F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**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.
Residents Affected - Few
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 packing, cover with petroleum gauze, secure with hydrocolloid dressing, on
Monday, Wednesday and Saturday.
Review of [Wound Physician Organization's name] Wound Care Physician notes dated 5/3/23 documented
wound #2 Stage 4 pressure ulcer right posterior, upper thigh. Wound size 6 cm [centimeters] x 5.8 cm x 1.4
cm. Dressing treatment Santyl, Alginate Calcium with silver 3 x per week for 9 days. Wound Progress:
Improved. debrided on this visit. Dated: 5/10/23 wound #2 Stage 4 pressure ulcer right posterior, upper
thigh. Wound size 6 cm x 5.8 cm x 2.5 cm. Dressing treatment Betadine gauze sponge non-sterile twice
daily 30 days. Wound Progress: Deteriorated. Debrided on this visit.
Review of the Treatment Administration Record (TAR) and the physician's orders for the month of May 2023
did not provide documentation of the wound care treatment order change dated 5/3/23 of Santyl, Alginate
Calcium with silver 3 x per week or the order change dated 5/10/23 of Betadine gauze sponge non-sterile
twice daily.
During an interview on 5/17/23 at 2:50 PM the Director of Nursing (DON) stated, we have a rounding nurse
that comes in on Wednesday and follows the wound care physician. After the rounding is completed the
nurse inputs [wound change] orders in the computer from the Wound Care Physician. The nurse comes in
for that reason. The DON stated the wound deterioration may be contributed to the wound care was not
followed as ordered by the Wound Care 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 7
Event ID:
106134
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
106134
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/18/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakes of Clermont Health and Rehabilitation Center
1775 Hooks Street
Clermont, FL 34711
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 5/17/23 at 4:05 PM the Wound Care Physician stated, the deterioration of the
wound was multifactorial [involving or dependent on a number of factors or causes], care not being done as
ordered was a contributor.
Review of the facility policy and procedure titled, SG [Standards and Guidelines] Physician and
Non-Physician Practitioner Orders issued: 2/1/2002 and revised: 10/24/22 read, Standards: With changing
ways in communication it will be the practice of this facility to honor physician's/Licensed Independent
Practitioner (LIP) orders in the following ways: Electronic Orders, including, but not limited, to direct entry
into the clinical record or electronic order system (or entered in the clinical record by nurse after
acknowledged from written order). Electronic Orders (Direct entry into the clinical record) Orders entered
into the clinical record following acknowledgement of a written physician's order by a facility staff member.
Review of the policy and procedure titled, SG Charting and Documentation issued on 1/1/2006 and revised
on 3/27/2021 reads, Standard: It is the standard of this facility that services provided to the resident or any
changes in the resident's medical or mental condition, shall be documented in the resident's clinical record
as is needed. Guidelines: 1. Observations, medication administered, services performed, etc., should be
documented in the resident's clinical records. 3. Entries into the clinical record should be made by the
appropriate staff members. Staff providing care and services to the resident may contribute to the overall
documentation in the clinical record in accordance with state and federal laws. Determination of the
resident's overall condition may require the collective review of documentation from multiple resources.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106134
If continuation sheet
Page 2 of 7
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
106134
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/18/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakes of Clermont Health and Rehabilitation Center
1775 Hooks Street
Clermont, FL 34711
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
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, My
expectation is they should be dated [insulin pens].
Review of the policy and procedure titled, Storage revised 08-2020 read, Policy: Medication and biologics
are stored safely, securely, and properly, following manufactures recommendations or those of the supplier.
The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff
members lawfully authorized to administer medications. Procedures I. General Guidance 5. When the
original seal of the manufacture's container or vial is initially broken, the container or vial will be dated. a.
The nurse shall place a date open sticker on the medication and record the date opened and the new date
of expiration. The expiration date of the vial or container will be 30 days from opening, unless the
manufacturer recommends another date or regulations/guidelines require different dating.
During an observation on 5/15/2023 at 09:58 AM in Resident #212's room there was a bottle of Nasacort
spray and Mentholatum cream on the bedside table.
During an interview on 5/15/2023 at 09:58 AM Resident #212 stated, Those are my medications that I use.
No one has informed me that I could not have medications at the bedside.
During an observation on 5/16/2023 at 08:25 AM in Resident #212's room there was a bottle of Nasacort
spray and Mentholatum cream on the bedside table.
During an observation on 5/17/2023 at 12:18 PM in Resident #212's room there was a bottle of Nasacort
spray and Mentholatum cream on the bedside table.
During an interview on 5/17/2023 at 12:26 PM Staff A, License Practical Nurse (LPN) stated, No
medications are allowed at the bedside without a physician order for self-administration of medication.
During an observation on 5/17/2023 at 12:30 PM with Staff A, LPN of Resident #212's room there was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106134
If continuation sheet
Page 3 of 7
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
106134
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/18/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakes of Clermont Health and Rehabilitation Center
1775 Hooks Street
Clermont, FL 34711
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 0761
a bottle of Nasacort spray and Mentholatum cream on the bedside table.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 5/17/2023 at 12:30 PM Staff A, LPN stated, Medications at the bedside are not
secured. It is the policy of the facility to not have medications at the bedside unless there is a physician's
order and then the medications are secured in the bedside table. We continually check when we enter the
rooms and will remove the medications if we observe medications at the bedside and educate the resident.
Residents Affected - Few
Record review of Resident #212's physician's orders did not contain an order for the resident to
self-administer medications.
During an interview on 5/17/20230 at 1:23 PM the DON stated, The expectation is for no medications to be
at the bedside. If a resident brings in medications, we send them home or remove the medications and lock
them up to return them until there is an order received for self-administration or the resident is discharged
home. If a resident is capable of self-administering medication, we discuss this at the IDT [interdisciplinary
Team] meeting and an order is written for self-administration. If an order is written for self-administration,
then the resident can keep medications in their room locked in their bedside table. All staff are responsible
to look and ask about unsecure medications in the rooms. We even utilize angel rounds for observations.
Record review of Policy and Procedures titled, Standards and Guidelines: SG Medication Storage Policy
Number: 12.07.09.055 Issued: 8/1/2006 read, Standard: It will be the standard of this facility to store
medications, drugs and biological in a safe, secure and orderly manner. Guidelines: 2. The nursing staff
shall be responsible for maintaining medication storage and preparation areas in a clean, safe and sanitary
manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106134
If continuation sheet
Page 4 of 7
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
106134
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/18/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakes of Clermont Health and Rehabilitation Center
1775 Hooks Street
Clermont, FL 34711
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an
observation of Resident #35's Peripherally Inserted Central Catheter (PICC) line dressing showed there
was a gauze underneath a transparent dressing. The dressing was dated 5/15/23. (Photographic evidence
obtained).
Review of Resident #35's Treatment Administration Record (TAR) documented the resident's PICC line
dressing was changed on 5/10/23 and 5/17/23, there was no additional documentation in the record
regarding the PICC line dressing change.
During an interview on 5/17/23 at approximately 1:30 PM the Director of Nursing stated, The nurse should
have documented the dressing change on 5/15/23, I see that did not happen. This is a documentation
issue.
Review of the policy and procedure titled, Standards and Guidelines: SG PICC IV [peripherally inserted
central catheter intravenous] Line revised: 3/27/21 read, Standards: It will be the standard of this facility to
adhere to IV/PICC line administration guidelines as set forth by infection control, state and federal
regulations. Licensed nurses shall provide care according to state and federal law. Dressing Changes: 2.
Dressing changes will be documented in the clinical record.
3. Review of Resident #11's admission record revealed the resident was admitted on [DATE] with the
diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant
side, unspecified dementia, and muscle weakness.
Review of Resident #11's TAR for April 2023 reads, Encourage Fluids (thickened) every 4 hours for
Recurrent UTIs [urinary tract infection]. Start Date: 05/02/2022 1400 [2:00 PM]. There was no entry on
4/20/2023 at 8:00 AM, 4/26/2023 at 10:00 PM, 4/27/2023 at 2:00 AM, 8:00 AM and 10:00 PM, 4/28/2023 at
2:00 AM and 8:00 AM.
Review of Resident #11's TAR for April 2023 reads, Upright after meals every shift. Start Date: 04/30/2022 .
Apply house barrier cream to coccyx every shift. Start Date: 04/30/2022 . Observe for S/S [signs and
symptoms] of aspiration every shift. Start Date: 04/30/2022 . Monitor for the following signs and symptoms:
bleeding gums, nose bleeds unusual bruising, bleeding wounds, tarry/black stools, pink or discolored urine.
Notify MD [Medical Doctor] if any symptoms present every shift. Start Date: 04/30/2022 . HOB [Head of
Bed] elevated greater than 30-45 degrees. Start Date: 04/30/2022. There was no entry on 4/26/2023 and
4/28/2023 for the night shift.
Review of Resident #11's TAR for April 2023 reads, Apply moisturizing lotion to whole body excluding skin
folds and web spaces two times a day for dry skin. Start Date: 01/12/2023 2100 [9:00 PM]. There was no
entry for 4/26/2023 and 4/27/2023 for 9:00 PM.
Review of Resident #11's TAR for April 2023 reads, Attach leg strap to secure catheter tubing every shift.
Start Date: 03/28/2023 . Catheter Care every shift related to neuromuscular dysfunction of bladder
unspecified. Start Date: 05/02/2022. There was no entry for 4/26/2023 and 4/27/2023 for night shift.
Review of Resident #11's TAR for May 2023 reads, Encourage Fluids (thickened) every 4 hours for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106134
If continuation sheet
Page 5 of 7
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
106134
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/18/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakes of Clermont Health and Rehabilitation Center
1775 Hooks Street
Clermont, FL 34711
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Recurrent UTIs. Start Date: 05/02/2022 1400 [2:00 PM]. There was no entry on 5/3/2023 at 6:00 AM,
5/4/2023 at 2:00 AM and 6:00 AM, 5/6/2023 at 6:00 AM and 6:00 PM, 5/7/2023, 5/8/2023 and 5/11/2023 at
6:00 AM, 5/12/2023 at 6:00 PM and 10:00 PM, and 5/13/2023 at 2:00 AM and 6:00 AM.
Review of Resident #11's TAR for May 2023 reads, Upright after meals every shift. Start Date: 04/30/2022 .
Apply house barrier cream to coccyx every shift. Start Date: 04/30/2022 . Observe for S/S [signs and
symptoms] of aspiration every shift. Start Date: 04/30/2022. There was no entry on 5/7/2023 and 5/12/2023
for the night shift.
Review of Resident #11's TAR for May 2023 reads, Monitor for the following signs and symptoms: bleeding
gums, nose bleeds unusual bruising, bleeding wounds, tarry/black stools, pink or discolored urine. Notify
MD if any symptoms present every shift. Start Date: 04/30/2022 . HOB [Head of Bed] elevated greater than
30-45 degrees. Start Date: 04/30/2022. There was no entry on 5/7/2023 and 5/12/2023 for night shift.
Review of Resident #11's TAR for May 2023 reads, Apply moisturizing lotion to whole body excluding skin
folds and web spaces two times a day for dry skin. Start Date: 01/12/2023 2100 [9:00 PM]. There was no
entry for 5/12/2023 for 9:00 PM.
Review of Resident #11's TAR for May 2023 reads, Attach leg strap to secure catheter tubing every shift.
Start Date: 03/28/2023 . Catheter Care every shift related to neuromuscular dysfunction of bladder
unspecified. Start Date: 05/02/2022. There was no entry for 5/7/2023 and 5/12/2023 for night shift.
During an interview on 5/18/2023 at 2:30 PM, the Director of Nursing confirmed that the TAR had blanks for
Resident #11 and stated that there were documentation issue.
Review of the facility policy and procedure titled SG Charting and Documentation issued on 1/1/2006 and
revised on 3/27/2021 reads, Standard: It is the standard of this facility that services provided to the resident
or any changes in the resident's medical or mental condition, shall be documented in the resident's clinical
record as is needed. Guidelines: 1. Observations, medications administered, services performed, etc.,
should be documented in the resident's clinical records . 3. Entries into the clinical record should be made
by the appropriate staff members. Staff providing care and services to the resident may contribute to the
overall documentation in the clinical record in accordance with state and federal laws. Determination of the
resident's overall condition may require the collective review of documentation from multiple resources
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
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106134
If continuation sheet
Page 6 of 7
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
106134
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/18/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lakes of Clermont Health and Rehabilitation Center
1775 Hooks Street
Clermont, FL 34711
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 0842
protectors.
Level of Harm - Minimal harm
or potential for actual harm
During an interview on 5/16/2023 at 08:45 AM Resident #28 stated I don't wear them anymore [heel
protectors].
Residents Affected - Few
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 Record (TAR) for 5/1/2023 through 5/16/2023 documented the
resident had heel protectors while in bed every shift.
During an interview on 5/17/2023 at 12:45 PM the Director of Nursing stated, The documentation is
inaccurate for [Resident #28's name] heel protectors. They were not applied, and the record should not
have been documented that they were applied. Staff are to document only if the order is followed and if it is
not followed the reason needs to be documented that the order was not followed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106134
If continuation sheet
Page 7 of 7