Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Baldomero Lopez Memorial Veterans Nursing Home during CMS and state inspections, most recent first.
The facility failed to consistently review and revise comprehensive care plans after multiple behavioral incidents, resident‑to‑resident altercations, and falls. One resident with dementia and PTSD experienced repeated verbal altercations and a fall with head impact after yelling at others near an exit door, yet his behavioral and fall care plans were not updated with new approaches. Another resident with severe cognitive impairment and daily wandering was involved in several altercations related to wandering, but his existing behavior and wandering care plans were not revised to reflect these events. A third resident with dementia had documented episodes of yelling at a roommate and attempting to trip another resident, without corresponding care plan updates. A fourth resident with dementia, agitation, and PTSD‑related psychosis had multiple falls and a resident‑to‑resident incident, but his fall care plan had not been recently updated. The MDS RN and DON confirmed that these care plans were not revised after the incidents, despite facility policy requiring care plan review and revision when significant changes or unmet outcomes occur.
The facility failed to provide adequate supervision and maintain a hazard‑free environment, resulting in multiple physical altercations among cognitively impaired residents with dementia, behavioral symptoms, and wandering. One resident with Alzheimer’s and PTSD was pushed to the floor, hit his head, and sustained skin tears, and in another incident he was found pinning another resident to a bed with his hands around the resident’s neck while the victim trembled. Other events included a resident being struck with a walker in a common area, a resident in a wheelchair being pushed and pulled by another resident, and two residents engaging in a fistfight in a room, with one being pushed to the floor, kicked, and developing bruising around the eye. Surveyors observed common areas and hallways with residents present but no staff in sight, especially during busy mealtimes, while CNAs reported difficulty monitoring residents due to workload and unit busyness. A supervision list showed several residents on 15‑minute and 30‑minute checks and one on 1:1, yet CNAs were unaware of some residents’ increased supervision status, and required monitoring documentation was missing for part of a shift, demonstrating inconsistent implementation of ordered supervision.
The facility failed to conduct thorough investigations into two separate resident-to-resident abuse incidents involving cognitively impaired residents with dementia and behavioral issues. In one case, a CNA found a resident pinning another to a bed with hands around the neck, but the risk manager relied only on a verbal report from an LPN, did not obtain a written statement from the witnessing CNA, and misunderstood key details of the event. In the second case, two residents engaged in a physical fight with punching, pushing, and kicking after one wandered into the other’s room; the LPN reported visible facial redness that later turned purple, yet the risk manager did not secure complete staff statements, had not read the detailed nursing note describing the punching, and made assumptions about what occurred. Despite a policy requiring timely internal investigations, the facility did not fully gather or reconcile staff accounts and documentation for these alleged abuse incidents.
Failure to Revise Care Plans After Behavioral Incidents and Falls
Penalty
Summary
The deficiency involves the facility’s failure to develop, revise, and implement comprehensive, measurable care plans that addressed residents’ behavioral symptoms and fall risks after significant events. For one resident with Alzheimer’s disease, dementia, PTSD, and moderate cognitive impairment, the record showed multiple resident‑to‑resident verbal altercations and an incident on 2/24/2026 in which he was pushed to the floor, hit his head, and sustained skin tears after yelling at another resident near an exit door alarm. Although the Risk Manager reported that care plan approaches were requested to be updated after incidents on 2/24/2026, 3/30/2026, and 4/2/2026, the behavioral care plan for this resident only addressed refusal of care and resistance to assistance, with no updates reflecting his pattern of yelling at other residents at the exit door. His falls care plan identified him as at risk for injury due to unsteady gait, dementia, pain, stroke history, psychotropic use, and antiplatelet therapy, but no new fall‑related approaches were documented after 3/6/2026 despite the fall with head impact. Another resident with early‑onset Alzheimer’s disease, dementia with psychotic and mood disturbance, severe cognitive impairment, and daily wandering had documented physical behavioral symptoms toward others and frequent wandering. Progress notes indicated excessive wandering, exit‑seeking behaviors that were not easily redirected, and involvement in five resident‑to‑resident altercations between 2/24/2026 and 4/2/2026, all related to his wandering. His care plan included a wandering/elopement problem and a behavioral problem describing constant pacing, wandering, impaired awareness of personal space, and risk for resident‑to‑resident conflict, with approaches such as frequent observation, redirection from other residents’ rooms and crowded areas, reassurance, and use of a sensory chew. However, there were no documented care plan updates specifically addressing the series of resident‑to‑resident altercations that occurred during the review period. A third resident with Alzheimer’s disease, dementia with mood disturbance, adjustment disorder, severe cognitive impairment, and no behaviors coded on the MDS had multiple documented resident‑to‑resident incidents. Progress notes described him standing over his roommate yelling about noise, an altercation with another resident on 3/16/2026, and an event on 3/25/2026 where he stuck his foot out in an attempt to trip another resident who was pacing in front of his view of the television. His behavioral care plan, initiated in 2024 and last edited on 2/18/2026, focused on increased confusion and agitation at the end of the day that may lead to verbal aggression, with general approaches such as discussing behaviors, assisting with coping methods, altering care approaches if he became combative, protecting others’ rights and safety, monitoring behaviors, and psychiatry referral. No care plan revisions were documented to specifically address his observed attempts to trip another resident or the repeated resident‑to‑resident altercations. A fourth resident with Alzheimer’s disease, dementia with agitation and other behavioral disturbance, PTSD‑related psychosis, severe cognitive impairment, and frequent physical and verbal behavioral symptoms toward others had multiple falls and a documented resident‑to‑resident altercation. Progress notes showed several unwitnessed or observed falls in common areas and on the floor, as well as an incident where he took another resident’s hat and attempted to push another resident out of a wheelchair, after which he was pushed by the other resident. His falls care plan identified him as at risk for falls due to expected physical decline, psychotropic use for PTSD, resistance and combativeness, and antiplatelet therapy, with approaches last updated in 2024 and 2025. No recent updates were made to his care plan to reflect the series of falls or the resident‑to‑resident interaction. The MDS RN and DON acknowledged that care plans for these residents had not been reviewed and revised with new approaches after the problem behaviors and incidents occurred, despite facility policy requiring care plan review and revision when significant changes, unmet outcomes, or new needs are identified. The facility’s written policy on care plan development, revised 11/28/2017, states that care plans will be reviewed and revised as needed, including when a significant change in condition is noted or when outcomes are not achieved, and that all team members must report changes in condition and unmet goals to the primary/charge nurse and MDS coordinator. Documentation is required to be consistent with the resident’s plan of care, and revisions may be made by any member of the interdisciplinary team on an as‑needed basis. In the cases of these four residents, surveyors found that despite documented behavioral incidents, resident‑to‑resident altercations, and repeated falls, the corresponding care plans were not updated with new, measurable approaches to address the identified behaviors and risks, resulting in a failure to ensure comprehensive care plans that met all of the residents’ needs.
Inadequate Supervision Leading to Multiple Resident‑to‑Resident Altercations
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and a hazard‑free environment, resulting in multiple resident‑to‑resident physical altercations on a locked unit. The Risk Manager (RM) reported that one resident with Alzheimer’s disease, cognitive communication deficit, and adjustment disorder was involved in three altercations with another resident with early‑onset Alzheimer’s disease, severe dementia with psychotic and mood disturbance, and daily wandering. In one incident, the first resident was pushed to the floor, hit his head, and sustained skin tears on both hands. In another incident, a CNA stated he was the only staff member on the hall with the door closed providing care when he heard screaming; upon entering the room, he found the first resident pinning the second resident to the bed with his hands around the second resident’s neck, and the second resident was visibly shaking and trembling. The second resident’s MDS documented physical behavioral symptoms toward others on one to three days per week and daily wandering, and his care plan identified problematic behaviors including constant pacing, wandering, invading personal space, and entering other residents’ rooms, placing him at risk for resident‑to‑resident conflict. Additional altercations occurred among other cognitively impaired residents with behavioral symptoms. The RM stated that one resident in the common area watching television was hit with a walker by another resident; both were examined and had no injuries. Another resident with dementia, adjustment disorder, and increased confusion and agitation at the end of the day, leading to verbal aggression, pushed a resident with severe cognitive impairment, dementia with agitation and psychotic disturbance, and frequent physical and verbal behavioral symptoms, and tried to pull him out of his wheelchair while they were in the common area watching television. A separate incident involved two residents with dementia and behavioral issues: one resident with PTSD, wandering into other residents’ rooms, and combativeness entered another resident’s room. An LPN reported he initially expected the room’s resident to tell the wandering resident to leave, but instead the two residents began “full on punching each other.” The LPN described the altercation as like a fight in the jungle, with one resident pushed to the floor and kicked, resulting in redness and later bruising around the eye of the resident who was pushed. Observations and staff interviews showed that supervision on the locked unit was inconsistent and often inadequate, particularly in common areas and during mealtimes. Surveyors observed residents sitting in the common area watching television with no staff in sight, and residents wandering up and down hallways while staff were in and out of rooms providing care. During dinner, one staff member sat in a corner of the dining room observing while another delivered trays, and at the same time, multiple residents were in the common area with no staff at the nurses’ station or in view. CNAs working on the locked unit reported that residents can become very physical with each other, that it is difficult to watch everyone because the unit is very busy, and that mealtimes and afternoons are especially challenging as residents become more confused and are “everywhere” while staff are passing meals and providing care. The facility also failed to consistently implement and communicate increased supervision requirements for residents identified as needing closer monitoring. A supervision list showed multiple residents on every 15‑minute and every 30‑minute checks, and one resident on 1:1 supervision. However, one CNA stated she did not have any residents on increased supervision, even though her assignment included two residents on every 30‑minute checks. Another CNA believed she had one resident on every 30‑minute checks, but her assignment included two such residents. A third CNA, who had a resident on every 15‑minute checks, showed that there was no documentation of checks from midnight to 7:00 a.m. for that resident, and she had to start a new sheet at the beginning of her shift. The DON stated that all staff should know which residents are on increased supervision, that this information is given at shift change, and that supervision sheets should be completed every 15 or 30 minutes as ordered, but acknowledged that staff were not aware of all residents on increased supervision. The DON also confirmed that the wandering resident involved in multiple altercations was on every 15‑minute checks at the time of one of the incidents. The RM stated the unit is very busy, that residents cannot be restrained due to regulations, and that she had not tracked or trended the incidents on the unit to identify patterns.
Incomplete Investigations of Resident-to-Resident Abuse Incidents
Penalty
Summary
The deficiency involves the facility’s failure to conduct complete and thorough investigations into two separate resident-to-resident abuse incidents. In the first incident, a CNA reported that he was the only staff member on the hall and was in another resident’s room with the door closed for privacy when he heard screaming. He entered one resident’s room and observed one resident pinning another resident to the bed with his hands around the other resident’s neck. The victim was visibly shaking and trembling. Progress notes documented that the residents were involved in a resident-to-resident altercation, that they were separated, and that no visible injury or acute distress was observed at the time of the nurse’s entry. The risk manager later stated she only had a verbal report from an LPN, did not obtain a written statement from the CNA who witnessed the event, and had an inaccurate understanding of the location and nature of the altercation, believing it occurred by the door and that the victim had placed hands on the aggressor’s neck. She also stated she had not heard that the victim had been pinned to the bed. The residents involved in the first incident had significant cognitive and behavioral histories documented in their records. One resident had Alzheimer’s disease, cognitive communication deficit, and adjustment disorder with mixed anxiety and depressed mood, with a care plan noting risk for mood and behavior fluctuations related to Alzheimer’s dementia and PTSD. The other resident had early-onset Alzheimer’s disease, major depressive disorder, mixed anxiety disorders, and severe dementia with psychotic, mood, and anxiety disturbances. His MDS showed severely impaired cognition, daily wandering, and physical behavioral symptoms toward others on several days, and his care plan described problematic behaviors including constant pacing, wandering, impaired awareness of personal space, and a tendency to enter other residents’ rooms, placing him at risk for resident-to-resident conflict. Despite these factors and the serious description of the event by the CNA, the risk manager did not secure complete staff statements or clarify conflicting accounts before completing and submitting the investigation reports. The second incident involved two other residents who engaged in a physical altercation after one resident wandered into another’s room. An LPN reported that he saw the wandering resident enter the room and initially expected the room’s occupant to ask him to leave. Instead, the two residents began “full on punching each other,” and one resident was pushed to the floor and kicked while on the ground. The LPN stated that the resident on the floor had redness around his eye immediately after the incident, which later turned purple. Progress notes for both residents documented that staff heard yelling, observed both residents exchanging punches, and that one resident pushed the other onto his buttocks against the open door and then kicked him while he was on the ground. The notes also recorded that the hall nurse assessed both residents and documented no visible injuries and that both denied pain, and that the resident who entered the room stated he did not realize it was not his own. In this second incident, the risk manager reported that the resident who entered the room was on 15-minute checks due to aggression and rapid mood changes. She stated it was reported to her that this resident went into the other resident’s room, was pushed to the floor, and then kicked. However, she believed that the CNA was the first person in the room and that the LPN was called in to help, which conflicted with the LPN’s account that he was the first to arrive and witnessed the punching. The risk manager acknowledged she did not have written statements from all staff, had not read the nursing progress note describing both residents exchanging punches, and assumed that the “altercation” referred only to the push and kick. She stated she could have probed more into what happened. The nursing home administrator stated she expected statements to be taken and each incident fully investigated, and the facility’s policy required the risk manager or designee to initiate an internal investigation of incidents within one business day after receiving a report, underscoring that the incomplete collection and review of staff statements and records in both incidents constituted a failure to ensure thorough investigations of alleged resident-to-resident abuse.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Land O Lakes
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Blue Heron Health And Rehabilitation | 5.5 mi | ★★★★★ | 0 | 0 |
| Luxe At Lutz Rehabilitation Center (the) | 7.2 mi | ★★★★★ | 1 | 0 |
| Pruitthealth-north Tampa, Llc | 7.5 mi | ★★★★★ | 1 | 0 |
| St. Andrew Post-acute Rehabilitation Center | 10.4 mi | ★★★★★ | 0 | 0 |
| Tampa Lakes Health And Rehabilitation Center | 10.6 mi | ★★★★★ | 0 | 0 |
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