Department of Health & Human Services Printed: 02/21/2026

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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of
or potential for actual harm residents sampled:

Residents Affected - Few Number of residents cited:

(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 TITLE (X6) DATE

REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

Previous Versions Obsolete Page 1 of 13
106003
Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 0641 [NAME], TORREEN (115) [NAME], [NAME] (51024) - Position, Mobility Limited ROM Notes [DATE] 12:03
PM During Resident interview on [DATE] at 10;23 am, who stated she hasn't been able to walk since she
Level of Harm - Minimal harm or became disabled in 1979- a pickup truck hit her and her husband, she was in a coma for 4 months and her
potential for actual harm husband died. During record review on [DATE] at 10:32 am, Per ADL care plan and EMR she is on Pradaxa
once per day for afib and is a Hoyer lift x2 staff. Most current comprehensive and most recent quarterly dated
Residents Affected - Few [DATE]:MDS/CAA sectionC, BIMS 4E, No behaviors exhibited, GG, Upper and lower extremity reads no
Impairment I, Diagnoses:: Disorder of urinary system, unspecified Status: Active UNSPECIFIED ATRIAL
FIBRILLATION Status:AGE-RELATED OSTEOPOROSIS WITHOUT CURRENT PATHOLOGICAL
FRACTURE NEED FOR ASSISTANCE WITH PERSONAL CARE HISTORY OF FALLING SLEEP APNEA,
UNSPECIFIED:TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS CHRONIC DIASTOLIC
(CONGESTIVE) HEART FAILURE Status: UNSPECIFIED ASTHMA, UNCOMPLICATED : MUSCLE
WEAKNESS (GENERALIZED) : CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED
Status MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE VITAMIN D DEFICIENCY,
UNSPECIFIED OTHER SYMPTOMS AND SIGNS INVOLVING COGNITIVE FUNCTIONS AND
AWARENESS CHRONIC PULMONARY EMBOLISM Status: DYSPHAGIA, OROPHARYNGEAL PHASE:
DIVERTICULITIS OF INTESTINE, PART UNSPECIFIED, WITHOUT PERFORATION OR ABSCESS
WITHOUT BLEEDING UNSPECIFIED GLAUCOMA Status: Active Onset HYPO-OSMOLALITY AND
HYPONATREMIAPREDIABETES Status: GENERALIZED ANXIETY DISORDER Status: HEART FAILURE,
UNSPECIFIED MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIESJ, Active Pain management as
needed pain medication every 8 hours as needed O. No special treatments Physician's orders: T C.O.: PT to
tx 3 x a week for 60 days which may include therapeutic exercises, therapeutic activities, NMR, gait training,
manual therapy, group therapy, WC mgt, pt and caregiver education and DC planning. ordered by [NAME],
[NAME] on [DATE]Apply neck brace as needed for support and to alleviate [Link] needed for weakness
and pain in neck ordered by Dr. ClarkDiscontinued Cefdinir 300 mg oral capsules, 1 capsule every 12 hours
for 7 days, for the treatment of a urinary tract infection (UTI) on [DATE] ordered by Dr. ClarkPatient to utilize
pommel cushion in WC as needed for positioning and per patient request. Late entry for [DATE] ordered by
Dr. [NAME] . Pertinent diagnosishx of recent UTI antibiotic ended [DATE]Disorder of urinary system,
unspecified UNSPECIFIED ATRIAL FIBRILLATIONAGE-RELATED OSTEOPOROSIS WITHOUT
CURRENT PATHOLOGICAL FRACTURE NEED FOR ASSISTANCE WITH PERSONAL CARE HISTORY
OF FALLING SLEEP APNEA, UNSPECIFIEDTYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS
CHRONIC DIASTOLIC (CONGESTIVE) HEART FAILURE Status: UNSPECIFIED ASTHMA,
UNCOMPLICATED : MUSCLE WEAKNESS (GENERALIZED) : CHRONIC OBSTRUCTIVE PULMONARY
DISEASE, UNSPECIFIED Status MAJOR DEPRESSIVE DISORDER, RECURRENT, MODERATE
VITAMIN D DEFICIENCY, UNSPECIFIED OTHER SYMPTOMS AND SIGNS INVOLVING COGNITIVE
FUNCTIONS AND AWARENESS CHRONIC PULMONARY EMBOLISM Status: DYSPHAGIA,
OROPHARYNGEAL PHASE: DIVERTICULITIS OF INTESTINE, PART UNSPECIFIED, WITHOUT
PERFORATION OR ABSCESS WITHOUT BLEEDING HYPO-OSMOLALITY AND
HYPONATREMIAPREDIABETES Status: GENERALIZED ANXIETY DISORDER Status: HEART FAILURE,
UNSPECIFIED MORBID (SEVERE) OBESITY DUE TO EXCESS CALORIESROM Care plan:FOCUSMs.
[NAME] has potential for pain r/t History of Arthritis with joint pain, Neuropathic pain, Ms. [NAME] is at risk for
falls r/t impaired mobility and weakness Ms. [NAME]/responsible party wishes to remain in facility LTC per
physician [Link]: Resident will not experience a decline in overall function related to pain
through next review date. Resident will state/demonstrate relief or reduction in pain intensity within one hour
after receiving interventions through next review date. INTERVENTIONS: * Coordinate pain management
with Hospice PRNAdminister and monitor for effectiveness and for possible side effects from routine and/or
PRN pain medications (see MAR/physician orders) Educate resident/family about comfort measures,
analgesic medications, and discuss fears/concerns regarding pain, comfort, and disease process
PRNMonitor & report to nurse: Signs and symptoms of pain, Worsening of painNotify the resident's physician
if they do not state /demonstrate relief or reduction of pain with current pain management regime CARE
PLAN: Ms. [NAME] has potential for injury and/or pathological fracture r/t Osteoporosis Date Initiated:
[DATE] Revision on: [DATE] GOAL The resident will remain free of avoidable injuries or complications
related to osteoporosis through review date Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE]
INTERVENTION Initiated: [DATE] LPN RN Monitor/document for risk of falls. Educate resident, family
FORM CMS-2567 (02/99) /caregivers
Event ID: on safety measures that need to ID:
Facility be taken in order to reduce risk Ifofcontinuation
falls. (If resident
sheet has a care
Previous Versions Obsolete plan for falls, refer to this). Date Initiated: [DATE] LPN RN Monitor/document/report Page 2 PRN of 13s/sx or
106003
complications related to osteoporosis: Acute fracture, Compression fractures, Loss of height, Kyphosis
(dowagers hump, thoracic curve), Pain, especially back CARE PLAN: [NAME] has a self care deficit with
Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 0645 PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
potential for actual harm record review and interview the facility failed to ensure a resident who was diagnosed with a serious mental
illness received pre-admission screening and resident review (PASARR) program for 1 Resident, Resident
Residents Affected - Few #19, of 3 residents reviewed for PASARR. Findings include: Review of Resident #19's admission record
documented Resident #19 was admitted on [DATE] with diagnoses that included Post-Traumatic Stress
Disorder (PTSD) onset date of 10/28/2024, anxiety onset date 8/28/2023 and depressive disorder onset date
8/29/2023 Review of Resident #19's State of Florida Agency of Health Care Administration Preadmission
Screening and Resident Review (PASRR) dated 5/4/2024 showed no documentation was entered in Section
I: PASRR Screen Decision-Making A. MI [Mental Illness] or suspected MI [Mental Illness] (check all that
apply): that recorded Resident #19's diagnosis of post-traumatic stress disorder. Review of Resident #19's
State of Florida Agency of Health Care Administration Preadmission Screening and Resident Review
(PASRR) read 5. Does the individual have primary diagnosis of : Dementia? No Review of Resident #19's
psychiatric progress note dated 12/5/2025 read visit type: Psychiatry: Stable 12-week follow up (on no
meds). Documented . past psychiatric history of depression, anxiety, PTSD and [Link]
assessment and [Link]-traumatic stress disorder, [Link] (post-traumatic stress disorder): The
history suggests that this patient has suffered from significant trauma resulting in nightmares, flashbacks,
and hypervigilance in the past. The symptoms have caused significant distress and functional impairment to
the patient. The symptoms have lasted for more than one month and have occurred without any substance
use or organic brain [Link] of Resident #19's care plan, date initiated 9/22/2025, documented
Resident #19 had potential for re-traumatization, alteration in thought process related to diagnosis of PTSD.
During an interview on 12/17/2025 at 12:22 PM, the Director of Nursing stated the PASSAR does not have
diagnosis of PTSD and PTSD should be documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

Previous Versions Obsolete Page 3 of 13
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Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 - Minimal harm or Based on observation, interview, and record review the facility failed to ensure resident were provided with
potential for actual harm wound care as ordered for 1 (Resident#+141) of 3 residents reviewed for skin [Link] include:
During an observation on 12/15/2025 at 9:54 AM Resident #141 was lying in bed, Resident #141 eft shoulder
Residents Affected - Few wound dressing was dated 12/11. During an observation on 12/16/2025 at 9:12 AM Resident #141 was lying
in bed his left shoulder wound dressing was dated 12/[Link] of Resident #141 physician orders dated
12/11/2025 read, Left Upper Arm: Cleanse with NS [normal saline], pat dry, apply calcium alginate to wound
bed and cover ABD [abdominal] pad and rolled gauze every evening shift AND as [Link] of
Resident #141 physician order dated 12/11/2025 read, Right Buttock: Cleanse with Dakins 0.125%, allow to
air dry, apply medical grade honey, collagen particles and calcium palatinate to wound bed and cover with
bordered foam every evening shift AND as [Link] of Resident #141 physician order dated
12/11/2025 read, LLE [Lower Left Extremity]: Cleanse with NS, Pat dry, calcium alginate to wound bed and
cover with ABD pad and kelix every evening shift AND as neededReview of Resident #141 physician order
dated 12/11/2025 read, Right Upper Back: Cleanse with NS, pat dry, apply calcium alginate to wound bed
and cover with bordered dressing every evening shift for wound care AND as neededReview of Resident
#141 physician order dated 12/11/2025 read, Right Lower Back: Cleanse with NS, pat dry, apply calcium
alginate to wound bed and cover with bordered dressing every evening shift AND as [Link] an
interview 12/17/2025 at 12:25 PM with the Assistant Director of Nursing #2 (ADON #2) stated, I will round
with the wound care provider and then all recommendations I will communicate with the physician, and the
physician will have the final say regarding the wound care orders. The wound care orders in the system will
supersede any recommendations done by the wound care provider. During an observation on 12/17/2025 at
12:30 with the ADON #2 confirm wound on left should was dated 12/11/2025. During an observation on
12/17/2025 at 1:00 PM with ADON #2 and Staff I Licensed Practical Nurse wound on right lower back, right
upper back, left lower extremity and right buttock were dated 12/11/2025 and the right lower buttocks wound
was overly [Link] an interview on 12/17/2025 at 1:15 PM with the ADON #2 stated wounds should
be changed daily. During an interview on 12/18/2025 at 10:30 AM with the Director of Nursing (DON) stated,
Nurses should check physician orders and provide care based on the orders. Physician orders should be
followed. Review of the facility policy and procedure titled Wound Care with the last review date of 6/11/2025
read, Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of
developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 6. Wound care
procedures and treatments should be performed according to physician orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

Previous Versions Obsolete Page 4 of 13
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Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
potential for actual harm interview and record review the facility failed to provide dialysis services consistent with professional
standards related to the assessment of the resident's condition and monitoring for 1 (Resident #12) of 1
Residents Affected - Few resident reviewed for [Link] include: Review of Resident #12's clinical record documented
admission on [DATE] with diagnosis that included acute respiratory failure with hypoxia, atrial fibrillation
(irregular heart rhythms), end stage renal disease (kidneys function less than 15% of normal ability) and
dependence on renal dialysis. Review of Residents #12's physician orders dated 10/25/2025 read Dialysis
center, Tue, Thursday, Saturday pick up time 0540am. [Dialysis center name, address and number]. Review
of Resident #12's dialysis communication book contained no communication of assessment of Resident #12,
no Vital signs, and no weights. There was no communication from before or after dialysis treatment and no
communication from dialysis. During an interview on 12/18/2025 at 10:26 AM with interview of Administrator
of Dialysis center stated, We receive hardly any communication from the facility. They [the facility] are one of
the harder facilities to get a hold of or communicate with. I have to keep calling them to come and pick him
up, after dialysis. We are trying to rearrange the schedule to get him in later. He was here Tuesday, and
today [12/18/2025] and scheduled for Saturday, then next week will be here on Monday, Wednesday and
Friday. I faxed the schedule to [ the facilities name] . He hasn't missed any. He is always in pain as you know
if they take meds before they come, we just pull the medication right out with dialysis. No documentation at
all from the facility. No binder nothing some other facilities will send information. We do not send any
information to the facility unless they have a binder with communication or if they call and request anything.
During an interview on 12/18/2025 at 10:44 AM with Staff Q, Certified Nursing Assistant (CNA) stated that
they make sure that the residents are clean, have something to eat to go with them and their blanket. No, we
do not do weights or vital signs. We do have restorative nursing that goes around with a clip board, and they
will do weights on resident and log the weights and vital signs, but all the residents are different some just
once a month some daily, but we do not weigh or take vital signs before they go to dialysis. During an
interview on 12/28/2025 at 10:50 AM with Staff R, CNA stated I will make sure the resident is clean, has a
lunch and blanket. No vital signs or weighs on the resident is obtained. If they have a book, we will send the
book with them. During an interview on 12/28/2025 at 11:15 AM with Staff N, License Practical Nurse (LPN)
Unit Manager stated that the resident is supposed to be weighed, and vital signs taken prior to leaving for
dialysis and we normally send a face sheet. We do not receive anything back from dialysis. During an
interview on 12/28/2025 at 1:00 PM with the Director of Nursing stated we should have communication notes
from our facility with the resident assessment, vital signs and weight, in the resident's binder. We normally
get treatment records from the dialysis centerReview of facilities policy and procedure titled Hemodialysis
dated 6/11/2025 read It will be the policy of this facility to provide the necessary care and services to those
residents receiving hemodialysis while a resident at the facility . 6. The physician and dialysis center will be
alerted to resident non-compliance issues of food and fluid . 9. The facility and the Dialysis Center should
maintain regular communication and should a change in condition occur before or during the dialysis
treatment, the sending facility should communicate the changes in needs to the receiving facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

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Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following
irregularity reporting guidelines in developed policies and procedures.
Level of Harm - Minimal harm or
potential for actual harm Based on record review and interview the facility failed to ensure residents have completed medication
orders including dosage for 1 (Resident #25) of 6 residents reviewed for unnecessary [Link]
Residents Affected - Few include:Review of Resident #25 physician orders dated 10/9/2025 read, Lidocaine Pain Relief 4% Patch.
Apply to per additional directions topically one time a day for pain at [Link] of Resident #25 physician
orders did not have an order for removal of Lidocaine Pain Relief Patch. Review of Resident #25 physician
orders dated 9/9/2025 read, Diclofenac Sodium External Gel 3 % (Diclofenac Sodium (Actinic Keratoses)
apply to bilateral knee topically two times a day for knee pain. Review of Resident #25 physician orders
dated 11/12/2025 read, Diclofenac Sodium External Gel 1% (Diclofenac Sodium Topical) apply to right knee
topically three times a day for right knee [Link] an interview on 12/18/2025 at 10:30 AM with the
Director of Nursing stated, [Resident #25 name] has no removal orders for lidocaine patch. There should be
an additional order for the removal. Diclofenac does not have a dose amount included and it should. It was
part of an old batch orders and needs to be updated. Review of the facility policy and procedure titled
Pharmacy Services with a last review date of 6/11/2025 read, Policy: It will be the policy of this facility to
provide pharmacy and pharmacist services to meet the needs of the resident. 2Procedrue: 1. The drug
regimen of each resident must be reviewed at least once a month by a licensed pharmacist. 2. Pharamcist
must report any irregulates to the attending physician and the facility's medical director and director of
nursing, and these reports must be acted upon.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

Previous Versions Obsolete Page 6 of 13
106003
Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of
jeopardy to resident health or residents sampled:
safety
Number of residents cited:
Residents Affected - Few
[NAME], [NAME] (7) [NAME], [NAME] (45576) - FTag Initiation No Notes [NAME], [NAME] (7) [NAME],
[NAME] (45576) - RESIDENT NOTE No Notes

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

Previous Versions Obsolete Page 7 of 13
106003
Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food
in accordance with professional standards.
Level of Harm - Minimal harm or
potential for actual harm Based on observation, interview and record review, the facility failed to ensure that required food
temperature monitoring logs were maintained and complete in 1 of 3 nourishment rooms as evidenced by
Residents Affected - Few missing days Based on observation on 12/15/25 at 9:22AM the surveyor observed that the Magnolia Hall
nourishment room food temperature log had not been completed for several dates, despite food items
requiring temperature monitoring being [Link] an interview on 12/15/25 at 9:25AM the Dietary
Manager stated that food temperature logs should be documented [Link] of facility policy titled,
Refrigerated Storage review date 10/1/23 showed it reads Foods and Nutrition Services (FNS) should
maintain safe refrigerated storage areas. Refrigerated items should be properly stored, labeled and
maintained by dietary staff. Adequate circulation of air around refrigerated products is essential to maintain
food temperatures. Procedure: Refrigeration equipment will be monitored by dietary staff daily for adequate
temperatures and functionally at routine intervals during hours of operation. Temperatures will be recorded
on the appropriate logs to demonstrate monitoring.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

Previous Versions Obsolete Page 8 of 13
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Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of
jeopardy to resident health or residents sampled:
safety
Number of residents cited:
Residents Affected - Few
[NAME], [NAME] (7) [NAME], [NAME] (45576) - FTag Initiation No Notes [NAME], [NAME] (7) [NAME],
[NAME] (45576) - RESIDENT NOTE No Notes

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

Previous Versions Obsolete Page 9 of 13
106003
Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
Level of Harm - Minimal harm or
potential for actual harm (continued on next page)

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

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Department of Health & Human Services Printed: 02/21/2026
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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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 0842 Based on observation, interview, record review the facility failed to accurately document wound care
treatments for 1 (Resident #141) of 3 residents review for skin conditions and 1 (Resident #99) of 6 residents
Level of Harm - Minimal harm or reviewed for medication management. Findings include:During an observation on 12/15/2025 at 9:54 AM
potential for actual harm Resident #141 was lying in bed, Resident #141 eft shoulder wound dressing was dated 12/11. During an
observation on 12/16/2025 at 9:12 AM Resident #141 was lying in bed his left shoulder wound dressing was
Residents Affected - Few dated 12/[Link] of Resident #141 physician orders dated 12/11/2025 read, Left Upper Arm: Cleanse with
NS [normal saline], pat dry, apply calcium alginate to wound bed and cover ABD [abdominal] pad and rolled
gauze every evening shift AND as [Link] of Resident #141 physician order dated 12/11/2025 read,
Right Buttock: Cleanse with Dakins 0.125%, allow to air dry, apply medical grade honey, collagen particles
and calcium palatinate to wound bed and cover with bordered foam every evening shift AND as needed.
Review of Resident #141 physician order dated 12/11/2025 read, LLE [Lower Left Extremity]: Cleanse with
NS, Pat dry, calcium alginate to wound bed and cover with ABD pad and kelix every evening shift AND as
neededReview of Resident #141 physician order dated 12/11/2025 read, Right Upper Back: Cleanse with
NS, pat dry, apply calcium alginate to wound bed and cover with bordered dressing every evening shift for
wound care AND as neededReview of Resident #141 physician order dated 12/11/2025 read, Right Lower
Back: Cleanse with NS, pat dry, apply calcium alginate to wound bed and cover with bordered dressing
every evening shift AND as [Link] an interview 12/17/2025 at 12:25 PM with the Assistant Director
of Nursing #2 (ADON #2) stated, I will round with the wound care provider and then all recommendations I
will communicate with the physician, and the physician will have the final say regarding the wound care
orders. The wound care orders in the system will supersede any recommendations done by the wound care
provider. During an observation on 12/17/2025 at 12:30 with the ADON #2 confirm wound on left should was
dated 12/11/[Link] an observation on 12/17/2025 at 1:00 PM with ADON #2 and Staff I Licensed
Practical Nurse wound on right lower back, right upper back, left lower extremity and right buttock were dated
12/11/2025 and the right lower buttocks wound was overly [Link] an interview on 12/17/2025 at
1:15 PM with the ADON #2 stated wounds should be changed daily. During an interview on 12/18/2025 at
10:30 AM with the Director of Nursing (DON) stated Nurses should not check off a task as completed until it
is fully completed. Documentation should be [Link] an interview on 12/18/2025 at 12:04 PM with
Staff B Registered Nurse (RN) stated, I made a mistake. I was giving report, and I was going to go after to do
the dressing change. I had a new admission come in and I was so tired. I forgot to do the dressing changes.
Review of the facility policy and procedure titled Wound Care with the last review date of 6/11/2025 read,
Policy: It will be the policy of this facility to provide assessment and identification of residents at risk of
developing pressure injuries, other wounds and the treatment of skin impairment. Procedure: 6. Wound care
procedures and treatments should be performed according to physician orders. 10. Document in the clinical
record when treatments are performed.2)Review of Resident #99 physician order dated 11/29/2024 read,
Metoprolol Tartrate Oral Tablet 25 MG [milligram] (Metoprolol Tartrate) Give 1 tablet by mouth one time a
day for HBP [high blood pressure] hold if sbp<110 dbp<60 and or pulse <60 [systolic blood pressure less
than 110, diastolic blood pressure less than 60 and or pulse less than 60].Review of Resident #99
Medication Administration Record for the month of December 2025 for Metoprolol Tartrate Oral Tablet 25 mg
documented on 12/2/2025 and on 12/9/2025 at 1800 [6:00 PM] blood pressure and pulse documented NA
[not applicable].Review of Resident #99 Medication Administration Record for the month of November 2025
for Metoprolol Tartrate Oral Tablet 25 mg documented at 1800 on 11/2/2025 NA documented for pulse,
11/10/2025 NA for blood pressure and pulse, 11/16/2025 NA for blood pressure and pulse, 11/21/2025 NA
documented for pulse, and 11/26/2025 NA for blood pressure and [Link] an interview on 12/18/2025
at approximate 10:10 AM with Staff I Licensed Practical Nurse stated, I don't recall that. Usually, I will take
the blood pressure before giving the medication and document it. The facility expects me to document the
blood pressure in the medication record. Before I give the medication I always check the blood pressure and
make sure it follows physician orders. During an interview on 12/18/2025 at 10:30 AM with the Director of
Nursing stated, Vital signs should be recorded in the medication record before the medication is going to be
administered. The staff should document blood pressure manually and or in a progress [Link] of the
facility policy and procedure titled Charting and Documentation with a last review date of 6/11/2025 read,
Policy: It is the policy of this facility that services provided to the resident, or any changes in the resident's
medical or mental condition, shall be documented in the resident's clinical record as is needed. Procedure: 1.
Observations, medications administered, services performed, etc., should be documented in the resident's
FORM CMS-2567 (02/99) clinical
Event ID:records. Facility ID: If continuation sheet
Previous Versions Obsolete Page 11 of 13
106003
Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 (continued on next page)

potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet

Previous Versions Obsolete Page 12 of 13
106003
Department of Health & Human Services Printed: 02/21/2026
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
106003 B. Wing 12/18/2025

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

Lady Lake Specialty Care Center and Rehab 630 Griffin Avenue
Lady Lake, FL 32159

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review that facility failed to follow infection control standards during wound
Level of Harm - Minimal harm or care for 1 (Resident #141) of 3 residents reviewed for skin conditions and 3 (Resident #6, Resident#75, and
potential for actual harm Resident #100) of 5 residents reviewed for respiratory services. Findings include: LANE, [NAME] (75)
[NAME], [NAME] (45576) - Respiratory Care Oxygen Notes F880 3. Review of Resident #75's clinical record
Residents Affected - Few documented admission on [DATE] with diagnosis that included chronic respiratory failure (lungs can't
properly exchange oxygen and carbon dioxide), asthma, disorders of the lung, and absence of part of the
lung. During an observation on 12/15/2025 at 10:09AM Resident # 75 nebulizer was lying on the ground and
open to air. Photograph evidence [Link] an observation on 12/15/2025 at 3:30 PM Resident # 75
nebulizer was lying on the ground and open to air. Photograph evidence obtained. During an interview on
12/15/2025 at 3:30PM Resident #75 stated I get my breathing treatments every 6 hours if I don't, I can't
breathe, yes I received my treatments last night and already twice today, I get them every 6 hours. During an
interview on 12/15/2025 at 4:00 PM with Staff D, License Practical Nurse (LPN) stated nebulizer must be
placed back in the plastic bags after each use. Review of Resident #75's physician orders dated 11/7/2025
read Ipratropium-Albuterol Solution 0.5- 2.5 (3) MG/3ML 3 ml inhale orally four times a day for COPD
(chronic obstructive pulmonary disease). Review of Resident #75 Medication administration record for
December 2025 documented that Ipratropium-Albuterol Solution 0.5- 2.5 (3) MG/3ML 3 ml inhale orally four
times a day for COPD was administered as ordered. 1)During an observation on 12/17/2025 at 12:37 PM
Assistant Director of Nursing (ADON #2) asked Staff I Licensed Practical Nurse to perform wound care on
Resident #141. Staff I without preforming hand hygiene approached the treatment cart and started to collect
items need for wound care. Staff I did not have normal saline in the treatment cart. Staff I returned all the
supplies back to the treatment and walked to the central supplies. Staff I return to the treatment cart and
without performing hand hygiene retrieved all the wound care supplies. Staff I and ADON walked to Resident
#141 room and performed hand hygiene and donned gown and gloves. Staff I did not tie his gown. Staff I
gown was loose and portion of torso and shoulders was not cover by the gown. Staff I removed dressing
from Resident #141 right buttock. Removed gloves and washed hands. Donned new set of gloves and
proceeded to clean wound with a scrubbing motion, going over area that he had cleaned initially. Staff I
began to open dressing packet and treatments without preforming hand hygiene. Staff I stopped and went to
the bathroom and performed hand hygiene. Staff I applied treatment and dressing. During an interview on
12/18/2025 at 10:10 AM Staff I, LPN, stated, I was nervous but that is no excuse. I should have performed
hand hygiene and I should have made sure I had tied my gown properly in the beginning of wound care. I
should have clean the wound in a circular motion from inside of wound to the outer portion. Education was
provided to me. I was nervous but there is no excuse. During an interview on 12/18/2025 at 10:30 AM with
the Director of Nursing stated, Staff should wash their hands before gathering all the supplies. Gown should
have been properly donned. Staff should have washed hands before touching the clean supplies. The wound
should have been clean in circular motion from inside of wound to the outside so it would not contaminate
the clean area. Review of the facility policy and procedure titled Wound Care with a last review date of
6/11/2025 read, Procedure: 7. Wound care treatment should maintain proper technique, as is indicated by
the type of wound and physician orders. Review of the facility policy and procedure titled Hand Hygiene with
a last review date of 6/11/2025 read, Policy: This facility considers hand hygiene the primary means to
prevent the spread of infections. Procedure: 5. Use an alcohol-based hand rub containing at least 62 %
alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b.
Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, ect;
l. after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; Review of the
facility policy and procedure titled Enhanced Barrier Precautions with a last review date of 6/11/2025 read,
Policy: It will be the policy of this facility to implement enhance barrier precautions for preventing
transmission of novel or targeted multidrug resistant organisms. Definitions: Enhanced barrier precautions
refers to the use of gown and gloves for certain residents during specific high-contact resident care activities
that have been found to increase risk for transmission of multidrug-resistant organisms. Procedure: 4. For
residents for whom EBP ae indicated, EBP is employed when performing the following High-Contact resident
care activities-h. wound care. 2) During an observation on 12/15/2025 at 9:40AM Resident #6 nebulizer
mask was lying on top of a black handbag on top of the recliner not stored in a bag. [photographic evidence
obtained] During an observation on 12/15/2025 at 12:40 PM Resident #6 nebulizer mask was lying on top of
FORM CMS-2567 (02/99) the black
Event ID: handbag on top of the recliner. Review
Facility ID: of Resident #6 physician order dated 12/11/2025
If continuation sheet read,
Previous Versions Obsolete Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML 3 ml inhale orally four times Pagea day
13 offor
13SOB and wheezing.
106003
Review of Resident #6 Care plan intervention dated 6/25/2025 read, store respiratory equipment in infection
control bag when not in use.3)During an observation on 12/15/2025 at 12:46 PM Resident #100 nasal