Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0552
Ensure that residents are fully informed and understand their health status, care and treatments.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record reviews, the facility failed to administer medications in accordance with resident
preference for one (#1) of three residents sampled for medication administration.
Residents Affected - Few
Findings included:
A review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with
diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia,
pleural effusion, and asthma. Resident #1 was discharged from the facility on 9/30/2024.
A review of Resident #1's medical record revealed the following orders:
- An order, dated 9/11/2024 for Trelegy Ellipta 100-62.5-25 micrograms (mcg) aerosol powder, breath
activated, give one inhalation by mouth in the morning for COPD/shortness of breath. The order was
discontinued on 9/29/2024.
- An order, dated 7/6/2024 for Trelegy Ellipta 100-62.5-25 mcg aerosol powder, breath activated, give one
inhalation by mouth once daily. The order was discontinued on 7/6/2024.
A review of Resident #1's progress notes dated 7/6/2024 at 9:08 AM revealed Resident #1 informed facility
staff during medication administration she did not want Trelegy Ellipta administered due to a history of
adverse reactions and had not taken the medication in years. Resident #1's progress notes dated 7/6/2024
at 10:42 AM revealed Resident #1 had a history of adverse reactions to Trelegy Ellipta and she had been
using a different medication (Breztri) in place of the Trelegy Ellipta.
A review of Resident #1's 5-day Minimum Data Set (MDS) assessment, with an Assessment Reference
Date (ARD) of 9/13/2024 revealed under Section C - Cognitive Patterns, a Brief Interview for Mental Status
(BIMS) score of 14, indicating Resident #1 was cognitively intact.
A review of Resident #1's medication administration record (MAR) for September 2024 revealed Resident
#1 was administered Trelegy Ellipta 100-62.5-25 mcg on 9/12/24, 9/16/24 to 9/20/24, 9/23/24 to 9/25/24,
9/27/24, and 9/29/24.
A telephone interview was conducted on 10/23/2024 at 2:30 PM with Resident #1's representative (RR).
The RR stated facility staff offered Resident #1 Trelegy Ellipta several times during her admission to the
facility and Resident #1 had to inform the facility she was not able to take the medication due to a history of
adverse reactions. The RR also stated Resident #1 was usually able to recognize when facility staff
attempted to administer Trelegy Ellipta to her, but she was very lethargic near
(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 10
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
10/24/2024
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)
F 0552
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the end of her admission and may not have recognized the medication when the facility attempted to
administer it. The RR stated Resident #1 would normally take the medication Breztri instead of the Trelegy
Ellipta, but the facility pharmacy was not able to provide the medication, so the resident used her own
supply of Breztri from home.
An interview was conducted on 10/23/2024 at 3:09 PM with Staff B, Licensed Practical Nurse (LPN). Staff
B, LPN stated she cared for Resident #1 on several occasions and the resident was ordered Trelegy Ellipta
because when an order for Breztri was put into the resident's order set the facility pharmacy would change
the order to Trelegy Ellipta. Staff B, LPN also stated if a resident had a history of adverse reactions to a
medication, the nurse should contact the resident's physician to have the medication discontinued.
An interview was conducted on 10/24/2024 at 11:50 AM with the facility's Director of Nursing (DON). The
DON stated she spoke with Resident #1's provider Staff D, Advanced Practice Registered Nurse (APRN))
over the phone to discuss why Trelegy Ellipta was ordered for the resident during her admission to the
facility. The DON stated Resident #1 had an intolerance to several inhalant medications and the resident's
provider worked to find a inhalant medication she would be tolerant of to manage her COPD symptoms.
The DON stated if Resident #1 or the RR did not want Trelegy Ellipta to be administered, the resident's
provider should have been notified and the medication should have been discontinued.
A telephone interview was conducted on 10/24/2024 at 1:05 PM with Staff D, APRN. Staff D, APRN stated
Resident #1 had been prescribed multiple inhalant medications over the years to manage her COPD and
had an intolerance to Trelegy Ellipta. Resident #1 was taking Breztri while at home, which she was tolerant
of. Staff D APRN informed facility staff to not administer the Trelegy Ellipta to Resident #1 and to only
administer Breztri to the resident. Staff D, APRN stated Resident #1 was prescribed Trelegy Ellipta several
times during her admission to the facility due to a formulary interchange, which resulted in the pharmacy
replacing Breztri with Trelegy Ellipta any time it was ordered for the resident. Staff D, APRN also stated if
Resident #1 or the RR did not want Trelegy Ellipta administered, the nursing staff should have called her to
make the appropriate adjustments to the resident's orders.
A review of the facility policy titled Resident Rights, last revised in February 2021, revealed under the
section titled Policy Interpretation and Implementation, federal and state law guarantee certain basic rights
to all residents of the facility. These rights include the resident's right to be informed of, and participate in,
his or her care planning and treatment and the resident's right to choose an attending physician and
participate in decision-making regarding his or her care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106146
If continuation sheet
Page 2 of 10
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
10/24/2024
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)
F 0694
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record reviews, and interviews, the facility failed to assess, maintain in a sanitary manner,
and provide dressing changes for one (#5) of three residents with central intravenous (IV) catheters.
Residents Affected - Few
Findings included:
On 10/23/24 at 9:33 a.m., Resident #5 was observed lying in bed and appeared to be alert and oriented to
person and situation. An intravenous pole with pump was observed in the corner of the room, visible from
the doorway. The resident confirmed having an intravenous site, holding up his right arm where a single
lumen peripherally inserted central catheter (PICC) was observed. The woven outside portion of the
dressing appeared to be worn and old, the transparent middle portion revealed an approximate quarter-size
area of a dried red/black substance surrounding the catheter insertion site. One side of the woven portion
of the dressing was no longer attached to the resident. The dressing did not reveal a date of when it was
applied, the needless connector was not attached to the end of the catheter, and the line was not closed
shut. Resident #5 reported having the (IV) site for at least a week. The resident allowed photographic
evidence to be obtained.
On 10/23/24 at 9:53 a.m., Staff A, Licensed Practical Nurse (LPN) reported Resident #5 had a urinary tract
infection and a PICC dressing was changed every 7 days. The staff member observed Resident #5's PICC
line, confirming the dressing was not dated, the dressing was coming off, and there was no cap on the end
of the catheter.
On 10/23/24 at 10:25 a.m., the Director of Nursing stated there were 2 residents with IV sites and provided
a handwritten list of the 2 residents. Resident #5 was not on the list.
Review of Resident #5's admission Record revealed the resident was admitted on [DATE] and 8/16/24. The
record showed the resident was the responsible party and included diagnoses not limited to site not
specified urinary tract infection (onset 10/3/24) and Extended Spectrum Beta Lactamase (ESBL) resistance
(onset 9/9/24).
Review of Resident #5's Minimum Data Set (MDS) dated [DATE] revealed the resident's Brief Interview of
Mental Status score of 13, indicating an intact cognition. The resident had an indwelling urinary catheter
and in the 7 days prior to the assessment, the resident had received antibiotics.
Review of the IV vendors information showed a Right 3CG non-valved PICC was inserted into Resident
#5's right basilic vein with an internal length of 45 centimeters (cm) and 0 cm external length. The
information showed time in for the vendor was 3:40 p.m. (1540) and out time was 4:35 p.m. (1635) on
10/2/24.
Review of Resident #5's October Medication Administration Record (MAR) revealed the following physician
orders:
Insert PICC line, may use lidocaine 1% for placement - one time only for klebsiella urinary tract infection
(UTI) for 1 day. Ordered 10/2/24 at 9:00 a.m. and completed on 10/2/24 at 4:32 p.m.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106146
If continuation sheet
Page 3 of 10
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
(X3) DATE SURVEY
COMPLETED
A. Building
10/24/2024
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)
F 0694
-
Level of Harm - Minimal harm
or potential for actual harm
Ertapenem Sodium solution reconstituted 1 gram (GM) - Use 1 gram intravenously every 24 hours for
Klebsiella UTI related to Urinary Tract Infection site not specified for 10 days. Order 10/2/24 and started
10/2 and ended on 10/11/24. The MAR showed the 10/2 dose was not administered.
Residents Affected - Few
The review did not show staff were assessing the PICC line, did not include orders for flushing the line
before or after administration of the antibiotic or for after the treatment had ended.
Review of Resident #5's October Treatment Administration Record (TAR) did not include orders to change
the dressing on the resident's PICC line, change the end cap of IV catheter, or to monitor the site for any
issues.
During an interview on 10/23/24 at 4:00 p.m., the DON stated the expectation was for the dressings of
PICC/Central lines to be changed every 7 days, (and) if soiled or any impediment as needed. She stated
there should be orders for monitoring the site every shift, flushes, and dressing changes. The DON
reviewed Resident #5's orders and confirmed the resident did not have orders to monitor (the site) or for
dressing changes.
Review of the undated, blank Midline and CVAD (Central Venous Access Device) Dressing Change
Competency provided by the Director of Nursing (DON) on 10/24/24 revealed the dressing change was an
sterile procedure after removing the old dressing, staff should clean site, apply new securement device,
apply protective disk (optional), apply transparent dressing over the site, affix label with date and nurse's
initials, removed and replace the needleless connection device(s), measure external length of catheter,
measure resident's arm circumference, dispose of trash, wash hands, and document the procedure in
medical record and MAR.
Review of the policy - Peripheral and Midline IV Catheter Flushing and Locking, revised March 2022,
showed The purpose of this procedure are to maintain catheter patency and function; to prevent mixing of
incompatible medications and solutions my colon and to ensure entire dose of solution or medication is
administered into the venous system. The guidelines instructed 6. Use preservative- free 0.9% sodium
chloride for lacking a peripheral or midline catheter. Do not flush or lock a peripheral or midline catheter with
heparin. The frequency of flushing was shown as:
1.
For short and long PIVC's and midline catheters used for intermittent infusions, flush the catheter and
aspirate for blood return prior to each infusion and at least every 24 hours to access catheter function. Lock
following each use.
2.
For catheters not being used for intermittent infusion, flush and lock at least once every 24 hours. (See
Peripheral and Midline IV Catheter Removal.)
The procedure for flushing to maintain patency of catheter was described as:
1.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106146
If continuation sheet
Page 4 of 10
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
10/24/2024
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)
F 0694
Assemble supplies.
Level of Harm - Minimal harm
or potential for actual harm
2.
Perform hand antisepsis. [NAME] non-sterile gloves.
Residents Affected - Few
3.
Disinfect needless access device (end cap, access port) with alcohol wipe.
4.
Attach prefilled saline syringe to needleless access device.
5.
Unclamp catheter.
6.
Flush with preservative- free 0.9% sodium chloride using the push- pause technique. Leave 0.5 to 1.0
milliliter (mL) of flush and syringe to avoid pushing air into catheter.
7.
Remove syringe.
8.
Attach prefilled saline syringe to needleless access device.
9.
Lock with preservative- free 0.9% sodium chloride. Leaves 0.5 to 1.0 mL a flush in syringe to avoid pushing
air into catheter.
10.
Remove syringe and clamp catheter.
11.
Remove gloves.
12.
Discard used supplies in appropriate waste container.
The policy instructed staff to:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106146
If continuation sheet
Page 5 of 10
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
10/24/2024
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)
F 0694
1.
Level of Harm - Minimal harm
or potential for actual harm
Document procedure in Treatment Administration Record.
2.
Residents Affected - Few
Note location of catheter, condition of insertion site, and dressing in nurse's notes.
3.
Record any complications and/or communications with the physician in nurse's notes.
The policy - Legal Aspects of Infusion Therapy for Nurses, revised 2/2019 revealed the purpose was To
identify licensed personnel who are designated by the facility to perform infusion therapy. The policy
showed Nurses administering infusion therapies will practice within the scope of practice for their licensure
as established in the state nurse practice act, and within their clinical level of competency as established by
the facility training and competency evaluation programs. The scope of practice for Specific Infusion
Therapy for Nursing Functions showed the Following procedure/ functions associated with infusion therapy
must be verified with the state nurse practice act regarding Registered Nurse (RN) and Licensed Practical
Nurse (LPN) scope of practice, as the regulations differ from state to state. The procedure/functions
included but not limited to:
5. Caring for and maintaining infusion equipment and catheters (peripheral and central venous access
catheters) this includes flushing, dressing changes, site assessment, site rotation (for short peripheral
catheters only), changing IV tubing, and needleless connection devices.
9. Observing and reporting on catheter patency, insertion site, complications, (and) resident reaction to
treatment.
11. Documenting treatment, observations, complications, interventions, (and) resident response to
treatment.
The Facility/Administration Responsibilities for IV therapy revealed the following:
1. Developing and improving policies and procedures for infusion therapy.
2. Providing education or verifying qualifications on the staff that will be providing infusion therapy period
this may include IV fundamental classes, precepting and/for clinical competency evaluations.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106146
If continuation sheet
Page 6 of 10
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
10/24/2024
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)
F 0694
-
Level of Harm - Minimal harm
or potential for actual harm
3. Assuring that federal and state regulations are followed, along with the Facility policy and procedure.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106146
If continuation sheet
Page 7 of 10
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
10/24/2024
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)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record reviews, and interviews, the facility failed to ensure two (#5 and #7) of three residents
sampled for Intravenous (IV) sites had Enhanced Barrier Precautions posted and Personal Protective
Equipment (PPE) available nearby.
Residents Affected - Few
Findings included:
On 10/23/24 at 9:33 a.m., Resident #5 was observed lying in bed. The observation revealed the resident
had a single lumen peripherally inserted central catheter (PICC) inserted into the right upper extremity. The
resident stated the PICC was due to having an antibiotic for a urinary tract infection (UTI) and had the IV
site for at least a week. The observation revealed the door or entryway to Resident #5's room was not
posted with Enhanced Barrier Precautions and the nearest available PPE was in front of room [ROOM
NUMBER], 2 rooms away from the resident.
On 10/23/24 at 9:44 a.m. an observation was made of Resident #7's doorway. The door or entryway to the
room was posted for Enhanced Barrier Precautions and did not have available PPE. The resident showed
writer a right-side chest wall IV site which the resident reported getting chemotherapy and antibiotic for a
wound infection. The dressing on the site was dated 10/21/24. The nearest PPE was available in front of
room [ROOM NUMBER], around the corner and the third room from the resident room.
An interview was conducted with Staff A, Licensed Practical Nurse (LPN) on 10/23/24 at 9:53 a.m., the staff
member reported want to say Resident #5 had a UTI and Resident #7 had a wound to right foot with a
wound vac.
An interview was conducted with Staff C, LPN on 10/23/24 at 10:45 a.m., the staff member stated
Enhanced Barrier Precautions (EBP) was used for people with IV's, foleys, and colostomies. The staff
member stated that's the policy of the facility.
An interview was conducted with the Director of Nursing (DON) on 10/23/24 at 4:00 p.m., the DON stated
the policy for EBP was if they met protocol, met protocol at admission, if they warrant (the resident) was put
on EBP. The acceptable placement of PPE is within 2-3 rooms of the doorway and there should be PPE in
the caddy's at all times.
The policy - Enhanced Barrier Precautions, dated August 2022, revealed Enhanced Barrier Precautions
(EBP) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents.
1.
Enhanced barrier precautions (EBPs) are used as an infection prevention and control intervention to reduce
the spread of multi- drug resistant organisms (MDROs) to residents.
2.
EBPs Employee targeted gown and glove use during high contact resident care activities when contact
precautions do not otherwise apply.
a.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106146
If continuation sheet
Page 8 of 10
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
10/24/2024
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)
F 0880
Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to
before entering the room).
Level of Harm - Minimal harm
or potential for actual harm
b.
Residents Affected - Few
Personal protective equipment (PPE) is changed before carrying for another resident.
c.
Face protection may be used if there is also a risk of splash or spray.
3.
Examples of high- contact resident care activities requiring the use of gown and gloves for EBPs include:
a.
dressing;
b.
bathing/showering;
c.
transferring;
d.
providing hygiene;
e.
changing linens;
f.
changing briefs or assisting with toileting;
g.
device care or use (central line, urinary catheter, feeding tube, tracheostomy/ ventilator, etc.); and
h.
wound care (any skin opening requiring a dressing).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106146
If continuation sheet
Page 9 of 10
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
10/24/2024
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)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or
indwelling medical devices regardless of multi-drug resistant organism (MDRO) colonization.
6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or
discontinuation of the indwelling medical device that places them at increased risk.
Residents Affected - Few
10. Signs are posted in the door or wall outside the resident room indicating the type of precautions and
PPE required.
11. PPE is available and placed in an area near or outside of the resident's rooms.
(Photographic evidence was obtained)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106146
If continuation sheet
Page 10 of 10
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Back to topCitations
3 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.
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
F694 - Parenteral Fluids
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
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 October 24, 2024 survey of THE CLUB AT LAKE GIBSON?
This was a inspection survey of THE CLUB AT LAKE GIBSON on October 24, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at THE CLUB AT LAKE GIBSON on October 24, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are fully informed and understand their health status, care and treatments."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.