Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Charming Lakes Rehab during CMS and state inspections, most recent first.
The facility failed to provide proper ADL care, including fingernail hygiene, for three residents who were dependent on staff, resulting in one resident sustaining a hand injury from an overgrown nail. Staff were unclear about responsibilities for nail care, especially for diabetic residents, and documentation was lacking. Additionally, a resident requiring assistance with eating was observed left alone with an untouched meal, despite prior grievances and care plan instructions.
Staff assisted three residents with eating by standing over them rather than sitting at eye level, which did not preserve resident dignity during meals. Two residents with cognitive and physical impairments were fed in this manner, and a CNA acknowledged uncertainty about the correct protocol. The facility's policy did not address dignity during dining, and staff recognized the issue when observed by surveyors.
A resident with end-stage renal disease and a physician-ordered fluid restriction was found to have excess fluids at the bedside on multiple occasions. Staff interviews revealed inconsistent practices regarding the provision and monitoring of fluids, and the facility's policy did not clearly address staff-provided hydration. This resulted in failure to ensure the resident's fluid intake was properly restricted and monitored as ordered.
A resident was provided with a feeding tube without documented medical necessity or agreement, and did not receive appropriate care for the feeding tube as required.
A resident did not receive safe and appropriate respiratory care when needed, as required by their condition.
Surveyors found that the facility failed to ensure accurate dispensing, documentation, and removal of controlled substances for several residents. Multiple discrepancies were observed between medication control records and MARs, with some controlled medications remaining in carts after discontinuation and inconsistent documentation by LPNs and the DON.
The facility did not ensure proper monitoring and documentation of behaviors and side effects for residents prescribed psychotropic medications. In several cases, residents with cognitive or psychiatric conditions were administered these medications without clear or consistent documentation of monitoring, despite care plans and provider recommendations requiring it. Staff interviews confirmed gaps in documentation and the absence of required monitoring orders.
Surveyors found that medications, including over-the-counter drugs and prescription pills, were not consistently secured in locked storage as required. In one instance, an LPN left multiple medications unattended on a resident's overbed table during administration, and in another, numerous medication bottles were stored openly in an unlocked office. Additionally, a medication cart contained unsecured pills left from a previous shift.
Surveyors observed that several residents requiring pureed diets and thickened liquids were served foods that were lumpy or not of the required consistency, and one resident received thin liquids instead of nectar thick fluids. Staff and kitchen management confirmed the inconsistencies in food texture and liquid preparation, with direct observations and photographic evidence supporting the findings.
A resident's meal was left in their room while they attended dialysis, and staff later reheated the food in a microwave without clear knowledge of proper food safety standards. Staff demonstrated inconsistent understanding of required reheating temperatures and had difficulty locating a thermometer to check food temperatures. The facility's policy did not address reheating potentially hazardous foods, and the Food Service Manager confirmed that staff instructions were inaccurate.
Surveyors found that the facility did not dispose of garbage and refuse properly, with an overflowing dumpster and trash accumulating on the ground. The DON was made aware of the issue, but the trash remained unaddressed the following day.
The facility did not fully implement public health recommendations during a Legionella investigation, including failing to update the water management plan promptly, not conducting required water testing, and not notifying residents and families. Additionally, respiratory equipment was not stored in a sanitary manner, and staff, including a provider, did not consistently use PPE or display appropriate isolation signage for residents on transmission-based precautions.
Failure to Provide ADL Care and Assistance with Eating
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care, specifically fingernail care, for three residents who were dependent on staff for personal hygiene. One resident with severe cognitive impairment and physical limitations was observed with excessively long fingernails, some with dark sediment underneath, and a contracted hand where a fingernail had caused an injury by digging into the palm. Staff interviews revealed confusion about responsibility for fingernail care, with some staff believing only the podiatrist or nurses could trim nails, especially for residents with diabetes. Documentation of attempted nail care was lacking, and the injury to the resident's hand was not identified until brought to staff attention by the surveyor. Another resident, who was cognitively intact but dependent on staff for personal hygiene, was also observed with very long fingernails containing brown and black sediment. The CNA assigned to her care stated she did not trim nails for diabetic residents and did not report the need for nail care to a nurse manager. This resident was also known to put her fingers in her feces, further highlighting the need for regular and thorough nail and hand hygiene, which was not provided. A third resident with cognitive impairment and physical limitations was observed with long fingernails, contracted fingers, and crusted patches of skin on her palm. She required maximum assistance for personal hygiene, but staff reported difficulty finding nail clippers and inconsistent provision of nail care. Additionally, a separate concern was identified regarding a resident who required assistance with eating. Despite documented grievances from her spouse and a care plan indicating the need for setup or clean-up assistance, the resident was observed alone with an untouched meal and unable to access her drink, indicating a lack of timely assistance with eating.
Failure to Preserve Resident Dignity During Dining Assistance
Penalty
Summary
The facility failed to provide dining assistance in a manner that preserved the dignity of three residents. During meal observations, staff were seen assisting residents with eating while standing over them, rather than sitting at eye level. One resident with moderate cognitive impairment and Parkinson's disease was fed by a CNA standing behind and over his right shoulder while the resident faced a wall. Another resident, who required substantial assistance for eating and was rarely understood, was also fed by a CNA standing over and to the resident's left side. In both cases, the staff member did not sit to assist the resident, despite the presence of an empty chair in the room. Additionally, a third resident, dependent on staff for eating and rarely understood, was observed being fed by a CNA who stood over her during lunch. When questioned, the CNA was unsure of the correct protocol and later acknowledged that she should have been sitting to assist the resident, as standing could make the resident feel rushed. The facility's policy on resident rights did not address dignity during dining, and staff acknowledged the concerns when brought to their attention during the survey.
Failure to Adhere to Fluid Restriction Orders for Dialysis Resident
Penalty
Summary
The facility failed to follow physician orders for fluid restriction for a resident undergoing dialysis. The resident had a documented fluid restriction order of 1500 cc per day, with specific amounts to be provided by dietary and nursing staff each shift. The resident's care plan identified a risk for dehydration due to fluid restrictions and other medical conditions, and included interventions such as monitoring intake and providing fluids as ordered. Despite these orders and care plan interventions, observations revealed that the resident had access to a 20-ounce cup of water at her bedside on multiple occasions, with staff interviews indicating inconsistent practices regarding the provision and monitoring of fluids. One staff member stated that fluids are routinely refreshed at the end of the night shift and again at breakfast, while another staff member reported not providing fluids at the bedside due to the fluid restriction order. The resident was cognitively intact and aware of her fluid restriction, stating she needed to monitor her intake due to dialysis. Staff interviews revealed a lack of consistent adherence to the fluid restriction order, with some staff attributing excess fluids at the bedside to the resident's own actions or noncompliance. The facility's policy on fluid restrictions did not address fluids provided by staff for hydration, contributing to inconsistent implementation of the restriction. These actions and inactions resulted in the facility's failure to ensure the resident's fluid intake was properly restricted and monitored as ordered.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the intervention. Additionally, appropriate care and services related to the feeding tube were not provided as required. These actions resulted in a deficiency related to the use and management of feeding tubes.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate respiratory care for a resident when needed. The report indicates that the facility failed to ensure that a resident received necessary respiratory care, as required by their condition. Specific details about the actions or inactions of staff, the resident's medical history, or the circumstances at the time of the deficiency are not provided in the report excerpt.
Failure to Accurately Dispense, Document, and Remove Controlled Substances
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of residents, specifically in the accurate dispensing and administration of controlled substances. Surveyors observed that for several residents, there were discrepancies between the Medication Monitoring/Control Records and the Medication Administration Records (MAR). For example, medications such as Hydromorphone, Tramadol, Alprazolam, Fentanyl patches, and Percocet were signed out on the control records but not documented as administered on the MAR, or vice versa. In some cases, controlled medications that had been discontinued or were for residents no longer in the facility remained in the medication carts, contrary to facility policy and standard practice. Interviews with nursing staff and the DON revealed inconsistent practices regarding the handling and documentation of controlled substances. The DON stated that discontinued or unused controlled medications should be removed from the carts and stored securely until destroyed, with a log maintained of destroyed medications. However, LPNs reported that discontinued medications were sometimes left in the carts until someone collected them, and periodic audits of the carts were not consistently performed. Staff also acknowledged that there were instances where medications were signed out on the control record but not documented on the MAR, and vice versa. Record reviews for multiple residents showed that controlled substances were not always properly reconciled or documented. For example, one resident's Tramadol was signed out on the control record on several dates but not recorded as administered on the MAR. Another resident's Alprazolam, which had been discontinued months earlier, was still present in the cart and signed out on the control record without corresponding MAR documentation. Similar discrepancies were found for other residents, including missing documentation for administered doses and the presence of discontinued medications in the carts. These findings indicate a failure to maintain accurate records and ensure the secure handling of controlled substances for multiple residents.
Failure to Monitor Behaviors and Side Effects for Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure adequate monitoring of behaviors and side effects for residents prescribed psychotropic medications, as required by both facility policy and physician orders. For three out of five residents reviewed, documentation was either unclear, incomplete, or entirely absent regarding the monitoring of behavioral symptoms and medication side effects. In one case, a resident with severe cognitive impairment and multiple psychotropic prescriptions had medication administration records that used codes not aligned with the physician's orders, and staff interviews confirmed that documentation did not clearly indicate whether side effects or behaviors were present. Another resident, who had a history of traumatic brain injury and was prescribed psychotropic medications, had no physician orders or documentation for monitoring behaviors or side effects, despite care plan interventions requiring such monitoring. Additionally, a third resident with multiple psychiatric diagnoses and several psychotropic and antipsychotic medications had physician orders to monitor for specific behaviors but lacked any orders or documentation for monitoring side effects. Provider notes for this resident specifically recommended close monitoring for side effects, sedation, or increased confusion, yet the medication administration and treatment records did not reflect any such monitoring. Staff interviews further confirmed the lack of clear or consistent documentation practices for monitoring these residents. Across all three cases, the care plans included interventions to monitor for side effects and effectiveness of psychotropic medications, but these interventions were not consistently implemented or documented. The absence of clear, consistent, and complete monitoring and documentation for residents on psychotropic medications constituted a failure to comply with both facility policy and physician orders, resulting in a deficiency related to the use of unnecessary drugs.
Failure to Secure and Properly Store Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly secured and stored according to professional standards and facility policy. During an interview with a unit manager, it was observed that approximately 36 bottles of over-the-counter medications and one enema solution were stored openly on a bookshelf in her office, which was not locked when unattended. The unit manager acknowledged that the medications were present when she moved into the office and that the door was not locked when she left, contrary to the requirement that medications be secured at all times. Additionally, a review of a medication cart revealed a cup containing 11 pills in the top drawer, which the current LPN stated had been left by the previous nurse and had remained unsecured since the start of her shift. During a medication pass observation, an LPN left two oral medications and one intravenous medication on a resident's overbed table, out of his sight, while he left the area to don personal protective equipment. The facility's policy requires all medications to be stored in locked compartments accessible only to authorized personnel, and for medications to be secured at all times. These observations and interviews demonstrate that the facility did not consistently follow its own medication storage policy, resulting in unsecured medications in multiple locations and during medication administration.
Failure to Provide Properly Prepared Pureed Foods and Thickened Liquids
Penalty
Summary
Surveyors found that the facility failed to provide pureed foods and thickened liquids in the appropriate consistency for several residents with dysphagia and other conditions requiring mechanically altered diets. Observations revealed that three residents on Dysphagia Puree texture diets were served pureed foods that were lumpy and not of a homogenous, pudding-like consistency as required by facility policy and the National Dysphagia Diet guidelines. Specifically, pureed rice and meat were observed to be lumpy or contain sand-like particles, and pureed bread, while tasting smooth, appeared lumpy. The kitchen manager acknowledged that the pureed meat could be smoother and that the rice did not appear to be of a uniform texture. These issues were confirmed through direct observation, tasting, and photographic evidence. Additionally, a resident with an order for nectar thickened fluids was observed with thin coffee and regular consistency water on their meal tray, despite the meal ticket specifying nectar thick fluids. Staff confirmed that the water was not thickened and that the coffee was too thin, with thickener not fully mixed, resulting in a lump of unmixed powder at the bottom of the cup. These deficiencies were identified through interviews with staff, review of medical records and diet orders, and direct observation of meal service, affecting residents with severe cognitive impairment and significant medical needs related to swallowing and nutrition.
Failure to Safely Reheat and Handle Potentially Hazardous Foods
Penalty
Summary
The facility failed to ensure that potentially hazardous foods were held and reheated in accordance with professional food safety standards for one resident. During breakfast service, a resident who was out of the room for dialysis had their meal, including scrambled eggs, toast, milk, and orange juice, left on the overbed table. Staff interviews revealed that the meal would be reheated in the unit pantry microwave upon the resident's return, but the facility's policy did not address the proper reheating of potentially hazardous foods from a resident's meal. Staff members demonstrated inconsistent knowledge regarding the correct reheating temperatures and procedures, with one staff member stating foods were reheated to 135°F and another unsure of the required temperature. Both staff members had difficulty locating the thermometer used to check food temperatures. The resident involved had multiple diagnoses, including diabetes mellitus, seizure disorder, depression, cerebral infarction, muscle weakness, and dependence on renal dialysis, and required supervision or assistance with eating. The Food Service Manager acknowledged that the instructions provided to staff for reheating potentially hazardous foods were inaccurate. The deficiency was identified through observations, interviews, and record reviews, highlighting a lack of clear policy and staff understanding regarding safe food handling and reheating practices for residents' meals.
Improper Disposal of Garbage and Refuse
Penalty
Summary
Surveyors observed that the facility failed to dispose of garbage and refuse properly. On arrival, the trash dumpster was found to be overflowing, with trash and debris accumulated on the ground around it. The Director of Nursing (DON) was present outside at the time of the initial observation and was informed of the concern. The following day, the accumulation of trash and refuse remained unaddressed, as seen from a window in the 500 unit. No information about residents or their medical conditions was included in the report.
Infection Control Program Deficiencies: Legionella Response, Equipment Storage, and PPE Compliance
Penalty
Summary
The facility failed to implement an effective infection prevention and control program in several key areas. During an investigation of a possible Legionella outbreak, the facility did not fully follow local public health recommendations. The Executive Director (ED) and Director of Maintenance (DM) acknowledged that not all recommendations from the Department of Health (DOH) were implemented, such as obtaining professional consultation from water system experts, conducting post-remediation testing, installing point-of-use filters, and notifying residents and families about the ongoing investigation. The facility's water management plan was not updated in a timely manner, and there was a lack of documentation and monitoring of water temperatures at distal locations. The DM had not performed Legionella testing or assessments during his tenure, and water temperatures in some areas were below recommended levels. Observations revealed additional infection control lapses. Respiratory equipment, such as nasal cannula tubing, was not stored in a clean and sanitary manner, with tubing found wrapped around an emergency tank and lying on a wheelchair seat without proper storage. Staff were unable to identify the owner of the tubing, and the Director of Nursing/Infection Preventionist (DON/IP) confirmed that the expectation was for such equipment to be stored in a bag. Furthermore, a blanket was observed on the floor under a PTAC unit to absorb water, which the DON/IP stated was not appropriate. The facility also failed to ensure proper use of personal protective equipment (PPE) and appropriate signage for transmission-based precautions. In one instance, a provider entered a resident's room on contact isolation for ESBL/UTI without donning PPE, despite a caddy and sign indicating the need for precautions. In another case, a room with a resident on contact isolation for C. difficile lacked signage specifying the type of precautions, even though PPE was available outside the door. The DON/IP acknowledged that staff had been educated on these requirements and that signage should not be moved, but these expectations were not consistently met.
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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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Nursing homes near Lakeland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeland Hills Center | 0.5 mi | ★★★★★ | 17 | 0 |
| Vivo Healthcare Lakeland | 0.5 mi | ★★★★★ | 2 | 0 |
| Manor At Carpenters, The | 2.5 mi | ★★★★★ | 0 | 0 |
| The Club At Lake Gibson | 2.5 mi | ★★★★★ | 2 | 0 |
| Wedgewood Healthcare And Rehabilitation Center | 2.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.