Health inspection·April 17, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on record review and interviews the facility failed to implement an effective grievance program related to ensuring voiced concerns are acknowledged, documented, and resolved for the attending resident council members during six months (November, December, January, February, March and April) of six months reviewed. Findings included: Review of Grievance Logs for a six-month period from November 2024 to April 2025 revealed each month there were on-going call light concerns. Review of the Grievance Log for November 2024 revealed a grievance for Resident #1 dated 11/22/24 for Activities of Daily Living (ADL) care not provided, medications left at the bedside, and pain meds not provided in a timely manner. Follow up to grievance revealed: pain medication scheduled for as needed (prn), staff educated on ensuring that the residents receive their medications in a timely manner and as needed, and staff educated on providing ADL care in a timely manner, date resolved 11/22/24. Staff education in-service roster for medications should be administered timely dated 11/15/24. Review of the Grievance Log for December 2024 revealed a grievance for Resident #1 dated 12/9/24 for call light response time for care needed. Follow up to grievance revealed: unable to clarify response date due to system being down for repairs and staff educated. Date resolved 12/17/24. Review of the Resident Council Minutes dated 11/14/24 revealed a section titled Old Business no issues/concerns were listed and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed a list of upcoming activities, no mention of issues/concerns. Review of the Grievance Log dated November 2024 revealed six entries titled Resident Council all dated 11/14/24 with the following concerns: 1. Grievance Form dated 11/14/24 from Resident Council revealed complaint/grievance: staff loud in hallways on 3-11 & 11-7. The form is marked resolved dated 11/25/24, with education to the staff. 2. Grievance Form dated 11/14/24 from Resident Council revealed complaint/grievance: customer service in dining room. The form is marked resolved dated 11/20/24, with education to the staff. 3. Grievance Form dated 11/14/24 from Resident Council revealed complaint/grievance: use of phone Page 1 of 7 105620 105620 04/17/2025 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0585 in residents' room. The form is marked resolved dated 11/17/24, with education to the staff. Level of Harm - Minimal harm or potential for actual harm 4. Grievance Form dated 11/14/24 from Resident Council revealed complaint/grievance: takes a long time for clean clothes personable to be returned (weeks). The form is marked resolved dated 11/25/24, with education to the staff. Residents Affected - Some 5. Grievance Form dated 11/14/24 from Resident Council revealed complaint/grievance: staff dragging soiled linen bags on floor. The form is marked resolved dated 11/25/24 with education to the staff. Review of the Resident Council Minutes dated 1/9/25 revealed a section titled Old Business, revealed old business reviewed - accepted - and no check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed a list of upcoming activities, and response times of call lights grievance wrote. Review of the Resident Council Minutes dated 1/23/25 revealed a section titled Old Business, revealed old business reviewed and no check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed a list of upcoming activities, and no concerns/issues were noted. Review of the Grievance Log dated January 2025 revealed two entries titled Resident Council dated for 1/9/25. 1. Grievance Form dated 1/9/25 from Resident Council revealed complaint/grievance: call light response times, staff not responding to call lights in a timely manner on 3-11& 11-7 shifts. The form is marked resolved dated 1/14/25, with education to the staff. 2. Grievance Form dated 1/6/25 from Resident Council revealed complaint/grievance: staff wearing ear pods in resident areas on all shifts. The form is marked resolved dated 1/14/25, with education to the staff. Review of the Resident Council Minutes dated 2/9/25 revealed a section titled Old Business, revealed We discussed call light response times. Also talked about things in facility getting fixed in all departments so that residents have what they need at all times and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed not answering call lights/turning off call lights without doing what residents need. Morning shift not working right away, items not repaired in facility. Residents not happy about their laundry not being returned/lost. Wheelchairs not being able to go over door that leads to gazebo. Review of the Resident Council Minutes dated 2/20/25 revealed a section titled Old Business, revealed clothes not getting returned, call lights not getting answered at timely manner. Not getting meals at feeding and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed cannot get food when they want, does not get offered after snacks. Can't get food that we needs to fit our diet. Review of the Grievance Log dated February 2025 revealed one entry titled Resident Council dated for 2/6/25 revealing : 1. Grievance Form dated 2/6/25 from Resident Council revealed complaint/grievance: not getting offered snacks. The form is marked resolved dated 2/10/25, with education to the staff. No mention of call lights. 105620 Page 2 of 7 105620 04/17/2025 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the Resident Council Minutes dated 3/6/25 revealed a section titled Old Business, revealed cannot get food when they want, does not get offered afternoon snacks. Can't get food that we needs to fit our diet. Food is not always good. Staff taking too long to respond to call lights and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed coffee cold, never get what is on the food ticket, nobody gets given snacks! Not knocking on door/not introducing themselves. I don't know who CNA [Certified Nursing Assistant] is/are on weekends . Review of the Resident Council Minutes dated 3/20/25 revealed a section titled Old Business, revealed cannot get food when they want, does not get offered afternoon snacks. Can't get food that we needs to fit our diet. Staff taking too long to respond to call lights and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed Not enough CNAs during the night shift. Not getting changed throughout the night time. Staff needs more teamwork! (Getting back to luncheon for new hires) Needs longer head with reach showers are too cold nobody wants to shower. (Trees)(Roaches) getting washers and dryers fixed ASAP. List of snacks. Smokers don't need to smoke in outside area. Review of the Grievance Log dated March 2025 revealed two entries titled Resident Council dated for 3/26/25. 1. Grievance Form dated 3/26/25 from Resident Council revealed complaint/grievance: residents not getting changed timely on overnight shift. The form is marked resolved dated 3/31/25, with education to the staff. 2. Grievance Form dated 3/26/25 from Resident Council revealed complaint/grievance: laundry is taking too long to come back to the residents. The form is marked resolved dated 3/29/25. 3. Grievance Form dated 3/26/25 from Resident Council revealed complaint/grievance: not getting changed throughout the night. The form is marked resolved dated 3/29/25. Review of the Resident Council Minutes dated 4/3/25 revealed a section titled Old Business, revealed Not enough CNAs during the night shift. Needs longer shower heads in shower. It is always cold in shower room. not getting offered snacks. Roaches in rooms/bathrooms. Getting washers and dryers worked on and a check mark in the box stating all items from previous meeting were resolved. Under the section New Business revealed Still not getting offered snacks . CNAs are acting lazy . not taking time to properly clean residents. CNAs on phones or at nurse station talking and laughing not checking on residents. Review of the Grievance Log dated April 2025 revealed five entries titled Resident Council dated for 4/10/25. 1. Grievance Form dated 4/10/25 from Resident Council revealed complaint/grievance: CNAs on phones or at nurse station talking loud. The form is marked resolved dated 4/10/25, with education to the staff. 2. Grievance Form dated 4/10/25 from Resident Council revealed complaint/grievance: not making up beds right away after striping them. The form is marked resolved dated 4/10/25, with education to the staff. 105620 Page 3 of 7 105620 04/17/2025 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Grievance Form dated 4/10/25 from Resident Council revealed complaint/grievance: Still not getting offered snacks. The form is marked resolved dated 4/10/25, with education to the staff. During an interview on 4/16/2025 at 10:56 AM with a resident who participates in resident council stated the council has not had resolution on the call light response time especially on the evening and weekend shifts. During an interview on 4/17/2025 at 11:51 AM with the Activities Director (AD). The AD stated being responsible for planning and overseeing the recreational needs of the building. Part of the duties include assisting resident council if requested and is usually requested to take the minutes. The AD explained the resident council form includes attendees, old business and new business. Explaining the check boxes on the form are for the activity staff to ensure they review the items from prior meeting, not necessarily the item was resolved completely. The residents do have concerns that are continuing, especially call lights. During an interview on 4/17/25 at 2:56 PM with the Social Service Director SSD and the NHA. The SSD explained the grievance process. Anyone can complete a grievance for a resident, the concern/grievance form is turned into the SSD. The SSD logs the grievance and takes the grievance to the management meeting, that is held every morning for review. The grievance is given to the respective department for follow-up. The department manager completes the follow up and turns the completed grievance form back into the SSD for completion. The NHA stated the facility had noted an increase in grievances and put a performance improvement plan in place on 3/10/25. Review of the audit and plan revealed a plan for audits on day shift. The plan did not include any audits for evening, night and weekend shifts confirming concerns related to unresolved resident grievances. Review of the facility's policies and procedures titled Standards and Guidelines: Grievances - Resident Rights, with a revision date of 7/2024 revealed Guideline: The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Proceduere: . 10. The Grievance Officer, Administrator and Staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. 11. The Administrator will review the findings with the Grievance Officer to determine what corrective actions, if any, need to be taken. 105620 Page 4 of 7 105620 04/17/2025 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0773 Level of Harm - Minimal harm or potential for actual harm Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. Based on interview and record review the facility failed to obtain physician ordered cultures in a timely manner for two (#1 and #4) of three sampled residents. Residents Affected - Few Findings Included: 1. Review of Resident #1's admission record revealed an admission date of 11/15/24 for short term rehabilitation with diagnoses to include myoneural disorder, acute respiratory failure with hypercapnia, sepsis, chronic obstructive pulmonary disease and other co-morbidities. Review of Resident #1's medical nurse practitioner progress note dated 12/12/24 revealed: Resident #1 has been having increased episodes of diarrhea, with recommendations to obtain a stool sample. Review of Resident #1's order summary report revealed a physician order dated 12/12/24 and 12/13/24 obtain stool sample. Review of Resident #1's nursing note dated 12/13/24 revealed collected stool sample for lab. Review of Resident #1's order summary report revealed a physician order dated 12/15/24 obtain urinalysis (UA) for burning during urination. The laboratory results for the UA revealed the lab received the UA on 12/16/24 at 10:26 a.m. and reported on 12/16/24 at 2:25 p.m. The lab results revealed: cloudy appearance, blood level 250, protein 15-30, nitrite positive, leukocytes 500; the microscopic UA revealed WBCs (White Blood Cells) TNTC (Too Many To Count), RBCS 26-50, bacteria 1+ (few), epithelial cells 3-5, mucus few. Review of Resident #1's nurses progress notes dated 12/16/24 at 7:29 p.m. revealed notification to provider of UA results and provider wants to wait on the culture and sensitivity prior to ordering a treatment. Review of Resident #1's rehabilitation nurse practitioner progress note dated 12/16/24 revealed the resident was having diarrhea and stomach cramping earlier. Review of Resident #1's order summary report revealed an order for UA C/S (culture/sensitivity) for dysuria (painful and uncomfortable) dated 12/19/24 and 12/20/24. The laboratory results for the UA revealed the lab received the UA on 12/23/24 at 9:00 and reported 12/26/24 at 12:19. Review of Resident #1's rehabilitation nurse practitioner progress note dated 12/26/24 at 7:46 p.m. revealed: Resident concern is wanting to get the results of her stool sample and urine sample. The resident was told the results were in but has not been informed. Medical NP (nurse practitioner) was notified and asked to order medication to treat her UTI (Urinary Tract Infection). Review of Resident #1's order summary revealed an order for Ciprofloxacin HCl tablet 500 MG for UTI for 7 days dated 12/26/24. Review of Resident #1's medical nurse practitioner progress noted note dated 12/23/24 revealed no stool results available in chart, will have staff contact lab. Recent UA done without culture, therefore repeat UA with culture was ordered and awaiting the culture report. 105620 Page 5 of 7 105620 04/17/2025 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #1's record on 4/16/25 revealed there was no record of stool sample results for Resident #1. 2. Review of Resident #4's admission record revealed an admission date of 11/13/24 for short term rehabilitation with the diagnoses including: lymphedema, morbid (severe) obesity, cervical disc degeneration, and other co-morbidities. Review of Resident #4's rehabilitation nurse practitioner progress note dated 12/5/24 revealed: Resident is unable to turn herself. Resident reports pain upon the slightest touch or turn. Resident is morbidly obese and definitely needs to improve her therapy progress. I noted a large hematoma to her R (right) thigh, and I ordered an US (ultrasound) for that .Resident had fallen OOB (out of bed) when being turned for cleaning the previous day. Review of Resident #4's order summary report did not reveal an order for an ultrasound. During an interview on 4/17/25 at 12:22 p.m. with the rehabilitation nurse practitioner. The rehabilitation nurse practitioner stated if documentation in the note reveals an ultrasound was ordered, then the order needed to be completed. During an interview on 4/17/25 at 9:14 a.m. the Director of Nursing (DON) confirmed Resident #1's record did not contain information regarding the stool sample results, nor notification to the physician. The DON stated not knowing what happened with the UA. The DON stated the expectation would be for the orders to be followed, and the physician to be notified of results when they were received from the laboratory. Review of the facility's policy and procedures revised 6/2023, titled Standards and Guidelines showed Change in Resident Condition or Status - Resident Rights - Standard: Facility shall notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Guideline: To ensure the facility provides timely notification in accordance with State and Federal Regulations as it pertains to residents' rights. Procedure: 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving the resident. b. discovery of injuries of an unknown source. c. adverse reaction to medication. d. significant change in the resident's physical/emotional/mental condition. e. need to alter the resident's medical treatment significantly. f. refusal of treatments or medications of 3 or more consecutive times g. need to transfer the resident to a hospital/treatment center. h. discharge without proper medical authority; and/or 105620 Page 6 of 7 105620 04/17/2025 Highlands Lake Center 4240 Lakeland Highlands Rd Lakeland, FL 33813

F 0773 i. specific instruction to notify the Physician of changes in the resident's condition. Level of Harm - Minimal harm or potential for actual harm 2. A significant change of condition is a major decline or improvement in the resident's status that: Residents Affected - Few a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting). b. Impacts more than one area of the resident's health status. c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 3. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source. b. There is a significant change in the resident's physical, mental, or psychosocial status. c. There is a need to change the resident's room assignment. d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/treatment center. 4. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. 5. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. 105620 Page 7 of 7