Inspection·March 3, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor resident rights related to dignity for all residents, by not ensuring a residents quality of life was enhanced for one (Resident #20) of 25 sampled residents related to staff waiting to be invited into a resident's room and staff providing a service without discussing it with the resident. Findings included: Review of Resident #20's record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Major Depressive Disorder, Anxiety Disorder and had a Brief Interview For Mental Status (BIMS) score of 14 (Cognitively intact) dated 12/27/21. During an Interview on 02/28/22 at 11:10 a.m. with Resident #20, a male person wearing a company logo T-shirt and cap knocked on the door, proceeded into the residents room, went to her bedside, and started working on something on the side of the mattress next to the residents pillow. This person did not identify himself to the resident or ask the resident if he could touch her bed or excuse himself for interrupting the conversation the resident was having. At no time did this person acknowledge the resident. An interview with this person, approximately three minutes later, revealed that the person identified himself as Staff L, Maintenance. Staff L reported that he was told that the residents call-light cord needed a clamp placed on it so that it can be clamped to the bed and stay in place. He reported that he always announced himself and introduced himself to the resident and told them what he was about to do. He reported that in this case he did announce himself after knocking on the door. After the Staff L left the room, an interview with the resident revealed that she had seen Staff L around the facility but did not know why he was coming into her room or what he was doing until after she observed him placing the clamp. In an interview on 03/03/22 at 8:04 a.m., with the DON, she said her expectation was for staff to knock on the door and wait for a response to be invited into the room. She reported that all staff should tell the resident what they were about to do. She reported that she expected that privacy and dignity was provided. In an interview on 03/03/22 at 8:27 a.m., with Staff K, Maintenance Director, he said he supervised ten maintenance staff. He reported that the maintenance staff had full access to the building including resident rooms. Staff K reported that the maintenance staff were to knock on resident room doors prior to entering the resident's room, announce themselves and wait for a response before entering the room. He reported that if the resident needed to be removed from the bed the maintenance staff were to get help from the Certified Nursing Assistant (CNA). He reported that the maintenance staff (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 11 Event ID: 105949 Printed: 05/28/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 105949 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/03/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Florida Presbyterian Homes Inc 909 Lakeside Ave Lakeland, FL 33803 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)