Health inspection·July 18, 2024

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medication was stored appropriately in three out of three medication carts audited and on two out of two units related to unlocked treatment cart, medication on the floor, and medication unlocked on medication carts. Findings included: An observation was conducted on 7/17/24 at 9:50 a.m. of a treatment cart at the end of the 300-hall sitting outside of a resident room. The nurse was inside the room, behind the privacy curtain. The medication cart had 2 intravenous medications and 1 topical medication sitting in the attached plastic side compartment that has no lock. No other staff were in the hall. The nurse, Staff E, Licensed Practical Nurse (LPN) exited the resident room and was interviewed at that time. The nurse said she brought the medications to her cart, and she was going to go hang them up. An observation was conducted on 7/17/24 at 12:27 p.m. of a treatment cart unlocked near the 300-unit nurses' station. No staff were at the nurses' station at the time. The treatment cart remained unlocked at 1:00 p.m. after multiple staff members walked past the cart. An observation was conducted on 7/17/24 at 2:44 p.m. of a medication cart near the 300-unit nurses' station with 6 blister packs of medication sitting on top. There was no nurses at the medication cart. Staff were observed to be approximately 10 feet from the cart talking, but no one was watching the medication cart. An observation was conducted on 7/18/24 at 10:28 a.m. of a yellow pill on the floor in the hall outside of resident room [ROOM NUMBER]. There were no staff members in the hall. Staff H, LPN, was brought to the location. Staff H was not working that hall, but she removed the pill from the floor and believed it was pantoprazole, used for reflux or heartburn. She said the pill should not have been left on the floor, and she would dispose of it properly. An audit was conducted on 7/18/24 at 11:50 a.m. of a medication cart on the 400 unit with Staff F, LPN. The medication cart had 5 loose pills in the drawers of the cart. Staff F confirmed there should be no loose pills in the medication cart. She said night shift was supposed to clean the medication carts. Staff F said she had been educated on picking up loose pills if they dropped. An audit was conducted on 7/18/24 at 12:02 p.m. of a medication cart on the 300 unit with Staff D, Registered Nurse (RN.) The medication was observed to have 13 loose pills throughout the drawers of (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: 106146 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 106146 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Club at Lake Gibson 855 Carpenters Way Lakeland, FL 33809 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)