Health inspection·January 30, 2025

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 observations, interviews, and record review, the facility failed to ensure medications and biologicals were securely stored for one resident (Resident #43) of one resident sampled for medication storage. Findings included: On 1/28/2025 at 8:05 AM, in Resident #43's room, one tube of topical menthol analgesic was observed on the bedside table and one container of Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment was observed on the bedside nightstand. An interview was conducted with Resident #43 following the observation. Resident #43 stated he used the topical menthol analgesic for back pain and he used the Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment on his feet. Review of Resident #43's care plan, revision on 1/29/2025, read Observe resident taking his/her medications as needed to ensure proper storage and self administration of medication. Provide a lock box for resident to store medications PRN [as needed]. Obtain order from physician stating that resident is able to self administer medications. Provide education of proper storage of medications and monitor to ensure that resident is properly storing medications. On 1/29/2025 at 9:48 AM, in Resident #43's room, one tube of topical menthol analgesic was observed on the bedside table and one container of Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment was observed on the bedside nightstand. During an interview on 1/29/2025 beginning at 9:48 AM, Staff A, Licensed Practical Nurse/Unit Manager confirmed there was one tube of topical menthol analgesic on Resident #43's bedside table and one container of Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment on the bedside nightstand. She confirmed the medications should be securely stored in the resident's nightstand that was equipped with a key accessible lock. During an interview on 1/29/2025 at 10:10 AM, the Director of Nursing stated she would expect the resident would follow the rules and have the medications securely stored. Review of the facility policy titled Storage of Medications, last reviewed 1/31/2024, read Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. 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 5 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 01/30/2025 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)