Lakes Of Clermont Health And Rehabilitation Center

Based on observation, interview, and record review, the facility failed to obtain physician orders to provide wound care for 1 of 2 residents, Residents #45, reviewed for skin conditions.Findings include:During an observation on 2/23/2026 at 11:20 AM, Resident #45 was sitting in his wheelchair in his room. There was a dressing on Resident #45's right forearm with dark color dried substance matter on the dressing. The dressing did not have a date or initials (photographic evidence obtained).During an interview on 2/23/2026 at 11:20 AM, Resident #45 stated, This is a skin tear on my arm, but I do not recall how I got it.During an observation on 2/24/2026 at approximately 8:05 AM, Resident #45 was sitting up in his bed. There was a dressing on his right forearm with dark substance matter. The dressing was not dated or initialed. Review of Resident #45's physician orders revealed no wound care or dressing change orders in place.Review of Resident #45's Treatment Administration Record for February 2026 revealed no wound care or dressing change.During an observation on 2/24/2026 at 1:21…

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 respiratory in accordance with professional standard of practice for 1 of 2 residents, Resident #96, reviewed for respiratory services.Findings include:During an observation on 2/23/2026 at 9:53 AM, Resident #96 was lying in bed, receiving oxygen via nasal cannula at 3 liters per minute. The resident was not in acute respiratory distress at the time of observation.During an interview on 2/23/2026 at 9:54 AM, Resident #96 stated, I don't need any oxygen. My oxygen is usually 97 and 98%. The resident denied shortness of breath at the time of interview.Review of Resident #96's physician orders revealed no physician order for oxygen therapy.During an observation on 2/24/2026 at 8:41 AM, Resident #96 was lying in bed, receiving oxygen via nasal cannula at 3 liters per minute. The resident was not in acute respiratory distress at the time of observation.During an interview on 2/24/2026 at 9:04 AM, Staff D, Licensed Practical Nurse (LPN), stated, The oxygen was set at 3 liter per minute.…

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 medications were securely stored in 2 of 4 units. Findings include: 1) During an observation on 2/23/2026 at 10:47 AM, Resident #97 was lying in bed with eyes closed. On top of the cabinet table across from the resident's bed, there was one blue bottle of Wound Cleansing Solution (Photographic evidence obtained). During an observation on 2/23/2026 at 2:30 PM, Resident #97 was lying in bed. On top of the cabinet table across from the resident's bed, there was one bottle of Wound Cleansing Solution. During an interview on 2/23/2026 at 3:42 PM, Staff C, Licensed Practical Nurse (LPN), stated, The wound cleanser should not have been left in [Resident #97's name] room. It [wound cleanser] should be stored in the treatment cart. 2) During an observation on 2/23/2026 at 11:09 AM, Resident #108 was sitting in a wheelchair in her room. There was one container of zinc oxide diaper rash cream, and one bottle of Ammonium Lactate 12% (Photographic evidence obtained). During an interview on 2/23/2026 at 11:09 AM,…

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 while distributing water, providing wound care, and administering medications, and failed to ensure staff used proper Personal Protective Equipment (PPE) while providing care and services for 1 of 3 residents, Resident #97, reviewed for transmission-based precautions to prevent the possible spread of infection and communicable diseases.Findings include:1) During an observation on 2/23/2026 beginning at 2:30 PM Staff A, Certified Nursing Assistant (CNA), was carrying three foam cups that had lids on them and straws inserted through the lids. The cups were labeled 2/23/2026, 7P - 7A (indicates the 7:00 PM shift that ended at 7:00 AM in the morning). Staff A placed the used cups on the second shelf of a three-tier pushcart. Staff A did not perform hand hygiene and touched multiple cups located on the top shelf of the cart in preparation for delivery to the residents. The cups were labeled 2/23/2026, 2 PM. Staff A did not perform hand hygiene and retrieved two of the new cups…

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 the resident's family/responsible party was notified of falls, physician orders, and hospital transfer for 1 of 3 residents, Resident #1, reviewed for falls. Findings include: Review of Resident #1's clinical record documented the resident was admitted on [DATE] with diagnosis including but not limited to unspecified fracture of the upper end of the right tibia, encounter for other orthopedic aftercare, cellulitis (infection of the skin) of the right lower limb, repeat falls, abnormalities of gait and mobility, muscle weakness, muscle wasting and atrophy (wasting of muscle). Review of Resident #1's nurses note dated 5/22/2025 at 16:56 (4:56 PM) read Patient was seated on the floor on her buttocks in front of her wheelchair with legs extended out in front of her. Patient denies hitting her head. Able to move all extremities within normal limits. Review of Resident #1's clinical record found it did not contain documentation of Resident #1'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, record review, and interview, the facility failed to ensure residents received care and services in accordance with professional standards of practice for application of Thrombo-Embolic Deterrent (TED) stockings for 2 of 3 resident reviewed, Residents #174 and #62 (Photographic evidence obtained), and failed to ensure residents received medications as ordered by physician for 3 of 8 residents reviewed for unnecessary medications, Residents#175, #49 and #323. Findings include: 1) Review of Resident #174's admission record showed the resident was admitted on [DATE] with diagnoses that included cellulitis of the right lower limb, atrial fibrillation, thoracic aortic ectasia, and essential (primary) hypertension (high blood pressure). Review of Resident #174's physician order dated 9/8/2024 read, Compression hose to bilat [bilateral] lower extremities in the morning for orthostatic hypotension [low blood pressure] apply in AM [morning] and remove at HS [bedtime] and remove per schedule. During…

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 drugs and biologicals were stored in a secured manner in accordance with currently accepted professional principles (Photographic evidence obtained). Findings include: 1) During an observation on 9/16/2024 at 11:47 AM, there were three containers on Resident #32's dresser. One container contained red fluid and the other two contained transparent liquids. All containers had labels that read, Poison/Do Not Drink. During an interview on 9/16/2024 at 11:58 AM, Staff D, Registered Nurse (RN), stated, Those are for stool sample and should be in the bathroom. They were here since Saturday [9/14/2024]. It is poisonous. When we get a sample, we should have them in the bathroom. The medications and biologicals need to be stored in a secured place. During an interview on 9/18/2024 at 3:14 PM, the Director of Nursing stated, The biologicals should be securely stored when the sample is being collected. 2) During an observation on 9/16/2024 at 9:40 AM, there was one anti-itch spray on the bedside table in Resident…

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 stored food items were labeled and dated in Refrigerator No. 1 in the kitchen and in the nourishment room refrigerator (Photographic evidence obtained). Findings include: 1) During an observation while conducting the initial tour of the kitchen on 9/16/2024 at 9:24 AM, there was one bag containing food with no label or date stored in Refrigerator #1 in the kitchen. During an interview on 9/16/2024 at 9:26 AM, the Certified Dietary Manager (CDM) confirmed that the food item stored in Refrigerator #1 did not have a label or date. During an interview on 9/16/2024 at 9:55 AM, Staff E, Dietary Aide, stated the unlabeled bag contained chicken and mashed potato. 2) During an observation on 9/16/2024 at 9:46 AM, there were two bags containing food items with no label and date stored in the refrigerator of the nourishment room. During an interview on 9/16/2024 at 9:46 AM, the CDM identified the food items as yogurt and chicken and confirmed that they were not labeled and dated. 3) During an observation while…

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 resident records were complete and accurate for 3 of 8 residents reviewed, Residents #174, #62, and #374. 1) Review of Resident #174's admission record showed the resident was admitted on [DATE] with diagnoses that included cellulitis of the right lower limb, atrial fibrillation, thoracic aortic ectasia, and essential (primary) hypertension (high blood pressure). Review of Resident #174's physician order dated 9/8/2024 read, Compression hose to bilat [bilateral] lower extremities in the morning for orthostatic hypotension [low blood pressure] apply in AM [morning] and remove at HS [bedtime] and remove per schedule. During an observation on 9/16/2024 at 10:40 AM, Resident #174 was sitting in his wheelchair, with no TED stockings applied. During an observation on 9/17/2024 at 12:15 PM, Resident #174 was sitting up in his wheelchair at bedside, with no TED hose applied. During an interview on 9/17/2024 at 1:11 PM, Staff A, Certified Nursing…

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 used proper personal protective equipment (PPE) while providing high contact care to the residents on Enhanced Barrier Precautions to prevent the possible spread of infection and communicable diseases. Findings include: During an observation on 9/18/2024 at 9:22 AM, Resident #375's room door had a signage that read, Stop. Enhanced Barrier Precautions. Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing. During an observation on 9/18/2024 at 9:28 AM, Staff D, Registered Nurse (RN), entered Resident #375's room wore gloves but did not wear a gown. Staff A applied a dressing on the resident's sacral wound.…

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 interview and record review the facility failed to ensure wound care treatment was provided as ordered by the physician for 1 of 3 residents, Residents #7. Findings include: Review of Resident #7's medical chart documented the resident was admitted on [DATE] with diagnosis to include fusion of the spine in the lumbosacral region [surgery to connect two or more bones], acute respiratory failure, spinal stenosis and cauda equina syndrome [nerve roots in the lumbar spine are compressed, cutting off sensation and movement]. Review of the SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 4/29/23 Situation: Skin wound or ulcer. This started on: 04/29/2023. Skin Evaluation: Pressure Ulcer. Wound with full thickness tissue loss. Recommendations of Primary Clinicians: Continue to pack wound with lodoform packing strip and cover with Island dressing. Review of physician's orders dated 4/30/23 read, Right posterior thigh cleanse with NS [normal saline] pat dry, pack with Iodoform…

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 the drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles to include the expiration date when applicable in 1 of 3 medication carts observed and failed to ensure all medications were stored in locked compartments to permit only authorized personnel to have access. Findings include: During an observation on 5/15/23 at 10:55 AM of Medication Cart #2 located on the 300 hall with Staff F, Registered Nurse (RN) Unit Manager there were six insulin pens, three insulin Lispro Kwik Pens, one Humalog Kwik Pen, one Insulin Glargine Pen, one Lantus Solostar Pen, that were opened and undated to provide the expiration of the medication. (Photographic evidence obtained). During an interview on 5/15/23 at 11:00 AM Staff F, RN/Unit Manager verified the insulin pens were opened and stated, My expectation is for anyone that opens an insulin pen to date it. During an interview conducted on 5/15/23 at 11:23 AM the Director of Nursing (DON) stated,…

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' medical records were complete and accurate for 3 of 10 records reviewed, Residents #11, #28 and #35. Findings include: 1. Record review of Resident #28's physician orders dated 3/16/2023 read, Heel protectors while in bed every shift. During an observation on 5/15/2023 at 2:28 PM Resident #28 was lying in bed resting. The resident did not have heel protectors. During an observation on 5/16/2023 at 08:07 AM Resident #28 was lying in bed and did not have heel protectors. During an interview on 5/16/2023 at 08:45 AM Resident #28 stated I don't wear them anymore [heel protectors]. During an interview on 5/17/2023 at 08:13 with Staff C, Certified Nursing Assistant (CNA) in Resident #28's room stated, Heel protectors have not been used since the patient received the specialty bed. [Resident #28's name] is lying in the bed with no heels protectors on and heel protectors are not available. Review of the Treatment Administration…

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.