Florida Baptist Retirement Center

F-F757 for details). The anti-anxiety medication Ativan had been added to the resident's regimen as of 07/28/24.

Review of the monthly pharmacy recommendations from February 2024 through July 2024 lacked any recommendation related to the lack of behavior monitoring.

During a phone interview on 08/14/24 at 3:05 PM, the consultant pharmacist was unable to review his records, but would check later. The consultant pharmacist was told of the concerns related to the lack of behavior monitoring for Resident #9 and was asked to provide any recommendations or information to the Director of Nursing. As of the exit conference, no additional information had been provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 12 106097 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106097 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960

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)

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25404 potential for actual harm Based on record review and interview, the facility failed to ensure adequate monitoring of medications for 2 Residents Affected - Few of 6 sampled residents. The facility failed to ensure behavior monitoring for psychotropic medication use for Resident #9, and failed to ensure appropriate antibiotic use for Resident #14.

The findings included:

1) Review of the record revealed Resident #9 was admitted to the facility on [DATE REDACTED], with a diagnosis of Schizophrenia. Review of the orders revealed the resident had been on the anti-psychotic medication Haloperidol since 02/05/24, and the anti-anxiety medication Buspirone since 02/16/24. The anti-anxiety medication Ativan had been added to the resident's regimen as of 07/28/24.

Review of the current care plan initiated on 02/06/24 and revised 07/02/24 documented, I have anxious/restless behavior as evident by calling out for help loudly without a need. Resident has a history of providing false information to family and staff for attention seeking purposes.

Review of the monthly Medication Administration Records (MARs) from February 2024 through August 2024, along with the progress notes, lacked any documented behavior monitoring for Resident #9.

During an interview on 08/14/24 at 11:25 PM, the new Director of Nursing (DON), as of three weeks prior to

the survey, was asked about the lack of behavior monitoring for Resident #9. The DON stated it was part of

the documentation in the eMAR. When shown the lack of documentation of behavior monitoring for Resident #9, the DON was unsure and referred the question to the MDS (Minimum Data Set) Coordinator.

During an interview on 08/14/24 at 12:59 PM, when asked how staff document behavior monitoring at the facility, the MDS Coordinator explained it was part of a batch order set used when a resident was admitted or readmitted , which allowed the nurse to document behaviors on the eMAR. The MDS Coordinator stated the order set may have fallen off during one of the resident's readmissions and no one caught it.

2) Review of the record revealed Resident #14 was admitted to the facility on [DATE REDACTED] with an indwelling urinary catheter. Further review revealed an order for a urinalysis to be completed on 07/29/24. An order for Cipro (an antibiotic) was written to begin on 07/30/24, to give 500 milligrams (mg) every 12 hours for 14 days.

Review of the urinalysis along with the culture and sensitivity, that was collected on 07/29/24 and reported to

the facility on [DATE REDACTED], revealed Resident #14 did have a urinary tract infection (UTI). Further review of the culture revealed the antibiotic Cipro was resistant to the organism, and thus was not appropriate as the treatment for this UTI.

Review of the corresponding Medication Administration Records (MARs) revealed Resident #14 was administered the Cipro starting on 07/30/24 at 8:00 AM, twice daily through 08/11/24, thus receiving 22 extra doses of the antibiotic after having been determined to be resistant, or ineffective, as per the laboratory results

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 12 106097 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106097 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960

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)

F 0757 During an interview on 08/13/24 at 1:38 PM, when asked about the failure to stop the Cipro on 07/31/24, upon receipt of the culture documenting the Cipro was resistant to the organism, the Administrator, who was Level of Harm - Minimal harm or also a Registered Nurse stated apparently no one looked at the culture and noticed the Cipro was resistant. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 12 106097 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106097 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960

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)

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25404 potential for actual harm Based on record review and interview, the facility failed to complete physician ordered laboratory services Residents Affected - Few timely for 2 of 5 sampled residents reviewed for unnecessary medications (Resident #9 and #72).

The findings included:

1) Review of the record revealed Resident #9 was admitted to the facility on [DATE REDACTED]. Review of the orders revealed the need for a CBC (Complete Blood Count) and CMP (Comprehensive Metabolic Panel) to be drawn on 07/22/24. The record lacked any results for these labs.

During an interview on 08/14/24 at 12:36 PM, the Director of Nursing (DON) was asked to locate and provide

the CBC and CMP results from 07/22/24. The DON was unable to do so. The DON looked on the laboratory's website and found that four other residents had labs drawn on 07/22/24, and one on 07/23/24, but was unable to locate any for Resident #9. The DON reviewed the laboratory service binder and could not find any requisition page for 07/22/24 or 07/23/24, thus was unable to determine why the labs were not drawn as per order.

2) Review of the record revealed Resident #72 was admitted to the facility on [DATE REDACTED]. Further review revealed an order dated 08/07/24 for a urinalysis with a culture and sensitivity to be completed. A second order dated 08/07/24 documented a CBC (complete blood count) and CMP (comprehensive metabolic panel) was to be drawn on 08/09/24. The electronic record lacked any results for either of these orders. The progress notes lacked any reason the orders were not completed.

During an interview on 08/13/24 at 11:25 AM, when asked about laboratory results, the Director of Nursing (DON) stated they had been having issues with the results not automatically integrating into their electronic record, so they had been scanning the results into the record manually. The DON was asked about the ordered labs for Resident #72, and upon searching on the laboratory services website, the DON found the CBC and CMP was completed on 08/12/24, three days after the ordered date, but was unable to locate any results for the urinalysis. The DON looked in the laboratory binder and could not find any requisition for the urinalysis. During the interview Staff C, Registered Nurse (RN) joined the conversation. When asked the reason for the urinalysis, the RN stated for her behaviors. When asked if she knew why the urinalysis was not completed, the RN stated she did not know, but if the sample wasn't labeled correctly or was too old when the laboratory services arrived, it would be thrown out.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 12 106097 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106097 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960

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)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Potential for minimal harm 32078

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure an accurate and current menu was posted for residents who eat their meals at the facility.

The findings included:

On 08/11/24 (Sunday) at 9:00 AM, it was observed that the daily menu posted on the wall at the entrance to

the dining room was labeled as being the menu for Monday. This menu documented that the lunch meal to be provided on this day was Cracker Crumb Cod, Potato Wedges, Broccoli, Roll, and Brownie, with the alternate meal being Chili with Beans and Baked Potato.

During the meal observation at 08/11/24 at 12:10 PM, the main entree served to the residents was Turkey Shepherd's Pie (Ground Turkey, mashed potatoes, peas/corn/carrots), Dinner Roll, and Cheesecake. The only other meal observed being served at this time was an always available grilled cheese sandwich, tomato soup, and fresh fruit.

Observation of a weekly menu posted on the bulletin board in the dining room showed the menu was for Week 1, which included the dates of 08/20/24 - 08/26/24. A search through all the weekly menus posted on

the bulletin board did not contain a menu for any dates prior to 08/20/24.

While looking at the menus, the surveyor was approached by the significant other of Resident #2 who stated, If you can understand the logic of those menus posted, you are a better person than I am. That daily menu posted on the outside of the dining room has been there since last Monday. It would be nice to know what's being served.

An interview conducted with the Certified Dietary Manager on 08/14/24 at 10:08 AM revealed that she had been on vacation and this was her first day back. It seems the daily menus were not changed in my absence. I changed the menu this morning. She also stated that the weekly menus posted on the bulletin board in the dining room should have indicated the menu for Week 5, not Week 1.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 12 106097 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106097 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960

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)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 38212 potential for actual harm Based on observation, interview and policy review, the facility failed to implement Enhanced Barrier Residents Affected - Few Precautions (EBP) for 1 of 1 sampled resident with an indwelling catheter (Resident #14).

The findings included:

The policy titled Enhanced Barrier Precautions and implemented 04/01/2024 documents in part:

Enhanced Barrier Precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities.

Policy Explanation and Compliance Guidelines:

a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precaution.

9. Enhanced Barrier Precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that places them at high risk.

On 05/18/24, Resident #14 was admitted to the facility with diagnosis to include:

Urinary Tract Infection, Cerebrovascular Disease, Hypotension, Dementia, and Gout.

Resident #14 has a BIMS (Brief Interview for Mental Status) of 11, which indicates moderately impaired mental status. The resident had an indwelling urinary catheter present.

On 08/11/24 at 10:24 AM, Resident #14's room was observed; no EBP sign was noted on the door and no gowns were available. Resident #14 has a urinary catheter due to obstructive uropathy. During an interview with Resident #14, he stated that the staff wear gloves but they don't wear gowns during care.

On 08/12/24 at 12:27 PM, Staff A, a CNA (Certified Nursing Assistant) was observed donning a gown to deliver a meal tray. The EBP sign was noted on the door with a contact isolation sign also on the door. She was asked why she had donned the gown, and she replied, They told me to put on a gown since I was opening an item on [Resident #14] meal tray.

On 08/13/24 at 10:01 AM, Staff B, a CNA, performed urinary catheter care and peri-care on Resident #14.

The CNA donned gloves and a gown. The resident asked, I wonder when they will be taking the sign off my door. Staff B replied I think your last one [antibiotic] was yesterday or it may be today, but I just wanted to be

on the safe side.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 12 106097 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106097 B. Wing 08/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hidden Lakes Senior Living Community 1006 33rd St Vero Beach, FL 32960

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)

F 0880 On 08/13/24 at 10:50 AM, Staff B was asked why she had worn a gown during the care. She stated that the overnight nurse told her the antibiotic for his ESBL (Extended Spectrum Beta-Lactamase) was up yesterday, Level of Harm - Minimal harm or and today's nurse said she thought that it was up today, so I used the gown to be safe. When shown and potential for actual harm asked about the EBP sign, the CNA read it over and stated, I guess I need to wear the gown. The CNA stated she did not know about the EBP or the need to wear PPE (Personal Protection Equipment) for a Residents Affected - Few resident with a urinary catheter. Staff B further added, I don't think he had that sign or PPE when I worked last time, and he had the Foley.

On 08/13/24 at 9:30 AM, Staff C, an RN (Registered Nurse), was interviewed. She was asked why the PPE (Personal Protective Equipment) was on the door for Resident #14. She stated the precautions were for the ESBL in his urine. When shown the sign for EBP, the RN was unaware of the use of PPE during care. The RN stated that prior to his contact precautions, Resident #14 had not been on any type of precaution.

Review of the chart revealed no ESBL in the urine and no indication for contact isolation. No order was found for Enhanced Barrier Precautions for Resident #14 and his indwelling urinary catheter.

On 08/14/24 at 10:43 AM, the DON (Director of Nursing) was interviewed about the EBP and how the staff is made aware of the precautions for the residents. She stated the last update for the staff on EBP precautions was on 02/14/24. A new policy was initiated on 04/01/24 for EBP. She states no in-services were completed with staff following the implementation of the new policy which includes EBP for urinary catheters.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 12 106097