Health inspection·October 23, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to personalize resident care plans leaving Certified Nursing Assistants (CNAs) to choose between one- or two-person assistance transfers for two residents (#1 and #2) of three residents sampled. Failure to develop, revise and implement personalized transfer care plans puts residents at risk for falls.Findings Included: During an observation made on 10/23/2025 at 9:45 a.m., Resident #1 was observed in a common area, sitting up in their wheelchair in front of the television. Resident #1 did not respond to the interview.During a telephone interview on 10/23/2025 at 10:33 a.m., with Staff A, CNA, The staff member said regarding the shift on 10/09/25, I gave resident #1 a shower and was in her room putting her into her Geri chair . I was using a Hoyer Lift Staff A stated there was another CNA in the room with her. Staff A stated not able to recall the name of the other CNA. Staff A stated the other CNA would not come forward, they are all scared they are going to get in trouble. An interview was conducted on 10/23/2025 at 10:50 a.m. with Staff B, CNA working the same shift as Staff A. Staff B said, I worked the upper hall on 10/09/25. I've never been assigned to [Resident #1]. Staff B stated she wrote a statement during the investigation, I have not helped [Staff A] with [Resident #1's ] Hoyer lift today.An interview was conducted on 10/23/2025 at 11:07 a.m. with Staff C, CNA working the same shift as Staff A. Staff C denied being asked to assist with Resident #1's transfer on 10/09/25. Staff C stated when using a Hoyer lift, You should have two people. You can look at the Kardex (a CNA documentation used to summarize specific patient care information) to tell you if the resident requires one or two people for care.Review of Resident #1's admission record showed Resident #1 was admitted to the facility on [DATE] with diagnoses not limited to cerebral atherosclerosis, generalized muscle weakness, other lack of coordination, severe vascular dementia with anxiety, left knee contracture, and right knee contracture.Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE], revealed in section C. Cognitive Patterns a Brief Interview Mental Status (BIMS) score of 0 out of 15 revealing cognitive impairment. Review of section GG - Functional Abilities showed Resident #1 had lower extremity impairment on both sides and utilized a manual wheelchair for ambulation. Resident #1 was identified as dependent, where the resident needed the helper to do all the effort and the resident did none of the effort to complete the activity, or the assistance of two or more helpers were required for the resident to complete the activity. Resident #1 was dependent on staff for assistance to roll left and right, and returning to lying on back on the bed, moving from sitting on the side of the bed to lying flat on the bed, lying on the back to sitting on the side of the bed, transferring to and from bed to wheelchair, getting in and out of a tub/shower, and dependent on staff to maneuver the wheelchair. Review of Resident #1's care plan initiated on 7/21/2025 revealed a focus - Resident #1 has an Activities of Daily Living (ADL) self-care-performance deficit related to (r/t) Cerebral Atherosclerosis, vascular dementia, weakness, contractures left/ right knee. The focus was initiated on Page 1 of 3 106120 106120 10/23/2025 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 07/21/2025 and revised on 10/13/2025. The interventions included: Transfer: (Resident #1) requires Mechanical Lift (full body lift) with (2) staff assistance for transfers. sling size: large. The intervention was initiated on 10/09/2025 and revised on 10/10/2025 with the responsible position listed as Certified Nursing Assistant (CNA). The CNA was to encourage Resident #1 to participate to the fullest extent possible with each interaction. An interview was conducted with the Nursing Home Administrator (NHA), the Director of Nursing (DON), the Assistant Director of Nursing (ADON) and the Risk Manager (RM) on 0/23/2025 at 12:12 p.m. reviewing their investigation of the incident on 10/09/2025. The DON stated two nursing students, Student #1 and Student #2) were bringing clean sheets to the room when Student #1, pulled curtain back and observed CNA using Hoyer lift by herself.A telephone interview was conducted with Student #1 on 10/23/2025 at 1:50 p.m. Student #1 stated she came back into Resident #1's room after getting linen to make the bed. The curtain was closed, and she heard commotion coming from behind the curtain. She stated she opened the curtain a little bit to see the CNA (Staff A) using the Hoyer lift by herself.During an interview on 10/23/2025 at 2:40 p.m. with the ADON and Risk Manager (RM), the ADON stated prior to 10/9/2025, she could not remember if Resident #1's care plan was documented for one or two person to assist. She stated staff had been transferring the resident with the patient lift and this was not communicated to therapy. The ADON stated before 10/9/2025, the resident was not care planned to use a patient lift. ADON reported when the resident first came to the facility, the resident may have been a one person assist, but then the resident was placed on hospice. The ADON stated staff were empowered to make decisions for transfers if they needed to. The ADON stated if staff needed more help with transfers, they could use patient lifts, but they should have reported it to the unit manager. 2. On 10/23/25 at 10:50 a.m. Resident #2 was observed sitting in motorized wheelchair in their room. The resident reported using a Sit-to-Stand mechanical lift for transfers and was getting close to needing a full mechanical lift. The resident reported not remembering the recent fall and stated being informed by staff of a fall from the Sit-to-Stand lift. Review of Resident #2's admission record showed the resident was admitted to the facility on [DATE]. The record included diagnoses not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, generalized muscle weakness, not elsewhere classified difficulty in walking, unspecified site muscle wasting and atrophy not elsewhere classified, and dizziness and giddiness. Review of Resident #2's Care Plan initiated on 8/27/25 revealed a focus - Restorative Transfer Program: (Resident #2) requires assistance transferring from one surface to another related to: cognitive deficit, physical limitations. The focus was initiated and revised on 8/27/25. The interventions included Provide 1-2 assist as needed, with the responsible position listed as Nurse and Restorative Nursing Assistant ( RNA) A second focus in the same care plan revealed - (Resident #2) has an activities of daily living (ADL) self-care performance deficit related to (r/t) hemiplegia/hemiparesis, weakness, (and) difficulty walking. The focus was initiated on 7/28/23 and revised on 11/14/23. The interventions instructed Transfer: (Resident #2) requires mechanical lift (sit to stand) with (2) staff assistance for transfers. (Extra Large sling) Full weight bearing'. The intervention was revised on 2/20/25 with the responsible position listed as Certified Nursing Assistant ( CNA). The CNA was to encourage (resident pronoun) to participate to the fullest extent possible with each intervention. Review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicating an intact cognition. Section GG of the assessment revealed the resident utilized a motorized wheelchair for ambulation and was dependent upon staff to come to a standing position from sitting in chair and to transfer from chair/bed to chair. Review of Resident #2's Kardex revealed the resident's 106120 Page 2 of 3 106120 10/23/2025 Scott Lake Health and Rehabilitation Center 800 E County Rd 540a Lakeland, FL 33813

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ability to sit to stand was either substantial/maximum assist with staff doing more than half the effort or dependent upon staff for sit to stand and chair/bed-to-chair transfer. The documentation provided did not reveal the number of staff required to assist the resident with transferring. During an interview on 10/23/25 at 2:40 p.m. with the ADON and the Risk Manager (RM), the ADON stated the care plan should be updated if there was a change in status or a new order. The ADON stated if in therapy they noticed the resident appeared weaker, or the CNA reported the resident required more assistance, the resident was evaluated by therapy and the care plan was updated. The ADON reported nurses and nursing managers can update the care plan, but typically MDS will make updates to keep the notes uniform for audits. The ADON reported staff would look on the Kardex to see if a resident was a 1 or 2 person assist. The ADON stated staff cannot downgrade from a 2 person to 1 person assist but can go from 1 person to a 2 person or more assist. The ADON stated if a care plan instructs to assist with 1-2 persons, staff could potentially do a 1 person but can do a 2 person assist The ADON said, I don't think any of the care plans say that. It is up to the CNA to make the decision if that is what the care plan says. The ADON stated CNAs are not technically making an assessment, but they see what the resident can and cannot do and if a resident was having trouble transferring the CNA could determine if they need 1- or 2-person assistance. Review of the policy titled, Resident Assessment Instrument Comprehensive Care Plan, effective September 2024, showed the purpose was - To ensure that each resident in the facility receives individualized and appropriate care based on a thorough assessment using the Resident Assessment Instrument (RAI) and to comply with state and federal regulations. The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure their delivery of quality care period this process will involve interdisciplinary team members and be revised to reflect resident condition changes. The procedure, Care Area Assessment (CAA) Process included:Based on the MDS findings, potential issues will trigger the completion of the Care Area Assessment (CAA). This ensures that the facility considers all possible care needs and risks identified during the MDS process.The interdisciplinary team (IDT) will evaluate the triggered areas and develop interventions as necessary.The developing the Care Plan revealed The care plan will address physical, emotional, social, and cognitive needs, as well as any other relevant areas (e.g., nutritional, safety, mobility, (and) medication management).The Interdisciplinary Team Collaboration consisting of nursing, dietary, therapy, social services, and other relevant staff, will collaborate to create and review the care plan.The policy showed: The care plan will be reviewed quarterly and revised as necessary.The care plan must be updated in response to changes in the resident's condition, new assessments, or input from the resident/family.Significant changes in the resident's condition will trigger a new MDS assessment, guiding further revisions to the care plan. 106120 Page 3 of 3