Inspection·June 2, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **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 family/responsible party being notified at time of fall. Review of Resident #1 SBAR (Situation Background Assessment Response) Communication Form dated 5/22/2025 at 12:00 AM read . Resident was observed sitting on the floor in front of her WC [Wheelchair] . son visiting 5/22/2025 12:00 AM. Review of Resident #1's progress note dated 5/23/2025 at 01:00 AM read einteract SBAR for providers, Situation: The change in condition (CIC)/s reported on this CIC evaluation are/were: fall .new test ordered x-ray. Review of Resident #1's clinical record found it did not contain documentation of Resident #1's family/responsible party being notified of the fall and the physician's order for an x-ray. Review of Resident #1's health status note dated 5/23/2025 at 14:41 [2:41 PM] read ARNP [Advance Registered Nurse Practitioner] here to see resident new orders for Portable 3 view x-ray right knee, Dx [diagnosis]: pain, portable d/t [due to] weakness/fall risk. Review of Resident #1's einteract SBAR Summary for providers note dated 5/23/2025 at 20:40 PM [8:40 PM] read Transfer to hospital STAT [immediately]. (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 2 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 06/02/2025 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)