Solaris Healthcare Lake Bennet

F-F600

Resident #1, a [AGE] year old male was admitted to the facility from an acute care hospital on [DATE REDACTED] with diagnoses that included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), type 2 diabetes mellitus with polyneuropathy (weakness/numbness/burning), hypertension (high blood pressure), right bundle branch (heart signal) block, dysphagia (difficulty swallowing), cognitive communication deficit, hearing loss, dysarthria and anarthria (slow/slurred speech).

The Minimum Data Set (MDS) Comprehensive Admission Assessment with an Assessment Reference Date (ARD) of [DATE REDACTED] noted during the look-back period, resident #1 scored 12 out of 15 on the Brief Interview for Mental Status that indicated he was moderately cognitively impaired. The assessment showed the resident did not have any behavioral symptoms or rejections of evaluations or care necessary for goals to achieve health and well-being, he had upper and lower extremity (arms/legs) functional Range of Motion limitations, used a wheelchair, was dependent on staff for assistance to complete Activities of Daily Living and mobility, was always incontinent of bladder and bowel functioning, and difficulty swallowing. The MDS Unplanned Discharge Assessment with an ARD of [DATE REDACTED] noted during the look-back period, resident #1 did not have any behavioral symptoms or rejections of evaluations or care necessary for goals to achieve health and well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0684 Resident #1 had care plans related to impaired functional abilities ([DATE REDACTED], revised [DATE REDACTED]); altered metabolism related to type 2 diabetes mellitus and medication use ([DATE REDACTED]); risk for falls/requires staff Level of Harm - Immediate assistance for transfers ([DATE REDACTED], revised [DATE REDACTED]); potential nutritional problems ([DATE REDACTED]); and potential skin jeopardy to resident health or integrity alteration ([DATE REDACTED], revised [DATE REDACTED]). On [DATE REDACTED], a care plan for alteration of urinary elimination as safety evidenced by incontinence was initiated. Interventions included for nurses to monitor and document signs and symptoms of UTI. The Comprehensive Care Plan did not detail behaviors including refusals of Residents Affected - Few care/treatments, or non-compliance. There were no care plans for blood in urine or for an actual urinary infection.

The Order Summary Report for [DATE REDACTED] included a physician's order dated [DATE REDACTED] for Urinalysis/Urine Culture (UA/CS). The order was marked as completed on [DATE REDACTED]. On [DATE REDACTED] the physician ordered Tylenol 650 milligrams (MG) every six hours as needed for pain, and on [DATE REDACTED] Tramadol 50 MG, an opiate pain medication, was added for pain every eight hours. On [DATE REDACTED] Tylenol 650 MG was added for fever over 100. 0 degrees Fahrenheit (F).

A urine sample should be provided for both a urinalysis and culture test (UA/CS). Your physician might order

the urinalysis initially to look for blood cells and bacteria in the urine that can indicate an infection. If it's positive your provider would order a urine culture to grow microorganisms and identify the specific bacteria or fungus causing the infection, (retrieved on [DATE REDACTED] from www.clevelandclinic.org.

On [DATE REDACTED] a physician order indicated staff to send resident #1 to the emergency room (ER) for evaluation and treatment for blood pressure of ,d+[DATE REDACTED], diaphoresis (excessive sweating), and slow to respond to verbal commands per family request.

A nurse's Progress Note dated [DATE REDACTED] at 2:33 PM, revealed resident #1 had red-tinged urine during the previous night. A note dated [DATE REDACTED] at 8:23 AM, indicated the resident rolled out of bed onto the floor and required two staff to be assisted off the floor and back to bed.

On [DATE REDACTED] at 10:23 AM, in a telephone interview, Licensed Practical Nurse (LPN) C explained she obtained and entered UA/CS orders into the computer on [DATE REDACTED] during the 11:00 PM to 7:00 AM shift after a Certified Nursing Assistant (CNA) informed her blood tinged urine was observed in resident #1's incontinence brief. The nurse recalled she later passed on the information to LPN D for the oncoming 7:00 AM to 3:00 PM shift. She said the normal process was that after orders were processed, a printed copy was placed in a binder at the nurses station for the specimen bag, but she could not recall if she had done that, or if the next shift did it.

Review of the Medication Administration Record (MAR) showed a physician's order dated [DATE REDACTED] for Urinalysis/Urine Culture was signed as completed by Licensed Practical Nurse (LPN) A on [DATE REDACTED] at 5:20 AM. On [DATE REDACTED] at 10:11 AM, LPN D signed that resident #1 was administered Tylenol 650 MG for a temperature of 100.2 F and at 1:43 PM, the nurse administered Tramadol 50 MG for pain.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0684 On [DATE REDACTED] at 3:11 PM in a telephone interview, LPN A recalled on [DATE REDACTED] during the 11:00 PM to 7:00 AM shift, resident #1 had an order pending completion for a UA/CS. The nurse recalled she attempted to collect Level of Harm - Immediate the urine specimen in the early morning hours of [DATE REDACTED] but was unable, so she tried again, unsuccessfully, jeopardy to resident health or later in the shift. She said she thought she marked refused on the MAR, but confirmed she did not complete safety a progress note nor contact the physician, that the lab was not collected. She did not recall if she passed on

the information to the oncoming 7:00 AM to 3:00 PM shift nurse. She explained in early April, she was Residents Affected - Few informed by the Director of Nursing (DON) that the resident's wife had called for the results and the facility found the test was marked in the MAR as completed but it was never done. The LPN said the facility's normal practice was for night shift to obtain labs and it was difficult to get urine specimens overnight or early morning when residents were sleeping. She said she should have written a progress note and contacted the physician and stated, I learned my lesson that when I go do a procedure and they refuse, don't wait until the end of the shift; notify the DON and the doctor.

Review of resident #1's medical record revealed there were no nursing Progress Notes on [DATE REDACTED] completed by LPN A that documented the UA/CS physician's order was not implemented, nor that the physician was notified.

On [DATE REDACTED] at 3:50 PM, Registered Nurse (RN) B explained that nurses entered the order for the lab in the computer by going into the documentation program and selecting the tab for labs. They would select the test that was ordered by the physician and put in the diagnosis for the test. The nurse would notify the resident or

the family if a urine sample was needed and would try to obtain the sample. The nurse would print the order, place a copy in the specimen bag and get a cup to collect the urine. This gets completed just prior to collection of the sample. She confirmed another nurse created the order for resident #1's UA/CS, but she was the one to revise it. RN B confirmed the order should not be clicked off until it was actually done and said you would make a note if it was refused or you were unable to collect it. RN B conveyed you would notify the provider so they could reorder it or decide if they wanted to do something else. She explained the Unit Managers (UM's) would check the lab book to check the labs to ensure they were collected by the nurses. RN B said it was important to collect the labs timely before symptoms worsened.

On [DATE REDACTED] at 10:31 AM, LPN D recalled she cared for resident #1 many times during his stay including on

the 7:00 AM to 3:00 PM shift on [DATE REDACTED]. The nurse explained earlier in the shift on [DATE REDACTED], the resident had

a fever, so she called the Physician's Assistant (PA) who gave her orders for routine labs and Tylenol. She said at approximately 2:00 PM, the resident complained of pain and was administered Tramadol, and approximately a half hour later when the family arrived to visit, she re-checked the resident, and he was, lethargic (fatigue/sluggishness). LPN D stated she called the PA again who gave orders for STAT labs and IV fluids, but the family did not want to wait and were adamant about the resident going to the hospital immediately. The PA was called again, and orders were given to send the resident out to the ER via 911/EMS.

Review of nurse's Progress Notes completed by LPN D documented on [DATE REDACTED] at 10:11 AM, resident #1 had a temperature of 100.2 F. The attending physician was notified, and orders were obtained for Tylenol 650 MG and routine orders were obtained from the PA for laboratory testing. Later at 1:45 PM, the resident complained of left hip pain and was administered the pain medication, Tramadol 50 MG.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0684 A Progress Note documented by LPN D later on [DATE REDACTED] at 3:45 PM, noted resident #1's wife and daughter were at the facility visiting and the resident was observed as slow to respond to verbal and touch stimulation, Level of Harm - Immediate had dilated pupils, and sweaty/clammy skin. LPN D described that the resident's vital signs were assessed jeopardy to resident health or as a blood pressure of 85 systolic and 50 diastolic millimeters of mercury (mmHg), and heart rate of 90 beats safety per minute. She documented that the UM contacted the PA who ordered STAT laboratory tests and IV fluids. LPN D's note continued, the resident's daughter requested the resident be sent to the emergency room and Residents Affected - Few the PA was contacted for orders. LPN D's note dated [DATE REDACTED] at 4:24 PM, documented resident #1 left the facility by stretcher at 4:25 PM, with EMS to go to the hospital.

On [DATE REDACTED] at 10:16 AM, the North UM recalled in [DATE REDACTED], she was working when resident #1 received the pain medication, Tramadol in the afternoon and a short time later; LPN D informed her the resident seemed more lethargic and wasn't responding to his family who were very concerned with his change in condition.

The nurse explained the PA was called and provided orders for STAT labs and IV fluids, but the family was not satisfied with that intervention and wanted him to go to the hospital immediately, so the PA was called back and approved the orders for transport to the hospital. The UM explained that sometime later, in early [DATE REDACTED] she was informed by the DON that the resident's lab could not be found and had been signed off as completed by a nurse. She said resident #1 had at least one family member visit every day and nurses could have asked the family to assist in obtaining the urine if the resident was refusing. She said the Unit Managers were responsible for checking a binder kept at the nurse's station for collection tracking and the APRNs (Advanced Practice Registered Nurses) assisted to check for results. The UM did not explain how or why resident #1's lab result was not done.

Review of a Situation Background Assessment Recommendations-SBAR progress note completed by the North UM on [DATE REDACTED] at 4:53 PM, revealed, at 2 PM, nurse on unit administered Tramadol 50 MG po (by mouth) for pain x 1 dose. Resident eyes were dilated, slow to respond to verbal commands and diaphoretic at 1550 (3:50 PM). Temperature 100.2 this AM with complaints of sore throat. Throat was pink, and moist with no patchy areas noted. The North UM documented the resident 's vital signs were blood pressure of , d+[DATE REDACTED], heart rate of 90, respirations of 19, blood sugar of 159, and temporal temperature of 97.5 F. She noted resident #1 had excessive sweating on the trunk of his body. She said the PA ordered IV fluids, Normal Saline, get STAT labs for UA, C/S, a complete blood count with differential and a basic metabolic panel. The UM documented that the wife and daughter adamantly requested for him to go to hospital.

In a telephone interview on [DATE REDACTED] at 10:37 AM, the PA explained she regularly came to the facility to see residents and as part of her assessments, she reviewed orders, labs, medications, vital signs, imaging, etc.

The PA said lab orders and results were reviewed with the UM and stated, if I couldn't find results, I will go back and look to see when it was ordered to be collected, and if more than a day or two after it was to be collected, I notify nursing to see if it was even collected. She recalled on [DATE REDACTED], she received a call from the North Unit Manager that resident #1 wasn't looking good and thought he either had a UTI or sepsis, so she gave orders for STAT labs, including a UA and more frequent vital sign monitoring. Later they called back because the family wanted to send him to the ER immediately, so she gave those orders. She said she expected any UA/CS orders to be processed the same day and sent to the lab, and for nurses to notify the provider when a test wasn't completed. She could not recall the facility informing her resident #1's UA/CS from [DATE REDACTED] wasn't done. The PA stated, they can become septic, and we don't know the source of the infection; we have to treat them emergently.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0684 Review of Progress Notes documented by the PA dated [DATE REDACTED] and [DATE REDACTED], after the physician's diagnostic testing was ordered included documentation the resident was seen at the request of staff for a follow-up visit. Level of Harm - Immediate Both notes indicated, Patient's labs/diagnostics and care provider notes reviewed . jeopardy to resident health or safety In a telephone interview on [DATE REDACTED] at 11:59 AM, resident #1's wife recalled on [DATE REDACTED], the family received a voicemail from the resident who stated he wasn't feeling well. She explained she and her daughter came to Residents Affected - Few the facility, they observed him and described his condition as, cold, sweaty, clammy, and non-responsive.

She said her daughter was a paramedic and believed he was in distress, possibly septic shock. She said nurses called the physician who ordered labs, but the family was very concerned he needed emergent care and insisted he be sent to the ER immediately, so 911 was initiated. She said she believed her husband would have died had they not been there and insisted he go immediately. She said she later requested the UA results from the facility and learned they were never done. She recalled the experience was very stressful, her family was distraught during the crisis and thought they may lose their loved one. She said her husband required a breathing machine and ICU care at the hospital for over two weeks. Resident #1's wife said he had to go to another facility to recover with continued therapy and nursing care. She exclaimed her family suspected her husband had a UTI at that time and would ask facility nurses about their concerns, but

they would say he's fine, and tell her he just needed to, sleep it off. His wife said, they never did a urinalysis,

they just didn't do it. She continued, we came in and basically had to find him catatonic before they did something. The resident's wife stated, looking back, he had no energy and would fall back like a ragdoll; no wonder he had no energy; he wasn't like that before; even now, he has gone down a lot.

In a joint interview with the DON and Nursing Home Administrator (NHA) on [DATE REDACTED] at 1:05 PM, the DON conveyed if a lab was unable to be collected, nurses were expected to report to the oncoming nurse and notify the physician for further orders. She said the physician may say to recollect or could decide to do something else. She confirmed that the facility had a responsibility to follow up on any orders including the collection of labs such as urine. The DON recalled on [DATE REDACTED], the facility received a call from resident #1's wife who requested the UA/CS results from during his stay at the facility. She explained after she checked resident #1's medical records, she found the urine test was never done but LPN A had signed the MAR that

it was completed on [DATE REDACTED]. The DON explained when they questioned her, LPN A stated she attempted to obtain a specimen twice on [DATE REDACTED], but the resident refused. LPN A told them she did not inform the physician, nursing management, nor did she complete a progress note explaining what happened. The DON explained routine labs were collected by the 11:00 PM to 7:00 AM nurses, and any time a test was not done for any reason, nurses were expected to notify the physician. She said when the nurse signed the order as completed it fell off the record and stated, It's the Unit Manager or designee's responsibility to follow up on ordered lab results.

On [DATE REDACTED] at 10:11 AM, in a telephone interview, resident #1's attending physician explained he checked resident #1's medical record and recalled a UA/CS was ordered on [DATE REDACTED] for blood in the urine. The physician said he expected his lab orders to be carried out and for nurses to let him know if they were unable to obtain them so he could decide what to do next. He stated, undetected UTI can lead to sepsis; in this case that is what happened.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0684 In a telephone interview on [DATE REDACTED] at 10:53 AM, the facility's Medical Director said he was aware of resident #1's incident. The Medical Director related he knew the provider was not notified the urine sample was not Level of Harm - Immediate collected and the test was never completed. The physician explained he expected nurses to notify providers jeopardy to resident health or when they were unable to collect specimens and stated, unidentified UTI can lead to sepsis. safety

Review of resident #1's hospital records from [DATE REDACTED] showed during transport to the hospital EMS personnel Residents Affected - Few used a Bag-Valve Mask to manually maintain resident #1's breathing until they arrived at the ER at approximately 4:30 PM. After resident #1 arrived at the ER, life sustaining measures were immediately implemented including insertion of an endotracheal airway (breathing tube), respiratory ventilation (breathing by machine), insertion of vena cava (heart) infusion IV device, and irrigation (flushing) of the genitourinary tract (genital tract in/out of bladder) due to severe sepsis. The resident required IV medications to stabilize his blood pressure and IV antibiotics for UTI and septicemia (blood infection) and was transferred to the ICU.

The ICU physician's note read, Upon my evaluation, this patient has high probability of imminent, life-threatening, or organ-threatening deterioration and I provided life/organ saving interventions as noted above. Resident #1 required continued acute care hospitalization for more than two weeks until he was discharged to another long term care facility on [DATE REDACTED] for continued recovery. The resident's hospital diagnoses included: critical hypotension (low blood pressure), acute (sudden onset) toxic encephalopathy (brain dysfunction), acute hypoxemia (low blood oxygen) respiratory failure, acute tubular necrosis (severe kidney cell damage from oxygen loss), and septic shock from UTI.

Bag-Valve-Mask (BVM) ventilation is a critical life-saving technique used to provide oxygen and ventilation to patients who are apneic (temporary breathing cessation) or experiencing severe ventilatory (provision of air to the lungs) failure, (retrieved on [DATE REDACTED] from www.medscape.com).

The facility's undated policy and procedure, Laboratory Tests/Diagnostic Procedures: Communicating the results, revealed the facility would track ordered labs and diagnostic procedures and promptly notify the medical provider, resident and/or the representative. The procedure section described a facility designated nurse would review lab log sheets daily to verify protocol was followed and follow up on any discrepancies noted.

The facility's undated standards and guidelines titled Nursing-Change in Resident's Condition or Status noted the physician and representative were to be promptly notified of any changes in condition or status.

The procedure included nurse notifications to the attending or on-call physician when there was a refusal of treatment.

The Facility assessment dated [DATE REDACTED] noted the facility provided care and services for management of medical conditions including, Early Identification of Problems, and provided Person-Centered Care that included, disorders of the genitourinary system.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 105967

F-F684

Review of the medical records revealed resident #1, a [AGE] year old male was admitted to the facility from

an acute care hospital on [DATE REDACTED] with diagnoses that included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), type 2 diabetes mellitus with polyneuropathy (weakness/numbness/burning), hypertension (high blood pressure), right bundle branch (heart signal) block, dysphagia (difficulty swallowing), cognitive communication deficit, hearing loss, dysarthria and anarthria (slow/slurred speech).

The Minimum Data Set (MDS) Comprehensive Admission Assessment with an Assessment Reference Date (ARD) of [DATE REDACTED] noted during the look-back period, resident #1 scored 12 out of 15 on the Brief Interview for Mental Status that indicated he was moderately cognitively impaired. The assessment showed the resident did not have any behavioral symptoms or rejections of evaluations or care necessary for goals to achieve health and well-being, he had upper and lower extremity (arms/legs) functional Range of Motion limitations, used a wheelchair, was dependent on staff for assistance to complete Activities of Daily Living and mobility, was always incontinent of bladder and bowel functioning, and difficulty swallowing. The MDS Unplanned Discharge Assessment with an ARD of [DATE REDACTED] noted during the look-back period, resident #1 did not have any behavioral symptoms or rejections of evaluations or care necessary for goals to achieve health and well-being.

Resident #1 had care plans related to impaired functional abilities ([DATE REDACTED], revised [DATE REDACTED]); altered metabolism related to type 2 diabetes mellitus and medication use ([DATE REDACTED]); risk for falls/requires staff assistance for transfers ([DATE REDACTED], revised [DATE REDACTED]); potential nutritional problems ([DATE REDACTED]); and potential skin integrity alteration ([DATE REDACTED], revised [DATE REDACTED]). On [DATE REDACTED], a care plan for alteration of urinary elimination as evidenced by incontinence was initiated. Interventions included for nurses to monitor and document signs and symptoms of UTI. The Comprehensive Care Plan did not detail behaviors including refusals of care/treatments, or non-compliance.

A nurse's Progress Note dated [DATE REDACTED] at 2:33 PM, revealed resident #1 had red-tinged urine during the previous night. A note dated [DATE REDACTED] at 8:23 AM, indicated the resident rolled out of bed onto the floor and required two staff to be assisted off the floor and back to bed.

The Order Summary Report for [DATE REDACTED] included a physician's order dated [DATE REDACTED] for Urinalysis/Urine Culture (UA/CS). The order was marked as completed on [DATE REDACTED]. On [DATE REDACTED] the physician ordered Tylenol 650 milligrams (MG) every six hours as needed for pain, and on [DATE REDACTED] Tramadol 50 MG, an opiate pain medication, was added for pain every eight hours. On [DATE REDACTED] Tylenol 650 MG was added for fever over 100. 0 degrees Fahrenheit (F).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0600 A urine sample should be provided for both a urinalysis and culture test (UA/CS). Your physician might order

the urinalysis initially to look for blood cells and bacteria in the urine that can indicate an infection. If it's Level of Harm - Immediate positive your provider would order a urine culture to grow microorganisms and identify the specific bacteria or jeopardy to resident health or fungus causing the infection, (retrieved on [DATE REDACTED] from www.clevelandclinic.org. safety Further review of the medical record revealed a physician's order on [DATE REDACTED] to send resident #1 to the Residents Affected - Few emergency room (ER) for evaluation and treatment for blood pressure of ,d+[DATE REDACTED], diaphoresis (excessive sweating), and slow to respond to verbal commands per family request.

On [DATE REDACTED] at 10:23 AM, in a telephone interview, Licensed Practical Nurse (LPN) C explained a Certified Nursing Assistant (CNA) informed her blood tinged urine was observed in resident #1's incontinence brief, so

she obtained physician orders for the UA/CS. LPN C said she entered the UA/CS orders in to the computer system on [DATE REDACTED] during the 11:00 PM to 7:00 AM shift and later passed on the information to LPN D for the oncoming 7:00 AM to 3:00 PM shift. She said the normal process was that after orders were processed, a printed copy of the order was placed in a binder at the nurses' station for the specimen bag but could not recall if she had done that.

Review of the Medication Administration Record (MAR) for [DATE REDACTED] revealed a physician's order dated [DATE REDACTED] for Urinalysis/Urine Culture was signed as completed by LPN A on [DATE REDACTED] at 5:20 AM. A week later

on [DATE REDACTED] at 10:11 AM, LPN D documentation revealed resident #1 was administered Tylenol for a temperature of 100.2 F and at 1:43 PM, he was administered Tramadol for pain.

On [DATE REDACTED] at 3:11 PM, in a telephone interview, LPN A recalled on [DATE REDACTED] during the 11:00 PM to 7:00 AM shift, resident #1 had an order pending completion for a UA/CS. The nurse remembered she attempted to collect a specimen in the early morning hours of [DATE REDACTED] and was unable, so she re-attempted unsuccessfully later in the shift. She said she marked, refused on the MAR but did not complete a progress note nor contact

the physician. She could not recall if she passed on the information to the oncoming 7:00 AM to 3:00 PM nurse. She explained in early April, she was informed by the Director of Nursing (DON) that the resident's wife had called for the UA/CS results and the facility found the test was marked in the MAR as completed but

it was never done. The LPN said the facility's normal practice was for night shift to obtain labs, but it was difficult to get urine specimens overnight or in the early morning when residents were sleeping. She acknowledged she should have written a progress note to document the refusal and contacted the physician. LPN A confirmed when a resident refused a procedure she should promptly notify the DON and the physician.

Review of resident #1's medical record revealed there were no nursing progress notes documented on [DATE REDACTED] by LPN A regarding the physician's order for the UA/CS not being performed, nor that the physician or anyone else was notified the test was not done.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0600 On [DATE REDACTED] at 10:31 AM, LPN D recalled she cared for resident #1 many times during his stay including on

the 7:00 AM to 3:00 PM shift on [DATE REDACTED]. The nurse explained earlier in the shift on [DATE REDACTED], the resident had Level of Harm - Immediate a fever, so she called the PA who gave her orders for routine labs and Tylenol. She said at approximately jeopardy to resident health or 2:00 PM, the resident complained of pain and was administered Tramadol, and approximately a half hour safety later when the family arrived to visit, she re-checked the resident, and he was, lethargic (fatigue/sluggishness). LPN D stated she called the PA again who gave orders for STAT labs and IV fluids, Residents Affected - Few but the family did not want to wait and were adamant about the resident going to the hospital immediately.

The PA was called again, and orders were given to send the resident out to the ER via 911/EMS.

Review of nurse's Progress Notes completed by LPN D documented on [DATE REDACTED] at 10:11 AM, resident #1 had a temperature of 100.2 F. The attending physician was notified, and orders were obtained for Tylenol 650 MG and routine orders were obtained from the PA for laboratory testing. Later at 1:45 PM, the resident complained of left hip pain and was administered the pain medication Tramadol 50 MG.

A nurse's Progress Note documented by LPN D on [DATE REDACTED] at 3:45 PM, noted resident #1's wife and daughter were at the facility visiting and the resident was observed as slow to respond to verbal and touch stimulation, had dilated pupils, and sweaty/clammy skin. The resident's vital signs were assessed and measured with a blood pressure of 85 systolic and 50 diastolic millimeters of mercury (mmHg), and heart rate of 90 beats per minute. The Unit Manager contacted the PA who ordered STAT laboratory tests and IV fluids. The resident's daughter requested the resident be sent to the emergency room and the PA was contacted for orders. LPN D's note dated [DATE REDACTED] at 4:24 PM, documented resident #1 left the facility by stretcher at 4:25 PM, with EMS to go to the hospital.

On [DATE REDACTED] at 10:16 AM, the North Unit Manager (UM) recalled in [DATE REDACTED], she was working when resident #1 received Tramadol in the afternoon and a short time later; LPN D informed her the resident seemed more lethargic and wasn't responding to his family who were very concerned with his change in condition. The nurse explained the PA was called and provided orders for STAT labs and IV fluids, but the family was not satisfied with that intervention and wanted him to go to the hospital immediately, so the PA was called back and approved the orders for transport to the hospital. She explained that sometime later, in early [DATE REDACTED] she was informed by the DON that the resident's lab could not be found and had been signed off as completed by a nurse. She said resident #1 had at least one family member visit every day and nurses could have asked the family to assist in obtaining the urine if the resident was refusing. She said the Unit Managers were responsible for checking a binder kept at the nurse's station for collection tracking and the APRNs (Advanced Practice Registered Nurses) assisted to check for results. The Unit Manager did not explain how or why resident #1's lab result was not done.

Review of a Situation Background Assessment Recommendations-SBAR progress note completed by the North UM on [DATE REDACTED] at 4:53 PM, revealed, at 2 PM, nurse on unit administered Tramadol 50 MG po (by mouth) for pain x 1 dose. Resident eyes were dilated, slow to respond to verbal commands and diaphoretic at 1550 (3:50 PM). Temperature 100.2 this AM with complaints of sore throat. Throat was pink, and moist with no patchy areas noted. The North UM documented the resident 's vital signs were blood pressure of , d+[DATE REDACTED], heart rate of 90, respirations of 19, blood sugar of 159, and temporal temperature of 97.5 F. She noted resident #1 had excessive sweating on the trunk of his body. She said the PA ordered IV fluids, Normal Saline, get STAT labs for UA, C/S, a complete blood count with differential and a basic metabolic panel. The UM documented that the wife and daughter adamantly requested for him to go to hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0600 In a telephone interview on [DATE REDACTED] at 10:37 AM, the PA explained she regularly came to the facility to see residents and as part of her assessments, she reviewed orders, labs, medications, vital signs, imaging, etc. Level of Harm - Immediate The PA said lab orders and results were reviewed with the UM and stated, if I couldn't find results, I will go jeopardy to resident health or back and look to see when it was ordered to be collected, and if more than a day or two after it was to be safety collected, I notify nursing to see if it was even collected. She recalled on [DATE REDACTED], she received a call from the North UM that resident #1 wasn't looking good and thought he either had a UTI or sepsis, so she gave Residents Affected - Few orders for STAT labs and more frequent vital sign monitoring, but a short time later was called again because

the family wanted to send him to the ER, so she gave those orders. She said she expected UA/CS orders to be processed the same day and sent to the lab, and for nurses to notify the provider when a test wasn't completed. She could not recall the facility informing her resident #1's order for UA/CS from [DATE REDACTED] was not ever done. The PA stated, they [residents] can become septic, and we don't know the source of the infection;

we have to treat them emergently.

Review of Progress Notes completed by the PA dated [DATE REDACTED] and [DATE REDACTED], after the physician's diagnostic testing was ordered included documentation the resident was seen at the request of staff for a follow-up visit. Both notes indicated, Patient's labs/diagnostics and care provider notes reviewed .

In a telephone interview on [DATE REDACTED] at 11:59 AM, resident #1's wife recalled on [DATE REDACTED], the family received a voicemail from the resident who stated he wasn't feeling well. She explained she and her daughter came to

the facility, they observed him and described his condition as, cold, sweaty, clammy, and non-responsive.

She said her daughter was a paramedic and believed he was in distress, possibly septic shock. She said nurses called the physician who ordered labs, but the family was very concerned he needed emergent care and insisted he be sent to the ER immediately, so 911 was initiated. She said she believed her husband would have died had they not been there and insisted he go immediately. She said she later requested the UA results from the facility and learned they were never done. She recalled the experience was very stressful, her family was distraught during the crisis and thought they may lose their loved one. She said her husband required a breathing machine and ICU care at the hospital for over two weeks. Resident #1's wife said he had to go to another facility to recover with continued therapy and nursing care. The resident's wife stated, looking back, he had no energy and would fall back like a ragdoll; no wonder he had no energy; he wasn't like that before; even now, he has gone down a lot.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0600 In a joint interview with the DON and Nursing Home Administrator (NHA) on [DATE REDACTED] at 1:05 PM, the DON recalled on [DATE REDACTED], the facility received a call from resident #1's wife who requested the UA/CS results from Level of Harm - Immediate during his stay at the facility. The DON said after checking the medical records, she found the test was never jeopardy to resident health or done and LPN A had documented on the MAR that it was completed on [DATE REDACTED]. She explained the facility safety initiated a grievance and found through interview with LPN A she attempted to obtain a specimen twice on [DATE REDACTED], and the resident refused but she did not inform the physician, nursing management, nor complete a Residents Affected - Few progress note. The DON said resident #1 did not return to the facility after he was sent to the hospital on [DATE REDACTED], so the facility did not further investigate the reason for re-hospitalization . On [DATE REDACTED] at 11:15 AM,

the DON explained she believed resident #1 was hospitalized for something infection based and stated, I do believe it was UTI for his admitting diagnosis into the hospital. The DON recalled she spoke with resident #1's daughter on approximately [DATE REDACTED] and was informed the resident was not returning to the facility. The DON said the facility did not consider requesting the hospital records to see if the adverse incident may have contributed to resident #1's re-hospitalization . She explained the facility's investigation revealed when the nurse signed the order as completed it fell off the record and stated, It's the Unit Manager or designee's responsibility to follow up on ordered lab results.

On [DATE REDACTED] at 12:14 PM, the facility's Grievance Officer checked her records and recalled on [DATE REDACTED], the NHA received a call from resident #1's wife and daughter concerning lab collection for a UA and customer service. She said an investigation was completed and the facility found LPN A documented the test was completed on [DATE REDACTED] when in fact it was never done. She said the facility made the family aware of the investigation results and interventions.

In a joint interview with the NHA, DON and Risk Manager, on [DATE REDACTED] at 1:52 PM, the Risk Manager recalled

the facility conducted an investigation that started [DATE REDACTED], after resident #1's wife called for test results. She said the investigation revealed nurses had not implemented the physician's order nor notified the physician. When asked what the facility considered resident neglect to be, the Risk Manager stated, Neglect is not providing goods and services; goods and services did not occur because they did not provide the UA. The NHA, DON, and Risk Manager did not explain why the facility had not reported possible neglect to the State Agency (SA) when they realized the ordered lab was not done. On [DATE REDACTED] at approximately 2:00 PM, the NHA said the facility had submitted a Facility Reported Incident regarding neglect to the SA after it was brought to their attention during the survey.

On [DATE REDACTED] at 10:11 AM, in a telephone interview, resident #1's attending physician recalled resident #1 after reviewing his notes. He remembered a UA/CS was ordered on [DATE REDACTED] for blood in the urine. The physician said he expected his orders to be completed by nurses or to notify him if they were unable to fulfill the order so he could decide what should be done as a next step. He confirmed he was told recently as to what happened regarding resident #1 not getting the ordered urine testing and stated, undetected UTI can lead to sepsis; in this case that is what happened.

In a telephone interview on [DATE REDACTED] at 10:53 AM, the facility's Medical Director said he was aware of the incident concerning resident #1's hospitalization and he knew the provider was not notified the lab tests were not performed hence the missing test results. The physician explained that he expected nurses to notify providers when they were unable to collect specimens and stated, unidentified UTI can lead to sepsis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0600 Review of resident #1's hospital records from [DATE REDACTED] showed during transport to the hospital EMS personnel used a Bag-Valve Mask to manually maintain resident #1's breathing until they arrived at the ER at Level of Harm - Immediate approximately 4:30 PM. After resident #1 arrived at the ER, life sustaining measures were immediately jeopardy to resident health or implemented including insertion of an endotracheal airway (breathing tube), respiratory ventilation (breathing safety by machine), insertion of vena cava (heart) infusion IV device, and irrigation (flushing) of the genitourinary tract (genital tract in/out of bladder) due to severe sepsis. The resident required IV medications to stabilize Residents Affected - Few his blood pressure and IV antibiotics for UTI and septicemia (blood infection) and was transferred to the ICU.

The ICU physician's note read, Upon my evaluation, this patient has high probability of imminent, life-threatening, or organ-threatening deterioration and I provided life/organ saving interventions as noted above. Resident #1 required continued acute care hospitalization for more than two weeks until he was discharged to another long term care facility on [DATE REDACTED] for continued recovery. The resident's hospital diagnoses included: critical hypotension (low blood pressure), acute (sudden onset) toxic encephalopathy (brain dysfunction), acute hypoxemia (low blood oxygen) respiratory failure, acute tubular necrosis (severe kidney cell damage from oxygen loss), and septic shock from UTI.

Bag-Valve-Mask (BVM) ventilation is a critical life-saving technique used to provide oxygen and ventilation to patients who are apneic (temporary breathing cessation) or experiencing severe ventilatory (provision of air to the lungs) failure, (retrieved on [DATE REDACTED] from www.medscape.com).

The facility's undated standards and guidelines titled Abuse, Neglect, Exploitation & Misappropriation noted

the Risk Manager/designee conducted a thorough investigation and reported possible neglect to the State Agency as per regulatory guidelines. The document included the following definition of neglect, Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional stress. Neglect occurs when the facility is aware of or should be aware of goods and services that a resident requires, but the facility fails to provide them to the resident resulting in or may result in physical harm.

The facility's undated standards and guidelines titled Nursing-Change in Resident's Condition or Status noted the physician and representative were to be promptly notified of any changes in condition or status.

The procedure included nurse notifications to the attending or on-call physician when there was a refusal of treatment.

The Facility assessment dated [DATE REDACTED] noted the facility provided care and services for management of medical conditions including, Early Identification of Problems, and provided Person-Centered Care that included, Abuse/Neglect Prevention, and disorders of the genitourinary system.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46665

Residents Affected - Few Based on interview and record review, the facility failed to develop an individualized Comprehensive Care Plan to include an indwelling urinary catheter for 1 of 3 residents reviewed for urinary catheters, of a total sample of 6 residents, (#3).

Findings:

Review of the medical record revealed resident #3, an [AGE] year old female was admitted to the facility from an acute care hospital on 12/11/24. She had diagnoses that included wedge compression fracture of thoracic (mid-spine) and lumbar (lower spine) vertebrae, and Urinary Tract Infection (UTI).

The Minimum Data Set (MDS) Comprehensive Admission 5-day Assessment with an Assessment Reference Date (ARD) of 12/13/24 noted during the look back periods, resident #3 scored 10 out of 15 on the Brief

Interview for Mental Status that indicated she was moderately cognitively impaired. The resident required staff assistance to complete Activities of Daily Living (ADLs) and the use of an indwelling urinary catheter appliance. During the 7-day look back period, the resident required high-risk antibiotic medications. The Care Area Assessment (CAA) Triggers dated 12/24/24 and the Comprehensive Care Plan Decisions dated 12/25/24 included an indwelling urinary catheter.

The Order Summary Report noted resident #3 had physician's medication orders for antibiotics to treat a UTI that included: From 12/30/24 to 12/31/24, Macrobid 100 milligrams (mg) every 12 hours, and from 12/31/24 to 1/08/25, Cipro 500 mg every 12 hours.

Review of the Nurses Progress Notes showed on 12/12/24, resident #1 was unable to urinate and required insertion of an indwelling urinary catheter.

Review of the Care Plan Report with care plans completed 12/25/24, and revised 1/03/25 did not include a Focus, Goal, or Interventions for an indwelling urinary catheter.

In an interview on 5/15/25 at 11:37 AM, the MDS Coordinator explained Comprehensive Care Plans were completed with input from the Interdisciplinary Team, and the MDS department was responsible for coordination to ensure all individualized elements were included. She checked resident #1's medical record and said the MDS CAA was triggered for inclusion of an indwelling urinary catheter in the Comprehensive Care Plan and acknowledged it was omitted. The MDS Coordinator stated, it was overlooked and not placed

in the care plan.

Review of the facility's standards and guidelines dated September 2024 and titled, Resident Assessment Instrument Comprehensive Care Plan Policy noted the facility used the CAA to ensure all possible resident care needs and risks identified during the MDS process were considered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 105967 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 105967 B. Wing 05/17/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Bennet Center for Rehabilitation & Healing 1091 Kelton Ave Ocoee, FL 34761

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46665 jeopardy to resident health or safety Based on interview, and record review, the facility failed to attain or maintain the resident's highest practicable physical well-being by failing to ensure nurses implemented physician's orders for diagnostic Residents Affected - Few testing, notified the physician, and ensured provision of necessary care and services for 1 of 6 residents reviewed for Quality of Care, of a total sample of 6 residents, (#1).

The facility failed to implement a physician's order for Urinalysis with Culture and Sensitivity (UA/CS) for resident #1, failed to notify the physician that the ordered diagnostic test was not completed, and failed to follow up on the missing laboratory result. Additionally, the physician/provider did not recognize or act upon

the absence of the test result. Due to these combined failures in care coordination, resident #1's Urinary Tract Infection (UTI) went undiagnosed and untreated, leading to the development of septic shock, a life-threatening condition. This failure to provide necessary care and services placed the resident and other residents in Immediate Jeopardy that began on [DATE REDACTED], when the facility failed to ensure timely diagnostic testing and appropriate medical intervention.

On [DATE REDACTED], resident #1 was admitted to the facility from the hospital. Thirteen days later on [DATE REDACTED], the facility sent the resident back to the hospital where he required mechanical ventilation (life support for breathing) in the Intensive Care Unit (ICU) for septic shock from the UTI. Sepsis is when your body's immune system has a dangerous response to an infection. It is a medical emergency that can be caused by many different kinds of infections. The quicker you receive treatment, the better your outcome will be. Septic shock can occur when an infection in your body causes extremely low blood pressure and organ failure due to sepsis. Septic shock is life-threatening and requires immediate medical treatment. It's the most severe stage of sepsis, (retrieved on [DATE REDACTED] from www.clevelandclinic.org).

Findings:

Cross reference