Clermont Health And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to ensure insulin was administered as ordered by physician for 4 of 8 residents reviewed for unnecessary medications (Residents #1, #183, #72, and #102), and failed to ensure hypotensive medication was administered as per the parameters ordered by physician for 1 of 8 residents reviewed (Resident #27). Findings include: 1) Review of Resident #1's physician order dated 2/24/2025 read, Insulin Glargine-yfgn Subcutaneous Solution 100 UNIT/ML [milliliters] (Insulin Glargine-yfgn), Inject 30 unit subcutaneously two times a day for DM [Diabetes Mellitus] Give in morning and HS [Hour of Sleep]. Review of Resident #1's Medication Administration Record (MAR) for May 2025 for administration of Insulin Glargine-yfgn showed code 11 (insulin not required) was documented on 5/3/2025 at 8:00 AM, 5/13/2025 at 8:00 AM, 5/17/2025 at 8:00 AM, 5/23/2025 at 8:00 AM, and 5/30/2025 at 8:00 AM, and code 5 (hold/see nurses notes) was documented on 5/9/2025 at 8:00 AM and 5/27/2025 at 8:00 AM. Review of Resident #1’s nursing progress…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure proper positioning while tube feeding for 1 of 2 residents reviewed for tube feeding (Resident #40).Findings include: During an observation on 8/4/2025 at 9:19 AM, Resident #40 was lying in bed with the mattress flat and tube feeding pump running at 50 milliliters per hour. Resident #40 had her head on a pillow and the rest of her body was flat on the mattress. Review of Resident #40's physician order dated 7/30/2025 read, Enteral feed order every shift PEG [Percutaneous Endoscopic Gastrostomy] tube Feed: Glucerna 1.5 Cal [calorie] Continuous via tube to infuse at a rate of 50 ml/hr [milliliter/hour]. Total volume of 1100 ml infused in 22 Hours. Hang feed at 1900 [7:00 PM]. May turn off for care/services. Verify infusing Q [every] shift. Clear pump when total volume has infused. Review of Resident #40's physician order dated 6/11/2025 read, Elevate head of bed while feeding and medication is being administered every shift every shift for prevention. During an interview on 8/4/2025 at 9:25 AM, Staff A,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure the physician documented the rationale for disagreement with the pharmacist's recommendation for 1 of 5 residents reviewed for unnecessary medications (Resident #58). Findings include: Review of Resident #58's pharmacy review titled Note to Attending Physician/Prescriber dated 6/12/2025 read, 1. Can PRN [as needed] Geri-Tussin DM [Dextromethorphan] be discontinued due to non-use? No. 2. Can PRN Loperamide be discontinued due to non-use? No. 3. Can PRN Meclizine be discontinued due to non-use? No. 4. Can PRN Midodrine be discontinued due to non-use? No. 5. Can PRN Tramadol be discontinued due to non-use? No. Physician/Prescriber response: Disagree. Provide Rationale [Blank]. The document was signed by the Medical Doctor #4. During an interview on 8/7/2025 at 8:34 AM, the Director of Nursing (DON) stated, I receive monthly pharmacy reviews and sometimes in between. For short stay residents, we send over a pharmacy review request, the pharmacist looks the medications over and sees if anything needs to be discontinued…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for antidiabetic medication administration for 1 of 8 residents reviewed for medication management (Resident #34).Findings include: Review of Resident #34's physician order dated 8/14/2024 read, Monitor BS [Blood Sugar] every 12 hours for PRN [as needed] glipizide two times a day for PRN glipizide, Administer is [Sic.] BS is greater than 180. Review of Resident #34's physician order dated 2/8/2025 read, Glipizide Oral Tablet 10 MG [milligram] (Glipizide), Give 1 tablet by mouth every 12 hours as needed for DM [Diabetes Mellitus], Give if blood sugar is greater than 180. Review of Resident #34's Medication Administration Record (MAR) for June 2025 for monitoring blood sugar showed blood sugar was documented as 223 at 8:00 AM, and 224 at 8:00 PM on 6/2/2025; 336 at 8:00 AM, and 247 at 8:00 PM on 6/3/2025; 310 at 8:00 AM on 6/7/2025; 203 at 8:00 AM on 6/8/2025; 260 at 8:00 PM on 6/9/2025; 238 at 8:00 AM, and 232 at 8:00 PM on 6/10/2025; 316 at 8:00 AM on 6/11/2025; 266 at 8:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure a resident (Resident #192) was placed on contact precautions and failed to ensure staff used appropriate Personal Protective Equipment (PPE) and performed hand hygiene while providing care to the residents on contact precautions to prevent the possible spread of infection and communicable diseases. Findings include: During an interview on 8/5/2025 at 11:50 AM, Resident #192 stated, I have an infection. It's MRSA [Methicillin Resistant Staphylococcus aureus]. They [staff members] don't wear any gowns or anything when they help me. During an observation on 8/4/2025 at 11:50 AM, there was no contact isolation signage on the Resident #192'r room door. Review of Resident 192's nursing progress note dated 8/1/2025 read, Resident admitted to the facility via wheelchair. Female patient [AGE] years old with diagnosis of COPD [Chronic Obstructive Pulmonary Disease], asthma, respiratory failure, aortic stenosis. Resident on oxygen 2L [liters]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure Minimum Data Set (MDS) was accurate for 2 of 3 residents reviewed for discharge, Residents #174 and #175. Findings include: 1. Review of Resident #174's records showed the resident was discharged on 1/31/2024 to home. Review of Resident #174's Discharge Return Not Anticipated MDS dated [DATE] showed the resident was discharged to short-term general hospital. During an interview on 5/2/2024 at 12:00 PM, the MDS Director stated the documented discharge of Resident #174 to short term general hospital was incorrect and Resident #174's discharge should have been documented as to community. 2. Review of Resident #175's records showed the resident was discharged on 2/9/2024 to home. Review of Resident #175's Discharge Return Not Anticipated MDS dated [DATE] showed an unplanned type of discharge. During an interview on 5/2/2024 at 11:53 AM, the MDS Director stated Resident #175's MDS was incorrect under section A 310 G- type of discharge and should have…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents received oxygen as per physician order for 2 of 3 residents reviewed for respiratory care, Residents #139, and #154. Findings include: 1. During an observation on 4/29/2024 at 11:01 AM, Resident #139 was in bed, receiving oxygen via nasal canula at 3 liters per minute (LPM). During an observation on 4/30/2024 at 9:53 AM, Resident #139 was in bed, receiving oxygen via nasal canula at 3 LPM. Review of Resident #139's physician orders showed the order dated 4/8/2024 for administration of oxygen at 2 LPM via nasal cannula as needed for shortness of breath. During an interview on 4/30/2024 at 9:55 AM, Resident #139 stated, The nurse turns my oxygen on and off for me. I do not adjust it. During an interview on 4/30/2024 at 10:00 AM, the Director of Nursing (DON) confirmed the oxygen concentrator was set at 3 LPM for Resident #139 and verified the physician order for Resident #139 to receive oxygen at 2 LPM. 2. During an observation on 4/29/2024 at 11:45 AM, Resident #154 was in bed, receiving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents had a safe and homelike environment in 2 of 3 residential units, 200 Unit and 300 Unit (Photographic evidence obtained). Findings include: During an observation on 4/29/2024 at 9:31 AM, the rubber baseboard molding (a trim used to cover the bottom few inches of the wall) was separated from the wall on the right side of Resident #144's bed. During an observation on 4/29/2024 at 11:09 AM, the rubber transition floor strip (covers floor gaps where two-floor surfaces meet) from the hallway into Resident #78's room, had a quarter-size gap between broken pieces of the strip. During an interview on 4/29/2024 at 11:10 AM, the Maintenance Director stated, There are a lot of things needing repair on this floor. A resident could fall if we don't fix it [pointing to the rubber transition floor strip for Resident #78's room). Staff need to report these things when they see it. During an observation on 4/29/2024 at 11:27 AM, the rubber transition floor strip from the hallway into Residents #19 and #427's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure residents received appropriate urinary catheter care, and failed to ensure urinary flow into the urinary catheter bag was maintained for 1 of 3 residents reviewed for incontinence care, Resident #165. Findings include: Review of Resident #165's admission record showed the resident was most recently admitted on [DATE] with the diagnoses including urinary tract infection, type 2 diabetes mellitus with unspecified complications, hydronephrosis and neuromuscular dysfunction of bladder. Review of Resident #165's physician order dated 3/18/2024 read, Suprapubic Catheter: Suprapubic catheter to drainage bag for DX [diagnosis] Neurogenic bladder, suprapubic catheter size #18F [French] with 30 cc [cubic centimeters] balloon. Observe Q [every] shift for observation. Review of Resident #165's care plan dated 3/4/2024 read, Focus: Suprapubic Catheter. The resident uses a suprapubic catheter with risk for infection and/or complications related…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure foods were stored in a safe and sanitary manner in the main kitchen of the facility. Findings include: During an observation while conducting a tour of the main kitchen on 4/29/2024 at 9:30 AM, with the Certified Dietary Manager (CDM), there were two unlabeled and undated 2.5-gallon buckets of yellowish liquid on the second shelf of the main walk-in cooler, one 4-inch steam pan with a purple jelly like substance on the second shelf of the main walk-in cooler with no label to identify the contents and an expiration date of 4/23/2024, and one opened undated bag of plant-based chicken nugget on the third shelf of the walk-in cooler. During an interview on 4/29/2024 at 9:30 AM, the CDM confirmed the unlabeled and undated food items in the walk-in cooler, and stated, Everything in here should have a label and an expiration date sticker placed on it before storing it. Review of the facility policy and procedure titled Storage with an effective date of January 2023 and a review date of 1/5/2024, showed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration and failed to ensure staff followed infection control standards of practice for administration of subcutaneous medications to help prevent the possible transmission of infection and communicable diseases. Findings include: During an observation on 4/30/2024 at 8:05 AM, Staff B, Registered Nurse (RN), unlocked the medication cart and began preparing medication for Resident #118. Staff B did not perform hand hygiene. Staff B compared the individual medication packet to the physician's orders, poured the medications including Amlodipine 10 mg (milligram) tablet, Escitalopram 10 mg tablet, Buspirone 7.5 mg tablet, Carvedilol 3.125 mg tablet, Aspirin 81 mg Capsule, Iron 325 mg tablet, Vitamin B12 100 mcg (microgram) tablet, Vitamin D 125 mcg capsule, Raw Enzyme tablet, and Losartan 100 mg tablet into a single medication cup for oral administration, and returned each packet to the drawer. Without performing hand hygiene, Staff B locked the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure foods in the refrigerator/freezer were covered, dated, labeled, and shelved to allow circulation, failed to ensure the equipment was in good condition, and failed to ensure the kitchen and food service equipment were clean. Findings include: On 1/3/2023 at 8:46 AM, during a tour of four nourishment rooms including C-1, C-2, C-3, and post-acute areas with the Registered Dietician (RD), there were outdated or undated open products of juices, milk, nutritional drinks, and thickened water (Photographic evidence obtained). On 1/3/2023 at 9:16 AM, during an initial tour of the refrigerator, freezer and stock-room located in the kitchen with the RD, the following were observed: 1. a buildup of what appeared to be food particles and spills in the microwave, 2. dust and grease build up under the stove hood vent and on the light covers, 3. open boxes of raw cookie dough with open flaps exposing food items and a buildup of ice on the back wall and floor in the freezer, 4. food items with no use by date or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain accurate and complete medical records for 1 of 3 sampled residents, Resident #32. Findings include: Review of the medical records for Resident #32 revealed the resident was admitted on [DATE] with the diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, immobility syndrome, unspecified severe protein calorie malnutrition, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infections as the cause of disease classified elsewhere, chronic obstructive pulmonary disease, emphysema, pressure ulcer of sacral region, stage 4 pressure ulcer of left hip, other lack of coordination, dislocation of thoracic 12 lumbar 1 vertebra sequela, paraplegia, polyneuropathy, neuromuscular dysfunction, hyperlipidemia, anemia, other injury of unspecified body region, sepsis due to methicillin resistant staphylococcus aureus, obstructive and reflux uropathy, colostomy, resistance to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Review of the medical records for Resident #32 revealed the resident was admitted on [DATE] with the diagnoses including osteomyelitis of vertebra, sacral and sacrococcygeal region, immobility syndrome, unspecified severe protein calorie malnutrition, local infection of the skin and subcutaneous tissue, methicillin resistant staphylococcus aureus infections as the cause of disease classified elsewhere, chronic obstructive pulmonary disease, emphysema, pressure ulcer of sacral region, stage 4 pressure ulcer of left hip, other lack of coordination, dislocation of thoracic 12 lumbar 1 vertebra sequela, paraplegia, polyneuropathy, neuromuscular dysfunction, hyperlipidemia, anemia, other injury of unspecified body region, sepsis due to methicillin resistant staphylococcus aureus, obstructive and reflux uropathy, colostomy, resistance to multiple antibiotics, stage 4 pressure ulcer of left buttock, unstageable pressure ulcer of left heel, unstageable pressure ulcer of right heel, essential hypertension, presence of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.