognitive or functional decline. b. chewing or swallowing abnormalities. c. pain. d. Medication related adverse consequences. E. Environmental factors such as noise or distractions related to dining. F. Increased decreased need for calories and or protein. g. Poor digestion or absorption. H. Fluid and nutrient loss. 105620 Page 9 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0692 I. Inadequate availability of food or fluids. Level of Harm - Minimal harm or potential for actual harm Care planning 1. Residents Affected - Few Care planning for a significant/severe weight loss/gain undesirable/desirable or impaired nutrition will be a multidisciplinary effort and will include the physician, RD, nursing staff, consultant pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans will address to the extent possible: A. The identified cause of weight/loss gain. B. Goals and benchmarks for improvement/stabilization. C. Time frames and parameters for monitoring and reassessment. Interventions 1. Interventions for desirable/undesirable significant, severe weight loss/gain shall be based on careful consideration of the following: A resident choice in preferences. B. Nutrition and hydration need of the resident. C. Functional factors that may inhibit independent eating. D. Environmental factors that may inhibit appetite or desire to participate in meals. E. Chewing and swallowing abnormalities and the need for diet modifications. F. Medications that may interfere with appetite, chewing, swallowing, or digestion. G. The use of nourishments first before consideration of supplementation, enteral feeding, and medications. H. End of life decisions and advance directives. 2. The RD will discuss desired/undesired significant/severe weight loss/gain with the resident and or family, and interdisciplinary team. 105620 Page 10 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Interventions for desired/undesired significant/severe weight loss/gain should consider resident preferences and rights. A weight loss gain regimen should not be initiated for a cognitively capable resident without his or her approval and involvement. 4. If a resident declines to participate in a weight loss/gain goal, the RD will respect those wishes, reapproach at a later date or at the next assessment period, unless resident states otherwise, and document the residents wishes/preferences in the electronic medical record. 105620 Page 11 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based and observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for three (Residents #65, #68 and #176) of 18 sampled residents related to the use and storage of oxygen masks and tubing. Residents Affected - Few Findings included: 1. Review of Resident #176's medical record revealed that she was admitted to the facility on [DATE] and had diagnoses that included acute systolic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease with acute exacerbation, moderate persistent Asthma, and solitary pulmonary nodule. Observations of Resident #176 on 11/15/21 at 12:45 p.m., revealed that she was sitting up in her wheelchair next to her bed with oxygen (O2) running via nasal cannula. Closer observations revealed the oxygen tubing lying across the floor. Continued observation of the resident's room at this time revealed that the resident had a night stand next to her bed close to the window. It was noted that the resident had a Continuous Positive Airway Pressure (CPAP) mask sitting on the night stand un-bagged and unlabeled. (Photographic Evidence Obtained) On 11/16/21 at 8:51 a.m., an observation of the resident revealed that she was sitting up in her wheelchair next to her bed with O2 running via nasal cannula, and eating her breakfast. The resident reported that her nose was bleeding and had put on the light for the nurse. Closer observations revealed that the oxygen tubing was lying across the floor. The nurse entered the resident's room and checked the resident's concentrator. She picked up the oxygen tubing off the floor, passed the tubing across her hands checking for kinks, laid the tubing back down on the floor, and reported that the the concentrator was set appropriately. She proceeded to assist the resident with her nose bleed then washed her hands and left the room. Continued observation of the resident's room at this time revealed that the residents CPAP mask was sitting on the night stand un-bagged and unlabeled. (Photographic Evidenced Obtained) Observations of Resident #176 on 11/17/21 at 8:25 a.m., revealed her sitting up in her wheelchair. It was noted that the resident's O2 tubing was lying across the floor and that her CPAP mask was sitting on top of her night stand un-bagged and un-labeled (Photographic Evidence Obtained). Interview with Resident #176 at this time revealed that the CPAP machine at her bedside belonged to her and machine and mask had been sitting on the night stand since admission. She reported that it had not been cleaned since her admission. In an interview on 11/17/21 at 8:43 a.m. with Staff H, Certified Nursing Assistant (CNA), she said she was assigned to the resident and that oxygen tubing should never be on the floor. She said if the tubing was on the floor, the nurse needed to be notified so that it could be changed. She reported that if the resident had an O2 mask or a CPAP mask and it was not in use, the mask and excess tubing should be in a bag. In an interview on 11/17/21 at 8:47 a.m., Staff A, Licensed Practical Nurse (LPN) revealed that oxygen tubing should never be on the floor and CPAP masks should be bagged when not in use. During an observation of the resident's room with Staff A present, she confirmed that the oxygen tubing was on the floor and it should not be, and confirmed that the CPAP mask was un-bagged, and was unsure of why and did not know where the bag went. 105620 Page 12 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0695 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/17/21 at 8:58 a.m. with the Director of Nursing (DON), she revealed that O2 tubing should be bagged when not in use, tubing was allowed to be on the floor, as long as the nasal cannula did not touch the floor. She reported that she would not expect tubing on the floor if the resident was seated in the wheelchair. She reported that her expectation was that the CPAP mask should be bagged when not in use. Residents Affected - Few 2. A review of Resident #65 Admissions Record revealed that she was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included acute respiratory failure with hypoxia, pneumonia, and chronic obstructive pulmonary disease. On 11/16/2021 at 9:05 a.m. during an interview with Resident #65, a nebulizer canister attached to a tubing and aerosol mask was observed lying on the nightstand without being covered or bagged. Resident # 65 stated that the night shift nurse administered the nebulizer treatment, this morning. A review of the resident's Electronic Medical Record (EMR) revealed a physician order for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg (milligram)/3 ml(milliliter) inhale orally every 6 hours for COPD (chronic obstructive pulmonary disease), order date 9/6/2021. A review of Resident #65 Annual Minimum Data Set (MDS) conducted on 8/28/21, documented in Section C, Cognitive Patterns, revealed a Brief Interview Mental Status (BIMS) score of 14 that indicated her cognition was intact. On 11/16/21 at 9:33 a.m., an interview was conducted with Staff I Licensed Practical Nurse (LPN). She stated that after the used or when Resident #65's breathing treatment was completed, the nebulizer canister and aerosol mask should have been stored in a plastic bag. Staff I confirmed that not properly storing the canister and aerosol mask, is an infection issue. On 11/17/21 8:59 a.m., during an interview the DON, she stated that it was her expectation that all tubing, canisters and aerosol masks be properly stored or bagged when they were not in used. She concurred that the nebulizer canister, and aerosol mask should have been stored in a plastic bag. A review of the facility policy titled, Department (Respiratory Therapy)- Prevention of Infection, with a revise dated of November 2011. Under the subheading Infection control Consideration Related to Medication Nebulizers/ Continuous Aerosol #7 showed: Store the circuit in plastic bag, marked with date and resident's name, between uses. 3. A review of Resident #68 Admissions Record revealed that she was originally admitted to the facility on [DATE] and readmitted on /03/2020, with diagnoses that included portal hypertension, dementia with lewy bodies, hepatic failure, hereditary neuropathy, and alpers disease. On 11/16/21 at 10:02 a.m., Resident # 68 was observed lying in bed. Her CPAP machine was observed on the nightstand with the mask laying on the nightstand uncovered or properly stored. A review of resident #68 care plan revealed focused areas of: (Resident #68) is at risk for / has actual alterations in cardiac function, anemia, hypertension, portal HTN (hypertension) hyperlipidemia, dyspnea. Interventions included: CPAP at bedtime, remover in AM (morning) use home setting for dyspnea. 105620 Page 13 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident #68 annual Minimum Data Set (MDS) dated [DATE], documented in Section C, Cognitive Patterns, revealed a Brief Interview Mental Status (BIMS) score of 10 which indicated that her cognition was moderately impaired. On 11/16/21 at 10:02 a.m., an interview with conducted with Staff I Licensed Practical Nurse (LPN). She stated that Resident #68's CPAP mask should have been stored properly after it was removed. Staff I stated that not storing the CPAP mask in a bag after use is an infection issue. On 11/17/21 8:59 a.m., during an interview the DON she stated that it was her expectation that the CPAP mask was stored properly or bagged when it was not in used. She confirmed that the CPAP mask should have been stored in a plastic bag. 105620 Page 14 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility did not ensure two (Residents #123 and #225) of five residents reviewed for medication availability, received their physician ordered medications. Findings included: A review of the face sheet in the admission record for Resident #123 revealed an admission diagnosis of respiratory failure with hypercapnia and COPD (chronic obstructive pulmonary disease). An observation was conducted on 11/16/21 at 9:34 a.m. during medication administration with Staff A, LPN (licensed practical nurse) for Resident #123. During the observation an interview was conducted with Staff A, LPN who stated that there was an inhaler, Wixela, being sent for Resident #123 after the insurance approved it. It had not arrived yet. Staff A, LPN said the Wixela inhaler was ordered on the tenth. She said the insurance had to approve it. Staff A, LPN said she was not sure if Resident #123 had it and it ran out. But it was ordered the ninth. This inhaler takes awhile. She did not know the reason. A review of the physician's orders in the electronic medical record revealed the following findings: 11/10/21 Wixela inhub 250/50 mcg/dose 1 puff inhale orally two times a day for COPD. A review of the medication administration record (MAR) revealed the Wixela was not administered for seven days; from 11/10/21 to 11/16/21. The boxes for the sign off of the medication indicated codes 9 or 5. Review of the codes on the MAR revealed 5 was Hold, see nurse notes, and 9 was other/see nurse notes. A review of the progress notes in the medical record showed nursing documented the Wixela inhaler was unavailable or on order from the pharmacy from 11/10/21 to 11/15/21. None of the notes indicated the physician was notified. At 10:02 a.m. on 11/17/21, an interview was conducted with the DON (Director of Nursing), who confirmed the Wixela had not been administered. She also confirmed the nurses needed to notify the physician. There should be a progress note. The DON also confirmed there were no notes indicating the physician was aware. The DON said Staff A, LPN told told her she called the pharmacy yesterday to see where it was at. I get alerts for high cost medications, and I approved that one on the ninth. I will have to call the pharmacy to see why they haven't sent it. She said no one informed her the medication had not been sent. On 11/18/21 at 12:32 p.m., a telephone interview was conducted with the consultant pharmacist. She said the Wixela was a corticosteroid so it took a week to get the benefit. If the resident was without it two days it would still be in their body. They need the medication. If the patient was not showing any signs of breathing difficulty, then there was no outcome. It took a week to get rid of the drug from the body. The outcome would depend on the clinical signs. The consultant pharmacist said she could not say it was an adverse event. She had seen it prescribed as needed too. It would depend on what the doctor ordered. 105620 Page 15 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0755 Level of Harm - Minimal harm or potential for actual harm Resident #225 was admitted to the facility on [DATE] with diagnoses including chronic atrial fibrillation (afib), and COPD, according to review of the face sheet in the admission record. An interview was conducted with Resident #225 on 11/15/21 at 12:13 p.m. He said it took two weeks to get his medications straightened out. Residents Affected - Few Review of the physician's orders in the electronic medical record for Resident #225 showed the following: 10/12/21 Bictagravir-Emtricitab-Tenofov tablet 50-200-25 mg give 1 tablet by mouth one time a day. Combivent Respimat aerosol solution 20-100 mcg/act 1 puff inhale orally four times a day for COPD 10/11/21 Flecainide acetate tablet 50 mg give 0.5 tablet by mouth every 12 hours for Afib 10/12/21 Metoprolol succinate ER (extended release) tablet 24 hour 25 mg give 1 tablet by mouth one time a day for htn (hypertension) A review of the MAR in the electronic medical record revealed the following findings: 10/12/21 Bictagravir-Emtricitab-Tenofov tablet 50-200-25 mg give 1 tablet by mouth one time a day. The medication was not signed on 10/12 and the nurse signatures in the check off boxes were coded with a 9 on 10/13, 10/14, 10/15, 10/16, 10/17, 10/19, and 10/20. The box was not signed on 10/21. Further review of the MAR showed that Resident #225 did not receive any of his ordered medications on 10/12/21. Additionally the Spiriva respimat inhaler was not given on 10/13/21 or 10/25/21, indicated by a code 9. A review of the chart codes on the MAR revealed 9 meant Other/see nurse notes. A review of the progress notes in the medical record for the month of October showed the Bictagravir-Emtricitab-Tenofov tablet was unavailable on 10/12/21. There were no other notes about the rest of his medications that had not been given on 10/12. There were no notes for Bictagravir-Emtricitab-Tenofov tablet on 10/13/21. A note dated 10/14/21 indicated the pharmacy technician was notified and stated medication was in route. A subsequent note indicated the unit nurse was notified. Another note dated the same day, 10/14/21, revealed the Bictagravir-Emtricitab-Tenofov tablet was not in the electronic medication dispenser and the pharmacist said it would be sent tonight. A note dated 10/15/21 revealed Spiriva respirimat aerosol inhaler was unavailable. A note dated 10/16/21 indicated a medication was special and was not available in the electronic medication dispenser (EDK) emergency drug kit. There was no indication of what the medication was or that the physician or pharmacy were notified. An eMar note dated 10/17/21 indicated medication not available. The 10/18/21 note revealed the Bictagravir-Emtricitab-Tenofov tablet was signed accidentally but not given. The medication could not be pulled and was currently not available. Awaiting delivery from pharmacy. There were no further notes indicating the physician, DON, or pharmacy were notified. On 11/17/21 at 9:54 a.m., an interview was conducted with the DON. The DON said that when the patients were admitted the medications were the first thing the nurses input. The pharmacy received them as soon as they were put in. Some medications had to be sent by the pharmacy, but most of the medications were in the electronic EDK (emergency drug kit). The medications in the electronic EDK were 105620 Page 16 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0755 Level of Harm - Minimal harm or potential for actual harm routine medications. The pharmacy normally sent the medications within twenty-four hours. Resident #225 was admitted on 10/11. The DON said, It looks like there is a hole on 10/12. It's not clicked off by the nurse. Most of the medications start date was 10/12. The Spiriva was discontinued and started on the thirteenth. Most of them were started 10/12. She said she was not aware he was not getting his medications. She said It looks like the nurse just didn't click off on them. Residents Affected - Few In a follow up interview with the DON on 11/17/21 at 11:36 a.m., the DON said, I ran a medication variance report and notified the doctor. The doctor gave no new orders. She said she started some education on pulling medication from the electronic EDK and if the medication was not there, the nurses needed to notify the physician. On 11/18/21 at 12:23 p.m., a telephone interview was conducted with the consultant pharmacist. The consultant pharmacist said the facility should be calling the pharmacy and finding out why the resident was not getting the medication. She said, the nurse enters the order and on the next run or the next day, the order is delivered. If a medication is expensive and not covered, the DON needs to approve that. I don't know if they aren't calling the pharmacy. I am not sure of the reason. The nurse should be calling to get the medication. They shouldn't be waiting three or four days before they call us. They need to find out what the issue is about the specific product. I don't think two days would cause an adverse effect. We would look at the labs. There is probably not an outcome. They need to be finding out what the issue is. I don't know why they are not calling. 105620 Page 17 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for one (Resident #123) of four residents with twenty-seven opportunities observed during medication administration, resulting in a medication error rate of 7.41%. Residents Affected - Few Findings included: A review of the face sheet in the admission record for Resident #123 reflected an admission diagnosis of respiratory failure with hypercapnia and COPD (chronic obstructive pulmonary disease). An observation was conducted on 11/16/21 at 9:34 a.m., during medication administration with Staff A, LPN (licensed practical nurse). During the observation, an interview was conducted with Staff A who stated that there was an inhaler, Wixela, being sent for the resident after the insurance approved it. It had not arrived yet. Staff A prepared medications for Resident #123. After knocking on the door and announcing herself, Staff A put on a pair of gloves and gave Resident #123 her pills with water. Next, Staff A removed a small volume nebulizer (SVN) mask from a bag dated 11/15/21 and squeezed the contents of the syringe into the chamber, containing ipratropium bromide and albuterol 0.5/2.5 mg/3 ml. Staff A reattached the SVN mask to the chamber and placed the mask over Resident #123's face. Then Staff A turned the nebulizer on, removed her gloves, and performed hand hygiene. Staff A remained in the doorway while the nebulizer ran. When the nebulizer finished, Resident #123 turned it off and removed the mask. Staff A put on a pair of gloves. Resident #123 handed the mask to Staff A who disassembled it and took it to the bathroom sink where she rinsed it out with water and dried it with paper towels. Next Staff A reassembled the SVN mask and chamber after filling the chamber with Budesonide 0.5 mg/2 ml. Staff A placed the SVN mask on Resident #123's face. The Staff A turned the nebulizer on again. Staff A removed the gloves and performed hygiene. Staff A waited in the doorway for the nebulizer to run. When it finished Staff A put on gloves. Then, Staff A checked Resident #123's pulse ox with an oximeter. After removing the mask from Resident #123's face, Staff A disassembled the nebulizer and took it to the bathroom where she rinsed it out in the sink and dried with paper towels. Staff A, LPN did not instruct Resident #123 to rinse her mouth after the nebulizer treatment. After pouring the next treatment in the SVN chamber, alformeterol 15 mcg/3 ml, she reassembled the SVN mask and placed it over Resident #123's face. She removed the gloves and performed hand hygiene. Staff A waited in the doorway until the treatment had finished. Staff A turned the treatment off and after putting on gloves, disassembled the SVN mask. Staff A took it the bathroom sink and rinsed it out and dried it with paper towels. Staff A returned the mask to the bag after reassembling, and checked Resident #123's pulse ox again. An additional interview was conducted with Staff A at that time. She said the Wixela inhaler was ordered on the tenth. She said the insurance had to approve it. Staff A said she was not sure if Resident #123 had it and it ran out. But it was ordered the ninth. This inhaler takes awhile. She did not know the reason why. On 11/16/21 at 10:50 a.m. a follow up interview was conducted with Staff A. She confirmed she did not instruct Resident #123 to rinse her mouth after the Budesonide nebulizer treatment. She said she thought they need to rinse after using inhalers. She said Resident #123 usually did not rinse after nebulizers. A review of the physician's orders in the electronic medical record revealed the following findings: 11/10/21 Budesonide 0.5 mg/2 ml 2 milliliters inhale orally every 12 hours for COPD. Rinse mouth 105620 Page 18 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0759 with water after use, spit out, do not swallow. Level of Harm - Minimal harm or potential for actual harm 11/10/21 Wixela inhub 250/50 mcg/dose 1 puff inhale orally two times a day for COPD. Residents Affected - Few A review of the medication administration record (MAR) revealed the Wixela was not administered for seven days; from 11/10/21 to 11/16/21. The boxes for the sign off of the medication indicated codes 9 or 5. Review of the codes on the MAR revealed 5 was Hold, see nurse notes, and 9 was Other/see nurse notes. A review of the progress notes in the medical record showed nursing documented the Wixela inhaler was unavailable or on order from the pharmacy from 11/10/21 to 11/15/21. None of the notes indicated the physician was notified. At 10:02 a.m. on 11/17/21, an interview was conducted with the DON (Director of Nursing), who confirmed the Wixela had not been administered. She also confirmed the nurses needed to notify the physician. She said there should be a progress note. The DON also confirmed there were no notes indicating the physician was aware. The DON said Staff A told her she called the pharmacy yesterday to see where it was at. I get alerts for high cost medications, and I approved that one on the ninth. I will have to call the pharmacy to see why they haven't sent it. She said no one informed her the medication had not been sent. The DON also verified the Budesonide order indicated to rinse mouth after use, and the DON said the nurse should have instructed her to rinse her mouth. On 11/18/21 at 12:32 p.m. a telephone interview was conducted with the consultant pharmacist. She said there was a potential for developing thrush after using Budesonide. They do need to rinse their mouth. The Wixela was a corticosteroid so it took a week to get the benefit. If the resident was without it two days it would still be in their body. They did need the medication. If the patient was not showing any signs of breathing difficulty, then there was no outcome. It took a week to get rid of the drug from the body. The outcome would depend on the clinical signs. The consultant pharmacist said she could not say it was an adverse event. She had seen it prescribed as needed too. It would depend on what the doctor ordered. 105620 Page 19 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0806 Level of Harm - Minimal harm or potential for actual harm Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the face sheet for Resident #5 reflected an admission diagnosis of Type 2 diabetes mellitus. Residents Affected - Some On 11/15/21 at 11:26 a.m. an interview was conducted with Resident #5. She said the food was awful. Lunch and dinner were just bad. She told staff and they said everybody complained about it. They had offered alternatives once or twice. They used to offer an alternative on the menu but they took that off so you could not choose it. An observation was conducted on 11/16/21 at 11:48 a.m. of the menu outside the main dining room for the 100 and 200 nursing units. The lunch meal was corn bread, cake, cheese enchilada, Spanish rice, and vegetable blend. The alternate was chicken ala king. On 11/16/21 at 12:36 p.m., an interview was conducted during the lunch meal with Resident #5. She said the Spanish rice, vegetables, and cheese enchilada was awful. She ate the corn bread and the lemon cake. She said she was not aware there was an alternate and did not ask. A review of the Nutrition assessment dated [DATE] in the medical record for Resident #5 reflected a recommended diet order CCHO (consistent carbohydrate), NAS (no added salt) diet. A regular diet order was continued for the resident's request. A review of the undated Resident Dislikes for Resident #5 reflected she did not like fish/seafood or noodles. There were no preferences indicated in the document. A review of the care plan, undated, for Resident #5 reflected a Focus, Resident #5 has diabetes mellitus. Interventions included offer substitutes for meals not eaten. Review of progress notes in the medical record since Resident #5 was admitted revealed no indication Resident #5's preferences had been discussed. On 11/17/21 at 1:05 PM an observation was conducted of the lunch meal on Resident #5's bed side table. The lunch meal was roasted pork with gravy, mixed vegetables, and scalloped potatoes with a dinner roll and applesauce. In an interview with Resident #5 at that time she said she would eat the applesauce. The rest did not sound good. A review of the policy, Resident Food Preferences, revised July 2017, revealed the following: Policy Statement Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Policy Interpretation and Implementation 1. Upon the resident's admission (or within twenty-four (24) hours after his or her admission) the 105620 Page 20 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0806 dietitian or nursing staff will identify a resident's food preferences. Level of Harm - Minimal harm or potential for actual harm 2. Residents Affected - Some When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. 3. Nursing staff will document the resident's food and eating preferences in the care plan. 8. if the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with period 10. The food services department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. 11. The facility's quality assessment and performance improvement committee (QAPI) will periodically review issues related to food preferences and meals to try to identify more widespread concerns about meal offerings, food preparation, etc. A review of the policy, Menus, revised October 2017, reflected the following: Policy Statement Menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy. Policy Interpretation and Implementation 2. Menus for regular and therapeutic diets are written at least two weeks in advance, and are dated and posted in the kitchen at least one week in advance. 5. Input from the resident is considered in menu planning. 11. Copies of menus are posted in at least two resident areas, in positions and in print large enough for residents to read them. Review of the policy, Meal Choices, effective 1/15/21, showed the following information: Policy Statement Resident will have the option to choose from one of three meal categories for each meal period. Policy Interpretation and Implementation 1. Residents will have the choice of a main menu, alternate menu and an always available menu. 2. Menu option are posted daily for residents to view. If the resident does not like the main menu 105620 Page 21 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0806 Level of Harm - Minimal harm or potential for actual harm item, they are to let a staff member know that they would like to change to the alternate or an always available option. 3. Once the staff member has been notified of a request to change menu options, they are to inform dietary to update the meal ticket with requested options. Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure working systems were in place related to food choice, communicating menu options to residents, and assessing for food preferences for eleven (Residents #5, #65, #35, #63, #30, #117, #234, #103, #45, #23) out of 52 sampled residents. Findings included: 1. An interview was conducted with Resident #117 on 11/15/21 at 10:49 a.m. She said the facility did not offer her food choices for her meals, said there was no option to select preferences from a menu, and said, they just bring what they bring. Resident #117 was observed during lunch meal on 11/16/21 at 12:50 p.m. Her tray and meal ticket revealed an entrée of cheese enchiladas, Spanish rice, vegetable blend, and cornbread. The resident said she did not like rice. The meal ticket did not reveal any listing of likes or dislikes. A review of the resident's medical record revealed she was admitted to the facility on [DATE]. The Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which meant she was cognitively intact. There was a document titled Nutrition Assessment dated 11/03/21 which revealed the resident had poor food intake, but the assessment did not reveal any information about food preferences being assessed or discussed with the resident. (Photographic evidence obtained) An interview was conducted with Resident #35 on 11/15/21 at 3:27 p.m. She said the food in the facility was horrible, horrible, horrible .terrible, no taste. She said the food was not palatable and said that the food quality had declined since the time the facility was acquired by a new company. She said she had expressed her concerns about the food to the facility and no actions had been taken and said her daughter had attended a meeting about the food. The resident was observed in her room during the lunch meal on 11/16/21 at 12:57 p.m. There was no meal tray in her room. The resident said she had not eaten the lunch that was provided. She said she had received enchiladas, rice, vegetables, and cornbread. She said she did not like rice so she did not eat the rice, said the vegetables were so hard I couldn't chew them .the enchilada almost choked me, the cornbread tasted like it had been in the freezer .it was horrible. The resident said she had not requested the alternate because it was turkey something but I had it the other day and didn't like it. She said she ended up eating some applesauce and crackers that her daughter had brought her. Resident #35 was observed eating lunch in her room on 11/17/21 at 12:28 p.m. Her meal tray and meal ticket revealed an entrée of pork loin, scalloped potatoes, vegetable blend, a dinner roll, and cherry cobbler dessert. The meal ticket did not reveal any food likes or dislikes. The resident said she liked the entrée and that it tasted good. Review of the resident's medical record revealed she was originally admitted to the facility on [DATE]. The MDS dated [DATE] revealed a BIMS score of 15 out of 15 which meant the resident was cognitively intact. The most recent nutrition assessment was dated 08/25/21 and did not reveal any information about food preferences. (Photographic evidence obtained) An interview was conducted with Resident #30 on 11/15/21 at 3:46 p.m. She said the quality of the facility food had declined since the new company took over. She said the food quality and variety was poor and said residents were not provided with meal menus so they could choose what they wanted to eat. She said there had been a meeting the week before last about the food, but nothing had changed. 105620 Page 22 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview was conducted with the resident on 11/16/21 at 12:58 p.m. She confirmed she had eaten lunch in the dining room. She said, today I got the number 1 but sent it back and got the number 2. She said her meal had included turkey and rice, had eaten the turkey but not the rice and said, I don't like rice. She said, if we had a menu we could choose, and then we could get what we like and wouldn't waste the food .the biggest problem is we don't get the menu. She said if she had been able to choose her meal, she would have chosen the number 2 meal. Review of the resident's medical record revealed she was admitted to the facility on [DATE]. The MDS dated [DATE] revealed a BIMS score of 13 out of 15 which meant she was cognitively intact. The most recent nutrition assessment for the resident was dated 08/09/20. Resident #63 was observed in her room with a breakfast tray on 11/16/21 at 8:45 a.m. She said the food was not good and said, in reference to the food on her tray, does that look appetizing? Her tray revealed a container of oatmeal and a plate with pancakes that had been cut up, a scoop of firm-looking scrambled eggs, and a sausage link. The resident was observed in her room during the lunch meal on 11/16/21 at 12:44 p.m. There was no lunch tray present. The resident said she was given lunch but didn't like it, so she didn't eat it. She said she had been given soup that was so thick like oatmeal, and it shouldn't be that way. She said she was given cheesecake and couldn't eat it because she was lactose intolerant. She said she didn't want anything else. She said she had been served iced tea which she liked and drank. Resident #63 was observed in her room with her lunch tray on 11/17/21 at 12:22 p.m. Observation of her lunch tray and ticket revealed chef's soup, pork loin, rice, vegetable blend, dinner roll, and cherry cobbler. The meal ticket did not reveal any listing of food likes or dislikes. It did reveal an entry of lactaid milk. The resident said the soup was chicken noodle, but she didn't like it because it was too thick and said it had the consistency of mashed potatoes. The soup was observed to be thick. She said she did not like rice so would not be eating that item and did not like bread so would not be eating the dinner roll. She said she did not like anything on her tray except for the iced tea. Her meal ticket did not reveal any information about food likes or dislikes. The resident said she was not given the option to choose what she wanted to eat because the residents were not given the menus anymore. She said they used to be given menus and she used to be able to ask for what she liked and would eat. She said she didn't want to ask for anything else because it wouldn't do any good. Review of the resident's medical record revealed she was admitted to the facility on [DATE]. The MDS dated [DATE] revealed a BIMS score of 15 out of 15 which meant the resident was cognitively intact. There were no recent nutrition assessments in the record. There was a dietary progress note dated 08/27/21 which revealed, .Resident has lost 2.5% of her weight in 30 days also is developing ulcer (sacrum) .Resident complaint of poor appetite. Food preference were taken .Resident is asking for shakes, soups and fruits. Also prefers lactose free milk which has been receiving since the beginning of her treatment. The progress note did not provide any other details on the resident's food preferences. (Photographic evidence obtained) An interview was conducted with Staff E, Food and Service Director and Certified Dietary Manager (CDM) on 11/17/21 at 2:27 p.m. She reported that the facility Registered Dietician was responsible for assessing facility residents including for food preferences. She confirmed she did not perform any formal assessments with facility residents because that was not the process or expectation of the corporation. She said she did meet with residents when they asked to meet with her, and in those circumstances, she would document a progress note. She confirmed that she was aware of resident complaints about not having access to meal menus and not being able to make meal selections. She reported there had been changes made to their menu and meal ticket systems when the facility was taken over by a new corporation which had impacted on the residents. She confirmed she was aware the residents 105620 Page 23 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were dissatisfied with the changes. She said, with the old company we used to have [name of system] where the next meal was printed on the ticket .the new system does not have that option. She said with the old system and meal tickets, the facility process for residents was that they would circle what they wanted for the next meal and that would be received by the kitchen. She said, we haven't gotten to the place yet to figure out how to get a menu back in place for them (residents) .haven't gotten to a fix yet .right now [we're] working on getting likes and dislikes printed on the ticket again .hopefully by the end of the year, that's something I'm pushing for. Staff E confirmed there was no formalized system in place in the facility to ensure that all residents were offered food choices for their meals. She said they were hoping to have a process by the end of the year. She said in the meantime the facility had implemented a phone extension menu line for residents to call and hear the menu and said residents could also call her directly and tell here their meal choices. She said the Nursing Home Administrator (NHA) was working on a menu book but said, I'm not sure if it's being used. An interview was conducted with the NHA on 11/18/21 at 8:53 a.m. She reported she had been employed in her position at the facility for two months, and the resident's concerns about not having access to menus to make meal selections was brought to her attention two weeks ago. She confirmed she was working on making a menu book with the current menu but had not completed the project yet. She said the plan was that there would be a menu book on every resident unit and the unit Certified Nursing Assistants (CNAs) would present the menu to the residents and take their meal orders. The NHA confirmed the menu book was not completed and that this process was had not yet been implemented at the facility. An interview was conducted with Staff D, Registered Dietitian, and the Regional Director of Dietary Services (RDDS) on 11/18/21 at 11:04 a.m. Staff D confirmed she began working at the facility around the middle of July 2021. She said, I am the first person responsible for assessing resident food preference. She reported the expected timeframes for assessment were a screen within the first 24 hours of admission, followed by an admission assessment within the first 3-7 days of admission, and after that the assessments were expected to be completed at least on a quarterly basis. Staff D revealed that the assessment documentation templates she used in the Electronic Health Record (EHR) were the Malnutrition Risk and Morbid Obesity Assessment which she said was the screen and the Nutrition Assessment was the comprehensive assessment completed upon admission and quarterly. She confirmed that neither template included a section specific to food preferences and said, this screen (Malnutrition Risk and Morbid Obesity Assessment) doesn't have the option to write food preferences, so I write it down on paper and enter it into the nutrition management system (meal ticket system). Regarding the Nutrition Assessment template she said, sometimes when they don't want something I put it here in comments .a lot of times I just write them by hand and get them on the ticket. Staff D confirmed it was the facility expectation that she asked residents about their food preferences during every assessment and said, I could do a better job. Staff D was asked to reveal her documentation for Residents # 117, 35, 30, and 63. For Resident #63 Staff D confirmed she had not completed an assessment for the resident and had not assessed the resident for food preferences. She revealed a progress note she had entered on 08/27/21 that had been crossed out and said, I don't know why it's crossed out .I should put it back. For Resident #30 she said, there are no nutrition assessments from me and confirmed there was no documentation from her in the EHR on the resident's food preferences. For Resident #117 Staff D revealed she had started an annual nutrition assessment on 11/03/21 and confirmed there was nothing documented about food preferences. For Resident #35 Staff D revealed she had documented an assessment on 08/25/21 and confirmed it did not include anything about food preferences. The RDDS revealed that the meal ticket system was set up to filter out likes and 105620 Page 24 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dislikes and replace with substitutions and that because of that, the likes or dislikes were not printed on the tickets that went out with the resident trays. She revealed in the electronic system that preferences had been entered for the residents discussed but confirmed there was no way to determine if they were up to date and when they had last been assessed. Regarding the system's options for providing residents with printed next meal menus, the RDDS confirmed the system did not allow for the next day menu to be printed on the tray ticket, but that it did have the option for printing a separate select menu ticket which could be provided to the residents for them to choose their meal and food options for upcoming meals. She confirmed select menu tickets were not currently in use at the facility and said, we are learning how to use that feature .this system just started November first. 2. A review of Resident #65 Admissions Record revealed that she was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included acute respiratory failure with hypoxia, pneumonia, and chronic obstructive pulmonary disease. A review of Resident #65 Annual Minimum Data Set (MDS) conducted on 8/28/21, documented in Section C, Cognitive Patterns, revealed a Brief Interview Mental Status (BIMS) score of 14, indicating that she was cognitively intact. On 11/16/21 at 9:13 a.m., in an interview with Resident # 65, she stated that recently she was not offered a menu to choose her meals. She stated that she would like to choose her meals, or she liked it better when she was provided with a menu to choose her meals. She stated that she was not served the food she was supposed to be getting or her preferences. She stated that most of the time, the food she was served did not match the ticket on her tray. She stated that she told the facility that she did not like broccoli, but she was served broccoli anyway, instead of carrots as her preference. A review of Resident #65's Nutrition Quarterly notes documented 6/8/21, revealed that her diet was carb-controlled. At times complaint about food. Food preferences updated. Further review of the resident's Electronic Medical Recorded under the headings Nutrition/Dietary notes revealed no documentation related to the residents' preferences, nor any documentation revealing updated food preferences. On 11/18/2021 at 10:00 a.m. in an interview with Staff D (Registered Dietician), she stated that she did not document the residents' preferences in her notes, she made a note on the dietary slip. She stated that she reviewed the resident's dietary needs and document monthly. On 11/18/21 1:11 p.m., in an interview with Staff I, Licensed Practical Nurse (LPN), she stated that Resident #65 mostly discussed her meals with the CNAs because they served her meals and communicated with the kitchen related to resident preferences. 3. On 11/17/21 at 11:00 a.m., an interview was conducted with Residents #23, #45, #234, and #103. During the interview, Resident #45 stated that the residents used to receive menus, but they no longer received them. In the past, they were given options for meal preferences. They used to be able to check a box indicating their food preferences. This stopped about five or six months ago. Resident #23 stated that a meeting was held last month, in October. The Dietary Manager attended the meeting, where she was informed of the resident's desire to receive menus. The Dietary Manager informed the resident's that they were working on it. Residents #23, #45, #234, and #103 stated that they had not received the menus, and felt as though, they had to eat the same foods repeatedly. Resident #234 stated that she had been served chicken all the time. Resident #234 stated that she hated the food at 105620 Page 25 of 26 105620 11/18/2021 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0806 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the facility. She did not eat, when she received a meal that she disliked. She was not aware that she could have requested an alternate meal. Resident #45 stated that since the new corporation took over, the food was not as good as it used to be. On 11/18/21 at 10:48 a.m., an interview was conducted with Staff C, Social Services. She stated that the dietary department was responsible to handle food related grievances. Grievances should have been resolved within 3-5 days. The Social worker's responsibility was to speak to the resident regarding the grievance to ensure that they were happy with the outcome. She stated that she received several grievances related to food in July 2021 and August 2021. The most recent grievance was related to cold food and not being offered the alternate. It was resolved the same day. The previous grievance was related to not receiving a menu. The final grievance was related to food preferences, the resident received food items that he did not prefer. All the grievances mentioned were resolved. On 11/18/21 at 11:05 a.m., an interview was conducted with Staff B, Director of Social Services. He stated that when a resident filed a grievance related to food, the grievance was given to the dietary manager. The manager was responsible to follow up with the resident or their family. The resolution was signed by the Nursing Home Administrator (NHA) and returned to the social services office to be filed. On 11/18/21 at 12:10 p.m., an interview was conducted with the Activities Director. She confirmed that she had a few complaints from the residents regarding cold food. She along with Staff D, went room to room and completed an audit of food temperatures a couple of months ago. The NHA typed up a new menu book that was in the process of being implemented. Menus were posted at each nurses' station. If the residents did not like their meal, they could have asked their Certified Nursing Assistant (CNA) for the alternate or they could have called the kitchen. The facility has assigned department heads to complete room rounds and they could discuss food preferences during their rounds. The facility used to have dislikes printed on meal tickets, but she was not sure if they still done that way. If a resident used an adaptive device for meals, that was reflected on the meal ticket. A review of the resident council meeting minutes for the past six months revealed that residents expressed concerns regarding menus. Resident council meeting minutes documentation dated May 2021 revealed, under the heading Resolutions/Needs for assistance-New business 1. Menus to be readily available for residents. Resident council meeting minutes documentation dated June 2021 revealed, under the heading Discussion of old business Menus need to be available in rooms so that they may make their food choices ahead of time. Staff not knowing what alternate items are available. Under the Resolutions/Need for assistance-Old business 1. Administrator will get with dietary and ensure residents get the menus ahead of time. 2. Staff will be redirected on items available for alternative meals. Resident council meeting minutes documentation dated October 2021 revealed, Dietary discussed the roll out of a new fall menu for 4-week schedule and that it would soon be readily available for residents to view. 105620 Page 26 of 26