Lake Port Square Health Center: Therapy Gaps - FL
That conversation, on the morning of June 9, 2026, set off a federal inspection at Lake Port Square Health Center that exposed something the facility had no clean explanation for — three physical therapy sessions, ordered by a physician, with no documentation of what happened to them.
Resident 38, as he is identified in inspection records, had a physician's order dated April 21, 2026, directing physical therapy every day, one session per week for 60 days. The order covered therapeutic exercise, therapeutic activity, gait training, and caregiver education. It was not a casual suggestion. It was a signed medical order with a diagnosis code attached.
Inspectors pulled the facility's service log matrices for April and May 2026. Three dates had nothing written in them: April 14, April 28, and May 19. No record of a session. No record of a refusal. No record of illness. Nothing.
The Director of Therapy sat down with inspectors on June 10. The explanation she offered shifted with each question.
On April 14, she said the resident had missed his session, and she acknowledged there was no documentation. The therapist who should have treated him was in Thailand. "The therapist is in Thailand and cannot communicate with me to see what happen," she told inspectors. She said that if the resident had refused or wasn't feeling well, "it is not documented."
On April 28, she said the resident was on the therapist's daily assignment board, but "for whatever reason it is not documented why he did not receive the therapy session." She noted the therapy was being provided pro bono and had been since July 2024. Then she offered a theory: "He really doesn't like to get out of bed a lot — that could be the reason."
On May 19, she said again that he was on the assignment board, but again, no documentation of a visit.
She told inspectors what the therapist should have done: "The therapist should have documented the reasons why therapy session was not completed that day."
Later that afternoon, the Director of Therapy returned with a different account. She said she had spoken with the resident directly, and that he remembered being sick on the specific missing dates. That interview happened at 2:44 PM.
Three minutes later, inspectors spoke with the resident himself. His account was less precise than the director's. He said he had missed therapy once or twice because he wasn't feeling well. He said his therapist had been sick once, and the facility sent someone else. He said another time he was sick and didn't have therapy. He did not confirm the specific dates the director had just named.
A licensed practical nurse who worked with the resident told inspectors he was reliable about attending his Tuesday sessions. "He goes every Tuesday and he is pretty go about going," the LPN said. She added that he had not told her he had missed therapy, and that the therapy staff was good at providing services to residents.
The facility's own documentation policy, last reviewed in January 2026, states that records of a resident's care must be "maintained in a complete, timely and orderly fashion."
Three sessions. Three blank lines in the log. One therapist overseas and unreachable. One director cycling through possible explanations — vacation, illness, stubbornness, pro bono status — without landing on any of them with certainty.
Federal inspectors classified the violation as minimal harm or potential for actual harm. The resident, meanwhile, was still waiting on the morning the inspection began, not knowing whether anyone was coming.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lake Port Square Health Center from 2026-06-11 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
LAKE PORT SQUARE HEALTH CENTER in LEESBURG, FL was cited for violations during a health inspection on June 11, 2026.
The order covered therapeutic exercise, therapeutic activity, gait training, and caregiver education.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.