Inspection visit

InspectionSeptember 19, 2024

LAKES OF CLERMONT HEALTH AND REHABILITATION CENTERCMS #1061345 citations on this visit

5 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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** 4) Review of Resident #49's admission record showed the resident was admitted on [DATE] with diagnoses that included disseminated mycobacterium avium-intracellular complex, diverticulitis of large intestine with perforation and abscess without bleeding, colostomy status, bronchiectasis, unsteadiness on feet, and muscle weakness (generalized). Residents Affected - Few Review of Resident #49's physician order dated 9/2/2024 read, Tramadol HCl Oral Tablet 25 MG [milligram] (Tramadol HCl) Give 1 tablet by mouth every 8 hours as needed for severe pain (7-10). Review of Resident #49's MAR for September 2024 showed the resident received Tramadol HCl on 9/1/2024 at 9:17 PM for a pain level of 6, 9/4/2024 at 5:33 PM for a pain level of 5, 9/11/2024 at 7:00 AM for a pain level of 4, and 9/13/2024 at 8:59 PM for a pain level of 6. 5) Review of Resident #323's admission record showed the resident was admitted on [DATE] with diagnoses that included cellulitis of right lower limb, essential (primary) hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, ischemic cardiomyopathy, chronic systolic (congestive) heart failure, and chronic obstructive pulmonary disease. Review of Resident #323's physician order dated 9/14/2024 read, Morphine Sulfate Oral Tablet 15 mg (Morphine Sulfate) Give 1 tablet by mouth every 4 hours as needed for pain for 3 days severe pain (7-10) for up to 3 days . Start Date: 09/14/2024. End Date: 09/17/2024. Review of Resident #323's physician order dated 9/16/2024 read, Morphine Sulfate Oral Tablet 15 mg (Morphine Sulfate) Give 1 tablet by mouth every 4 hours as needed for pain for 3 days severe pain (7-10) . Start Date: 09/16/2024. End Date: 09/19/2024. Review of Resident #323's MAR for September 2024 showed the resident received Morphine Sulfate on 9/15/2024 at 11:09 AM for a pain level of 5, 9/15/2024 at 11:47 PM for a pain level of 4, 9/17/2024 at 11:25 AM for a pain level of 5. During an interview on 9/19/2024 at 9:45 AM, the Director of Nursing confirmed the medications were given out of parameters to Resident #49 and Resident #323 and stated that her expectation was that the nurses follow the parameters contained in the orders. Review of the facility policy and procedure titled Standards and Guidelines: SG Medication Administration last reviewed on 1/24/2024 showed it read, Policy: It will be the standard of this facility to administer medications in a timely manner and as prescribed by the physician, unless otherwise clinically indicated or necessitated by other circumstances such as lack of availability of medication (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 8 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 09/19/2024 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 or refusals of medication by the resident. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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 an observation on 9/16/2024 at 10:40 AM, Resident #174 was sitting in his wheelchair, with both legs swollen and 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 12:15 PM, Resident #174's Wife stated, He has not had any special stockings since he has been here at the facility. No one has discussed stockings. During and observation on 9/17/2024 at 1:11 PM, Resident #174 was sitting in his wheelchair, with no TED stockings applied. During an interview on 9/17/2024 at 1:11 PM, Staff A, Certified Nursing Assistant (CNA), confirmed Resident #174 had no TED stockings and stated, No one told me to put TED hose on him. I've never placed TED hose on him. 2) Review of Resident #62's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, essential (primary) hypertension, and peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs). Review of Resident #62's physician order dated 9/8/2024 read, TED hose on in AM and off at HS every shift TED hose on and off at HS. During an observation on 9/16/2024 at 10:40 AM, Resident #62 was lying in bed, with no TED hose on lower leg. Both legs of the resident were red and discolored with scabs. During an observation on 9/17/2024 at 10:00 AM, Resident #62 was lying in the bed, with no TED hose on bilateral lower extremities. During an interview on 9/17/2024 at 1:35 PM, Staff B, Licensed Practical Nurse (LPN), confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 2 of 8 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 09/19/2024 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 that Resident #174 and Resident #62 did not have TED stockings/hose on. Level of Harm - Minimal harm or potential for actual harm 3) Review of Resident #175's admission record showed the resident was admitted on [DATE] with diagnoses that included type 2 diabetes mellitus with hyperglycemia. Residents Affected - Few Review of Resident #175's physician order dated 9/9/2024 read, Lantus Solostar Subcutaneous Solution Pen-injector 100 unit /ml [milliliters] (Insulin Glargine) Inject 25 unit subcutaneously one time a day for DM [Diabetes Mellitus]. Review of Resident#175's Medication Administration Record (MAR) for September 2024 for administration of Lantus Solostar subcutaneous solution showed the staff documented 4 (4=Held per parameters) for the blood sugar level of 92 on 9/13/2024 at 10:00 PM, 5 (5=Hold/See Nurse Notes) on 9/14/2024 at 10:00 PM with the blood sugar level documented as X, 4 for the blood sugar level of 120 on 9/15/2024 at 10:00 PM, 4 with the blood sugar level documented as X on 9/16/2024 at 10:00 PM and 9/17/2024 at 10:00 PM. During an interview on 9/17/2024 at 12:20 PM, Staff B, LPN, stated, Insulin was not given [to Resident #175] because the blood sugar was out of parameters. During an interview on 9/18/2024 at 1:30 PM, with ARNP #1 stated, I was not informed that the staff was holding her [Resident #175's] Lantus Insulin because her blood sugar was low. I should have been informed, so that I was aware and could adjust her orders as needed. During an interview on 9/18/2024 at 10:05 AM, the Director of Nursing stated, The TED hose were not applied for [Resident #174's name] and [Resident #62's name] as ordered. I expect the physician orders to be followed as ordered. Daily dosage of Lantus Solostar Insulin is to be administered and if not given, the physician has to be called and informed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 3 of 8 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 09/19/2024 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 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 #44's room. During an interview on 9/16/2024 at 9:40 AM, Resident #44 stated, The spray is for my itchy back. During an interview on 9/18/2024 at 2:30 PM, the Director of Nursing stated, Residents need an order for self-administration of medication and to have the medication at the bedside and we also have to be sure the resident have the capability of taking the medication safely and according to the physician's order. Review of the facility policy and procedure titled Medication Storage revised on 10/24/2022 and last reviewed on 1/24/2024 showed it read, Standard: It will be the standard of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. Guidelines . 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications, drugs, and biologicals shall be locked when not in use and trays or carts used to transport such items shall not be left unlocked if out of a nurse's view. 8. Drugs shall be stored in an orderly manner in cabinets, drawers, carts or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer or other holding area to prevent the possibility of mixing medications of several residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 4 of 8 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 09/19/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 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 conducting the second tour of the kitchen on 9/17/2024 at 2:40 PM, there were two bags of food with no label or date in a pan stored in Refrigerator #5 in the kitchen. During an interview on 9/17/2024 at 2:41 PM, the CDM identified the food items as turkey and ham cuts and confirmed that they were not labeled and dated. Review of the facility policy and procedure titled Food Labeling and Dating revised on 3/2/2021 and last reviewed on 1/24/2024 showed it read, Standard: Foods are labeled and dated for identification purposes and to ensure they are discarded within acceptable time frames according to HACCP [ Hazard Analysis Critical Control Point] guidelines. Guidelines: 1. Food products that are purchased and brought into the Food & Nutrition department inventory are dated upon delivery and storage. A permanent marker is used to indicate date opened and date received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 5 of 8 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 09/19/2024 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** 3) Review of Resident #374's admission record showed the resident was admitted on [DATE] with diagnoses that included fracture of third lumbar vertebra, fracture of second lumbar vertebra, syncope and collapse, sequelae of cerebral infarction, polyneuropathies, mild protein-calorie malnutrition, major depressive disorder, hypothyroidism, unsteadiness on feet, and muscle weakness (generalized). Review of Resident #374's physician order dated 9/11/2024 showed it read, Ace-Wrap left ankle every day. Remove at night every shift apply ace wrap in AM, and off at HS. Review of Resident #374's physician order dated 9/5/2024 showed it read, Air mattress to bed monitor for proper placement and functioning every shift. Review of Resident #374's physician order dated 9/5/2024 showed it read, Apply House barrier cream to buttocks every shift. Review of Resident #374's physician order dated 9/5/2024 showed it read, Back brace on at all times when out of bed every shift. Review of Resident #374's physician order dated 9/5/2024 showed it read, Sacrum: apply house barrier cream every shift. Review of Resident #374's TAR for September 2024 showed no entry documented on 9/13/2024 for night shift for administration of Ace-wrap (start date of 9/11/2024 and discontinuation date of 9/16/2024); no entry documented on 9/13/2024 for night shift for monitoring air mattress (start date of 9/5/2024); no entry documented on 9/13/2024 for night shift for applying house barrier cream to buttocks (start date of 9/10/2024); no entry documented on 9/5/2024 and 9/13/2024 for night shift for applying back brace (start date of 9/2/2024); and no entry documented on 9/5/2024 for night shift for applying house barrier cream (start date of 9/5/2024 and discontinuation date of 9/10/2024). During an interview on 9/18/2024 at 4:18 PM, Staff D, Registered Nurse, stated, Nothing was charted. It is red in the PCC [Point Click Care] that means it was not touched. During an interview on 9/19/2024 at 9:19 AM, the Director of Nursing stated that the staff provided the care, but they were interrupted and forgot to complete the MAR. Review of the facility policy and procedure titled Charting and Documentation revised on 3/27/2024 and last reviewed on 1/24/2024 showed it read, 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. 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, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 6 of 8 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 09/19/2024 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 and essential (primary) hypertension (high blood pressure). Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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 Assistant (CNA), confirmed Resident #174 had no TED stockings and stated, No one told me to put TED hose on him. I've never placed TED hose on him. Review of Resident #174's Treatment Administration Record (TAR) for September 2024 for application of compression hose showed the treatment was administered on 9/8/2024 through 9/17/2024 at 9:00 AM and removed on 9/8/2024 through 9/16/2024 at 8:59 PM. 2) Review of Resident #62's admission record showed the resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, essential (primary) hypertension, and peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs). Review of Resident #62's physician order dated 9/8/2024 read, TED hose on in AM and off at HS every shift TED hose on and off at HS. During an observation on 9/16/2024 at 10:40 AM, Resident #62 was lying in bed, with no TED hose on lower leg. During an observation on 9/17/2024 at 10:00 AM, Resident #62 was lying in the bed, with no TED hose on bilateral lower extremities. During an interview on 9/17/2024 at 1:35 PM, Staff B, Licensed Practical Nurse (LPN), confirmed that Resident #174 and Resident #62 did not have TED stockings/hose on. Review of Resident #62's TAR for September 2024 for application of TED hose showed the treatment was administered on 9/3/2024 through 9/16/2024 on day and night shifts. During an interview on 9/18/2024 at 10:05 AM, the Director of Nursing stated, The TED hose were not applied for [Resident #174's name] and [Resident #62's name] as ordered. I expect the physician orders to be followed as ordered. The staff must complete the task first and place the TED hose on the resident and then document on record that the task was completed. They cannot just check the boxes that the task are done and not complete them. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 7 of 8 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 09/19/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Few 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. During an interview on 9/18/2024 at 9:32 AM, Staff D, RN, stated, I didn't use a gown. We need to use gloves only for providing care to the residents on enhanced barrier precautions. Review of Resident #374's physician order dated 9/17/2024 showed it read, Enhanced Barrier Precautions every shift for wound. During an interview on 9/18/2024 at 2:20 PM, the Regional Registered Nurse confirmed that Staff D, RN, did not use the proper personal protective equipment while applying the sacral dressing for a resident on Enhanced Barrier Precautions. Review of the facility policy and procedure titled Transmission Based Precautions revised on 6/10/2024 and last reviewed on 1/24/2024 showed it read, Guidelines . Enhanced Barrier Precautions (EBP): Enhanced Barrier Precautions are a transmission-based approach that falls between Standard and Contact Precautions. These precautions are primarily intended to apply to care that occurs within a resident's room where high-contact resident care activities, including transfers, are bundled together as part of morning or evening care. EBP, when implemented, are intended to be in place for the duration of a resident's stay in the center or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Examples of high-contact resident care activities requiring gown and glove use include: Dressing, Bathing/Showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator. Wound care: any skin opening requiring a dressing. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 106134 If continuation sheet Page 8 of 8

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Citations

5 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0684GeneralS&S Dpotential for harm
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
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.
0812GeneralS&S Dpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the September 19, 2024 survey of LAKES OF CLERMONT HEALTH AND REHABILITATION CENTER?

This was a inspection survey of LAKES OF CLERMONT HEALTH AND REHABILITATION CENTER on September 19, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LAKES OF CLERMONT HEALTH AND REHABILITATION CENTER on September 19, 2024?

Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·September 19, 2024