Inspection·October 27, 2022

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to review and revise the care plan related to behaviors for one resident (Resident #98) out of the sampled five residents. Findings included: On 10/26/22 at 10:02 a.m., Staff G, assigned Certified Nursing Assistant (CNA), reported Resident #98 was on 1:1 due to an altercation she had with Resident #52. She tore his skin on his arm. Resident #98 had been on 1:1 for about three months. She was put on 1:1 after the incident occurred. On 10/27/22 at 11:00 a.m., Resident #98 was observed in bed sleeping. Staff J, assigned (CNA), was in the room at that time and stated Resident #98 was on 1:1 due to her behaviors. He reported she was very calm today but was very aggressive with other residents on Tuesday. Staff J, CNA, reported Resident #98 was mostly aggressive with residents in the dining room. She likes to grab at people. On 10/27/22 at 10:45 a.m., Staff H, assigned Licensed Practical Nurse (LPN) stated Resident #98 was aggressive and would aim for anyone. One time she pulled her hair and wouldn't let go stated Staff H, LPN. She goes after everyone. She looks sweet but she was very aggressive. She's on 1:1 and had been for a few months stated Staff H, LPN. On 10/27/22 at 10:50 a.m., Staff I, LPN, Unit Manager, confirmed Resident #98 was on 1:1 due to being aggressive. A review of the admission Record revealed Resident #98 was initially admitted to the facility on [DATE] with diagnoses that included but were not limited to other psychotic disorder not due to a substance or known physiological condition and unspecified dementia, unspecified severity, with other behavioral disturbance. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] indicated 99 in the section for the Brief Interview for Mental Status (BIMS) score. 99 indicated the resident was unable to complete the interview. Section E Behavior of the MDS indicated Resident #98 did not exhibit physical or verbal behavioral symptoms. A review of the Progress Notes revealed the following notes: (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 5 Event ID: 106112 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 106112 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/27/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Tampa Lakes Health and Rehabilitation Center 750 Hayes Rd Lutz, FL 33549 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)