Inspection·August 7, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to administer blood pressure medication according to physician ordered parameters for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 39 residents, (#63).Findings:Review of the medical record revealed resident #63 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hypertension, heart valve insufficiency, and hyperlipidemia. Review of the Minimum Data Set quarterly assessment with assessment reference date of 7/29/25 revealed resident 63 had an active diagnosis of hypertension. Review of the Order Summary Report for August 2025 revealed resident #63 had a physician order dated 7/21/25 for Metoprolol Tartrate 12.5 milligrams to be given two times a day for beta-blocker. The order included parameters to hold the medication if resident #63's heart rate was less than 55 beats per minute or her Systolic Blood Pressure (SBP) was less than 120. Metoprolol is a beta-blocker medication used to treat hypertension (high blood pressure). Metoprolol affects the heart and circulation (blood flow through arteries and veins) by relaxing the blood vessels which helps to lower blood pressure and may cause very slow heartbeats (retrieved on 8/08/25 from www.drugs.com). Review of the Medication Administration Record (MAR) for July 2025 and August 2025 revealed nine nurses administered Metoprolol Tartrate to resident #63 outside of specified parameter, 10 times over a 30-day period. Documentation showed resident #63 received this medication on nine days although her SBP was less than the 120 indicated in the order parameters. The medication was administered on 7/06/25 with an SBP of 114, on 7/07/25 with an SBP of 112, on 7/08/25 with an SBP of 118, twice on 7/25/25 with an SBP of 116, on 7/27/25 with an SBP of 115, on 8/01/25 with an SBP of 112, on 8/02/25 with an SBP of 110, on 8/04/25 with an SBP of 107 and on 8/05/25 with an SBP of 118. Review of Progress Notes for July 2025 and August 2025 revealed no associated documentation for the above dates to explain why the Metoprolol was given outside of the physician ordered parameter. On 8/06/25 at 2:38 PM, Licensed Practical Nurse (LPN) C reviewed resident #63's MAR and confirmed she administered Metoprolol on 7/08/25 when it should have been held due to a low SBP. She acknowledged the medication was used to treat high blood pressure and giving it out of parameters could cause the resident's blood pressure to drop too low. On 8/06/25 at 2:46 PM, Registered Nurse (RN) B verified she gave resident #63 Metoprolol on 7/07/25 when it should have been held. She stated the parameters were set because the medication lowers blood pressure but you would not want it to drop too much. She explained she administered the medication outside the order parameters in error. On 8/07/25 at 10:38 AM, LPN D reviewed resident #63's MAR and acknowledged she administer Metoprolol outside of parameters on 7/25/25 and 8/01/25. LPN D stated it was in error. She explained Metoprolol does not always have a parameter set. But if there is one, it should be followed as prescribed. On 8/06/25 at 2:53 PM, the Director of Nursing (DON) - [NAME], RN/DON - verified medication was a blood pressure/cardiac medication. Used to lower blood pressure. Sometimes has parameters, but not always. Should follow the physician (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 3 Event ID: 105967 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 105967 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761 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)