Lake Port Square Health Center

During an interview on 6/10/2026 at 10:57 AM, Social Services Assistant stated, Both PASSRs [Resident #4 and Resident #9] need to be updated.

During an interview on 6/10/2026 at 11:43 AM, the Director of Nursing stated, Psych gives Social Services a list of all patients that were seen and they also sit in the meetings where we discuss changes and the residents.

Review of the facility policy and procedure titled Psychotropic Medication Use with a last review date of 1/22/2026 read, Policy Interpretation and Implementation.

Assessment and Evaluation of the Resident. 1.

When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident.

The evaluation includes the resident's: f. the state PASSAR evaluation.

105705 06/11/2026

Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748

Review of Resident #15's Nursing Progress Note Dated 06/07/2026 by Staff K, LPN (licensed practical nurse) reads, Normal Saline Flush Solution 0.9 %- Use 10 ml intravenously every shift for Midline Flush Bandage dry/intact with no s/s of infection/infiltration.

Flushed with no resistance.

Review of Resident #15's Physician Order dated 06/08/2026 reads, Review of Late Entry Nursing Progress Note Verbal order per MD to pull IV line as tx was complete. IV line pulled with no issues, Review of Resident #15's Physician Orders dated 06/02/2026, Reads, Change catheter site dressing one time a day every Thur (sic) for dressing change catheter securement device AND every 8 hours as needed for Dressing change catheter securement device., Observe midline site with intermittent therapy or when not in use for s/sx of infiltration/extravasation, redness, swelling and pain. every shift for monitor IV site, Normal Saline Flush Solution 0.9 % (Sodium Chloride Flush) Use 10 ml(milliliters) intravenously every shift for Midline Flush, ceftriaxone Sodium Intravenous Solution Reconstituted 1 GM(gram) Use 1 Gram intravenously one time a day for UTI(Urinary tract infection) until 06/06/2026, Sodium Chloride Solution 0.9% Use 125ml/hr (milliliters/hour) intravenously every evening shift for run for 2 liters for 1 day 05/30/2026, midline to be placed per (Medical Doctor).

Review of facility policy titled, Policy for Peripheral and Midline IV Dressing Changes, last updated 01/22/2026, reads, 4.

Change dressing if it becomes damp, loosened, or visibly soiled and at least every 7 days for TSM (transparent semi-permeable membrane) Dressing.

105705 06/11/2026

Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748

During an observation on 6/9/2026 at 12:48 PM, Resident #12 eating in her room.

The tray contained iced tea, dessert, rice, vegetables, and pork.

There was no frozen nutritional treat on the meal tray. [photographic evidence obtained]Review of Resident #12's physician order dated 11/26/2025 read, Frozen nutritional treat with Lunch and dinner two times a day for at risk for malnutrition.Review of Resident #12's medical record shows documented weights on 5/23/2026 187.4 lbs [pounds], 4/13/2026 194.6 lbs, 2/22/2026 189.8 lbs, and on 11/30/2026 196.1 lbs.

Review of Resident #12's Dietary/Nutrition Evaluation dated 6/4/2026, reads, Weight history. Wt [weight] stable. C.

Nutritional Approaches current nutritional supplements.

Yes. magic cup bid [twice a day].

During an interview on 6/10/2026 at 11:25 AM, Staff B, Licensed Practical Nurse (LPN), stated, Normally the frozen nutritional treat comes on the tray form the kitchen. I was not aware she [Resident #12] did not get her nutritional treat for lunch.

During an interview on 6/10/2026 at 11:32 AM, Staff E Certified Nursing Assistant (CNA), stated, I cannot recall if [Resident #12's name] gets a frozen nutritional treat. If she did it would come from the kitchen we do not have them in the refrigerator.

During an interview on 6/10/2026 at 11:33AM, Staff F, CNA, stated, No, [Resident #12's name] did not have a frozen treat on her treat for lunch yesterday.

That I know of she does not get them.

During an interview on 6/10/2026 at 3:01 PM, the Registered Dietician (RD) stated, I came in this week.

Normally the RD puts in the orders in the system and then will fill out a communication sheet that goes to the kitchen. [Resident #12's name] frozen nutritional treat was not communicated with the [kitchen program] and was not showing up in the meal ticket.

During an interview on 6/10/2026 at 3:06 PM, the Kitchen Manager stated, Nursing will normally write a communication form from nursing. If I get that [new orders in the communication sheet] I make the change but if I don't get it, I cannot make the change.

Some how this one got overlooked.

Nursing directly give it to me. It will show up on the ticket.

The frozen nutritional treats will aways come from the kitchen on the meal tray. No one came to me to ask me for a frozen treat these past few days that I can recall.

During an interview on 6/11/2026 at 6:21 AM with the Director of Nursing stat, The CDM walked out on Friday and he is the one that typically pull the order in and make sure that everything is on the tray.

Review of the facility policy and procedure titled, Supplemental Feeding with a last review date of 1/22/2026 read, Policy: It is the policy of the community to provide nutritive supplements as appropriate for residents with weight loss or when other nutrition risk factors are identified.

Procedures: 1.

Nutritive Supplements will be given when ordered by the physician.

105705 06/11/2026

Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748

During an interview on 6/10/2026 at 10:40 AM, the Director of Nursing stated, The nebulizer mask and tubing should be stored in a bag that is dated when not in used.

Review of the facility policy and procedure titled Departmental (Respiratory Therapy)-Prevention of Infection with a last review date 1/22/2026 read, Purpose: The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff.

Steps in the Procedure. 8.

Keep the oxygen cannula and tubing used PRN in a plastic bag, when not in use.

Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 7.

Store the circuit in plastic bag, marked with date and resident's name between uses.

105705 06/11/2026

Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748

Based on observation, interview and record review the facility failed to follow standards of

observation on 6/8/2026 at 9:15 AM Resident #86 was lying in bed. Resident #86's wife was at bedside.

There was a clear medication cup with cream inside.

Medication cup was not labeled.

There were two normal saline flush syringes on top on nightstand.

During an interview on 6/8/2026 at 2:11 PM, Staff I Licensed Practical Nurse (LPN) stated, I am not aware of any cream or normal saline flushes. I have not done any of it.

During an interview on 6/8/2026 at 2:13 PM, Resident #86's Representative stated, The staff came in and applied the cream when the changed him [Resident #86].

During an interview on 6/8/2026 at 2:16 PM, Staff G Certified Nursing Assistant (CNA) stated, The wound care nurse gave me the cream this morning; I left it in his [Resident #86] room and when I came back I applied it.

During an observation on 6/8/2026 at 10:25 AM Resident #38 was lying in bed.

There was a clear medication cup at bedside with a spoon and cream. [photographic evidence obtained]

During an interview on 6/8/2026 at 10:25 AM, Resident #38 stated that staff will apply the cream to him when they change him.

During an interview on 6/8/2026 at 2:20 PM, Staff H, CNA confirmed there was a clear medication cup with a spoon at Resident #38 bedside nightstand.

Staff H reported it is cream to apply when he is changed but should not have been left at bedside.

During an interview on 6/8/2026 at 2:21 PM, Staff B, LPN, stated, [ Resident #38's name] does not have an order to self-administer medication.

During an interview on 6/11/2026 at 6:22 AM, the Director of Nursing stated, [Residents #86 and #38's name] did not have orders to self-administer medications.

The medication should not be left unattended at bedside.

Review of the facility policy and procedure titled Medication Labeling and Storage with a last review date of 1/22/2026 read, Policy Statement.

The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls.

Only authorized personnel have access to keys.

105705 06/11/2026

Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748

During an interview on 6/8/2026 beginning at 9:38 AM, the Kitchen Manager agreed there was no stand-alone thermometer in the walk-in freezer.

During an observations on 6/8/2026 beginning at 9:48 AM, the thermometer in the 300 Hall nourishment room freezer registered 30 Fahrenheit degrees.

There were 7 thawed ice cream bars stored in the 300 Hall nourishment room freezer.

During interview on 6/8/2026 beginning at 9:48 AM, the Kitchen Manager reported the thermometer in the 300 Hall nourishment room freezer registered 30 degrees Fahrenheit.

She agreed the ice cream bars stored in the 300 Hall nourishment room freezer were thawed.

Review of the policy titled Food & Beverage Standards of Excellence, last reviewed 1/22/2026, read 5.

Food will be purchased, stored, prepared and served in a sanitary manner.Proper food temperature .

105705 06/11/2026

Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748

Review of the facility policy titled Sanitization, last reviewed 1/22/2026, read, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects.14.

Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered).15.

Areas used for garbage disposal are free from odors and waste fats, and maintained to prevent pests.

105705 06/11/2026

Lake Port Square Health Center 701 Lake Port Blvd Leesburg, FL 34748

in accordance with accepted professional standards.

#38) out of 2 residents reviewed for rehabilitation services.Finding includes:

During an interview on

guy who does my physical therapy has been on vacation and I have not gotten therapy in weeks.Review of Resident #38 physician order dated 4/21/2026 read, PT [physical therapy] recertification order for PT TX [treatment] QD [everyday]1 X/WK [week] x 60 days for thera ex, thera activity, Gait training, PT. /CG ed. TX DX R53. 1 one time for 60 Days.Review of Resident #38 Service Log Matrix for the Month of May 2026 there is no documentation for 5/19/2026 visit.Review of Resident #38 Service Log Matrix for the Month of April 2026 there is no documentation for 4/14/2026 and 4/28/2026 visits.

During an interview on 6/10/2026 at 10:18 AM with the Director of Therapy stated, He[Resident #38] did missed on April 14.

There is no documentation. He is on the assignment board for functional maintenance.

The therapist is in Thailand and cannot communicate with me to see what happen.

For whatever reason if he [Resident #38] refused or not feeling well it is not documented. On April 28 he is on case load assignment board that the therapist gets daily.

For whatever reason it is not documented why he did not receive the therapy session. It is Pro bono and been on it since last July 2024. On May 19 he is on the assignment board but no documentation of visit. He really doesn't like to get out of bed a lot that could be the reason. If we cannot do it on Tuesday we will move it a day.

The therapist should have documented the reasons why therapy session was not completed that day.

During an interview on 6/10/2026 at 11:25 AM with Staff B Licensed Practical Nurse (LPN) stated, He [Resident #38] is usually pretty go about going to therapy.

He goes every Tuesday and he is pretty go about going. He has not verbalized that he has missed therapy.

They are good at providing therapy to the residents.

During an interview on 6/10/2026 at 2:44 PM with the Director of Therapy stated, I spoke to [Resident #38's name and he remembers being sick on those particular days that are missing.

During an interview on 6/10/2026 at 2:47 PM Resident #38 stated he has missed therapy once or twice due to him not feeling well.

Stated his therapist has been sick once and they send someone and then the other time he was sick and did not have therapy due to this.

Review of the facility policy and procedure titled Documentation Requirements with a last review date of 1/22/2026 read, Policy: It is company policy that documentation of a resident's care will be maintained in a complete, timely and orderly fashion.