Inspection·October 20, 2023

F 0689 Level of Harm - Immediate jeopardy to resident health or safety During an interview on 10/17/2023 at approximately 10:55 AM Staff B, Licensed Practical Nurse (LPN) stated, I am the nurse for [Resident #4's name]. The CNA should not have left the resident alone in that position, it is not right. During an interview on 10/18/2023 at 8:57 AM, the Director of Nursing (DON) stated, My expectation is for the staff not to put a task [getting linen for the bed] before patient safety. Residents Affected - Few During a follow up interview on 10/18/2023 at 3:00 PM, the DON stated that the modality of the weighing is what keeps the weight consistent. [Staff A's name] has always weighed [Resident 4's name] that way because of her difficulty in walking and standing. We teach the staff that you need two people for the lift. During an interview on 10/18/2023 at 3:10 PM, the Administrator stated, Regardless of what the mechanical lift policy says, we train for two people on the [mechanical] lift. An interview was attempted on 10/19/2023 at 9:10 AM, with Resident #4. Resident #4 was not able to answer simple questions. Was only able to provide her name, was not able to state where she was or the situation. She was able to state she was fine. The resident was confused and laughed repeatedly during the attempted interview. During an interview on 10/19/2023 at 9:24 AM, the Certified Occupational Therapy Assistant (COTA), Interim Rehabilitation Director stated, Every resident is evaluated for Physical Therapy and Occupational Therapy. After the evaluation, therapy will put a blue dot on the resident's door to indicate that they have been assessed for a mechanical lift. The therapy notes would document the resident was maximum assist of two or unable to sit at edge of bed; this indicates that the resident should be transferred with the mechanical lift. Training on mechanical lifts is done by therapy. Every staff member gets trained by the Director of Rehab at orientation covering the transfer technique and process. HR [Human Resources] maintains the checklist for the training. Currently we are training all nursing staff on the proper use of the mechanical lift. Nursing and HR are tracking the staff that are trained on mechanical lifts and will let therapy know when it's complete. The blue dot on the resident's door indicates that the weight has to be done by a mechanical lift as well as the transfers. There should not be a weight taken [by mechanical lift] if there is not a blue dot on the resident's door. Residents will fluctuate in ability to transfer, extreme weakness, for patient and staff safety and a possible need for the mechanical lift. This is communicated to therapy and an evaluation for a mechanical lift will be completed by therapy. [Resident #4's name] has not been assessed for the use of the mechanical lift. During an observation on 10/18/2023 at approximately 9:47 AM, of Resident #4's room door there was no blue dot to indicate the resident had been assessed to be weighed using a mechanical lift and/or for transfers. (Photographic evidence obtained). During an interview on 10/18/2023 at 11:18 AM, via telephone Staff A, CNA stated, I was doing the weights for the resident and noticed the resident was soiled. I cleaned the resident up, put the resident in the sling and raised her up. I left the room to go to the linen cart. The linen cart was outside the door; I was looking for a flat sheet. I weighed the resident using the lift by myself. I didn't put her in the chair or over the bed because the other staff usually come right behind me and get her up to the wheelchair. I did not communicate to anyone I needed help. I do know that to operate the Mechanical lift you are to have two people. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 2 of 5 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 10/20/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an interview on 10/19/2023 at 10:13 AM, the DON stated [Resident #4's name] pushes on the handles of the scale and we cannot get an accurate weight. That is why the mechanical lift is being used to obtain her weight. She [Resident #4] was not reassessed by therapy before using the mechanical lift for weights. A request was made to view the video footage of the hallway. The DON stated, There was no video of the interior of the building only the exterior of the building. During an interview on 10/19/2023 at 11:55 AM, the Administrator stated, It was not safe to leave a resident alone, unsupervised in a room suspended in a sling of the mechanical lift. The potential would be injury. During an interview on 10/19/2023 at 3:10 PM, the DON stated, The resident [Resident #4] should never be left alone in a sling, the injuries could be numerous; fractures, spinal injury, and even could include death. During an interview on 10/19/2023 at approximately 3:18 PM, with the Administrator and the Regional Director of Clinical Operations a request was made for the policy and procedure for resident supervision and resident safety. At the time of survey exit the facility staff had not provided the requested policy and procedure. Review of the electronic medical record for Resident #4 documented the resident was admitted to facility on 6/15/2023 with a diagnosis of acute cystitis without hematuria, iron deficient anemia, dementia, hypertension, weakness, abnormality of gait, and muscle weakness. Review of the Minimum Data Set (MDS) dated [DATE] for the Quarterly Brief Interview for Mental Status (BIMS) score was documented as 12, indicating moderate cognitive impairment. Review of the [Psychiatric Association's name] read, Date of Service: 6/29/2023, 81 y/o [year old] not taking any antipsychotics alert responsive with confusion. Dementia: safety concern screening and follow up for patients with dementia staff counseled regarding safety concern: Fall Risk, risk of wandering, and physical aggression. Dated 9/14/2023 Patient is being seen for a follow up visit today. Patient last seen 8/15/2023. Patient is awake and alert. She is oriented to person, confused to place, time and situation. Patient is minimally verbal. Unable to obtain history. Review of the list of residents who have been approved by assessment for the use of a mechanical lift for weighing and/or transfers did not have Resident #4's name documented on the list. Review of the care plan for Resident #4 did not document the use of a mechanical lift for weights and/or transfers. Review of the physician orders for Resident #4 did not document an order for the use of the mechanical life for weights and/or transfers. Review of the policy and procedure titled SG (Standards and Guidelines) Mechanical Lifts read, Standard. It is the standard of this facility to provide a safe environment for our residents and staff. The Nursing and Therapy departments will coordinate the screening of residents to determine the appropriateness of mechanical lift transfers and/or repositioning. Staff responsible for the transferring/repositioning residents will receive instruction on the safe operation of the mechanical lifts. Guidelines. #5 When using mechanical lift staff will adhere to manufacture guidelines, physicians order and/or the care plan. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 3 of 5 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 10/20/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Review of the Instructions For Use Maxi Move by [Manufacturer Name] under General Information Page 5, read, Note: The need for a second attendant to support the patient must be assessed in each individual case. Review of the FDA Patient Lifts Safety Guide Step #10 reads, Do not leave patient unattended while in lift. Never keep patient suspended in sling for more than a few minutes. Residents Affected - Few The Immediate Jeopardy (IJ) was removed on site on 10/20/2023 after the receipt of an acceptable IJ removal plan. Review of the Removal Plan dated 10/20/2023 documented, On 10/17/2023, Resident [#4] was immediately assessed by nurse with no injury or changes from baseline. On 10/17/2023, Staff member [A] identified was immediately removed from the assignment and suspended pending investigation. Staff member [A] was re-educated on not leaving the resident unsupervised and unattended in a mechanical lift and assuring 2 people assist in mechanical lift transfers. On 10/17/2023, a Federal Immediate report was completed for allegation of neglect. DCF (Department of Children and Families) was notified, MD (Medical Doctor) was notified, and family notified of incident. Police were called and no further follow-up required. On 10/17/2023, an audit was completed by Director of Nursing to review the incident log for any incidents or injuries regarding improper use of mechanical lift in the last 90 days. No other incidents were reported. On 10/17/2023, all 18 residents identified as affected by this deficient practice were audited for safety and supervision while using a mechanical lift. No issues were identified. On 10/17/2023, the Director of Nursing and Executive Director were reeducated by the Regional Director of Clinical Operations on the components of this regulation: Free of Accidents and Hazards/Supervision/Devices, providing adequate supervision for a resident during use of a mechanical lift for obtaining weights, ensure staff are following policy and procedures for transfers, recognition of transfer needs, review of residents [NAME] and care plan prior to care and services being rendered, following plan of care, and education on transfer to include mechanical lift - resident safe handling with 2 person assist to ensure supervision. As of 10/20/2023, re-education completed with Licensed nursing staff (RNs [Registered Nurse] and LPNs) and Certified Nursing Assistants by the Director of Nursing Services/designee on the following components of this regulation: Free of Accidents and Hazards/Supervision/Devices, providing adequate supervision for a resident during use of a mechanical lift for obtaining weights, ensure staff are following policy and procedures for transfers, recognition of transfer needs, review of residents [NAME] and care plan prior to care and services being rendered, following plan of care, education on proper transfers to include mechanical lift - resident safe handling with 2 person assist to ensure supervision, competency carried out with return demonstration, and newly hired employees will continue to receive education and competency on above in orientation. Mechanical lift training to include the appropriate number of team members present to utilize the mechanical lift will be included in annual competencies moving forward and will be completed by Director of Nursing/designee. On 10/17/2023, an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the above plan [Performance Improvement Plan]. Root Cause Analysis determined: 1. Employee used poor judgement and failed to provide adequate supervision while utilizing a mechanical lift to obtain the resident weight. 2. Employee left the resident unattended and unsupervised when she went out of the room to get linen for resident's bed. Review of the audit dated 10/17/2023, documented 18 potentially affected residents were audited for safety and supervision while using a mechanical lift. Review of the audit dated 10/17/2023, titled Review of 90 days of incidents' documented there were no injuries or incidents regarding improper use of the mechanical lift in the last 90 days. Review of the Ad-Hoc QAPI meeting on 10/17/2023, documented To remove any areas of concern, The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 4 of 5 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 10/20/2023 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Lakes of [NAME] has initiated and/or completed the following PIP. The facility is now aware of opportunities for improvement related to the use of mechanical lifts. Focus will be on preventing accidents and incidents/supervision/devices, failure to follow SG, and best practices for use of mechanical lift. The QAPI meeting was attended by the Administrator, DON, MD, MDS Coordinators, HR, Business Office Manager, Activities Director, Maintenance Director, Unit Managers, Evening Supervisor, Infection Preventionist/Clinical Educator, COTA, Health Information Manager, and the Social Services Assistant. Residents Affected - Few Review of the root cause analysis and performance improvement plan verified completion on 10/17/2023. Review of the inservice dated 10/17/2023, through 10/20/2023, titled Mechanical Lift with content that included providing adequate supervision for a resident during use of a mechanical lift for obtaining weights, ensure staff are following policy and procedures for transfers, recognition of transfer needs, review of residents [NAME] and care plan prior to care and services being rendered, following plan of care, education on proper transfers to include mechanical lift - resident safe handling with 2 person assist to ensure supervision documented 15 of 16 RNs, 17 of 19 LPNs, and 49 of 51 CNAs received training. One RN, 2 LPNs and 3 CNAs were verified as on paid time off. Review of the Resident Transfer and Ambulation Competency dated 10/17/2023, through 10/20/2023, documented 14 of 16 RNs, 15 of 19 LPNs, and 46 of 51 CNAs completed a mechanical lift competency with return demonstration. During interviews completed on 10/20/2023, the Administrator and DON verified having received education and verbalized understanding to ensure staff are following policy and procedures for transfers, adequate supervision for a resident during the use of a mechanical lift, and safe handling with 2 person assist to ensure supervision. During staff interviews completed on 10/20/2023, 4 RNs, 3 LPNs, and 10 CNAs verified having received education and verbalized understanding of adequate supervision for a resident during the use of a mechanical lift and safe handling with 2 person assist to ensure supervision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 5 of 5