Below average — CMS composite of the measures below.
The next survey window likely opens 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 Lady Lake Specialty Care Center And Rehab during CMS and state inspections, most recent first.
The facility failed to maintain sanitary conditions in the kitchen, with black discoloration observed on the ceiling and vent above food preparation areas. Uncovered food items were found beneath these areas. Additionally, the facility did not document food temperatures before serving meals, as required by policy. The Dietary Manager acknowledged these deficiencies.
The facility failed to prevent infection spread due to improper hand hygiene and equipment sanitization. An LPN did not sanitize a blood pressure cuff after use, and an RN repeatedly failed to perform hand hygiene during medication administration. Additionally, a CNA did not change gloves or wash hands after handling a soiled brief and before assisting a resident. The DON confirmed the expectation for proper hand hygiene and equipment cleaning.
The facility failed to maintain a sanitary environment in the 200-hall shower room, with cracked walls and tiles, and streaks of dark substances observed. Dirty linen and personal items were left in the room, and staff continued to use the area for resident showers. Interviews revealed a lack of oversight and communication regarding cleaning and maintenance responsibilities.
The facility failed to provide proper respiratory care for two residents. One resident received varying oxygen levels against a physician's order, while another had an empty humidified water bottle and outdated tubing. Staff admitted to not following prescribed oxygen settings and weekly tubing changes, leading to deficiencies in care.
A facility failed to maintain a medication error rate below 5%, resulting in a 7.14% error rate. A resident received incorrect dosages of Midodrine HCL and Vitamin D3, contrary to physician orders. The resident's blood pressure was outside the prescribed range for Midodrine administration, and the Vitamin D3 dosage exceeded the ordered amount. Staff interviews confirmed non-compliance with medication administration policies.
A facility failed to secure medications, leaving them unattended on a resident's bed. An LPN admitted to being distracted and forgetting the medications, which included several prescription drugs. The Director of Nursing emphasized the importance of securing medications and ensuring residents take them as prescribed.
The facility failed to ensure accurate medication administration and record-keeping for two residents. One resident's medications were left unattended and documented as administered despite not being given. Another resident's medical records lacked transfer and change in condition forms for two hospitalizations. The DON confirmed these deficiencies.
The facility did not post accurate nurse staffing information daily for three out of six days. Observations showed that the posted information for July 12, 13, and 14, 2024, did not match the actual hours worked by RNs, LPNs, and CNAs. The Staffing Coordinator admitted to posting projected staffing data instead of actual figures, contrary to the facility's policy requiring daily updates at the start of each shift.
The facility failed to ensure medications were labeled and stored according to professional standards in six medication carts. Observations revealed multiple instances of opened insulin and eye drops without dates of opening or expiration dates, and two medication carts were found unlocked and unattended. Staff interviews confirmed awareness of the requirements but indicated non-compliance.
Sanitation and Food Temperature Documentation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during multiple tours. On two separate occasions, black discoloration was noted on the ceiling and air conditioning vent above a food preparation area. Uncovered food items, including peeled bananas and raw chicken pieces, were found directly beneath the discolored ceiling and vent, indicating a lack of adherence to sanitary food preparation standards. The Dietary Manager acknowledged the unsanitary condition of the ceiling and vent, confirming the need for cleaning. Additionally, the facility did not document food temperatures to ensure they were at safe levels before serving meals to residents. During a follow-up tour, it was observed that breakfast foods were being plated for service without recorded temperature checks. The Dietary Manager confirmed that there was no documentation of food temperatures for the morning meal, which had been served earlier. This lack of documentation was contrary to the facility's policy, which requires that food temperatures be taken and recorded for all meals to ensure food safety.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitization
Penalty
Summary
The facility failed to prevent the possible spread of infection due to improper sanitization and hand hygiene practices. During an observation, a Licensed Practical Nurse (LPN) used a blood pressure cuff on a resident and returned it to the medication cart without cleaning it, despite acknowledging that it should have been sanitized with Clorox wipes after each use. Additionally, a Registered Nurse (RN) was observed not performing hand hygiene during multiple instances of medication preparation and administration for several residents. The RN admitted to not performing hand hygiene as required before and after medication handling. Furthermore, a Certified Nursing Assistant (CNA) was observed handling a soiled brief and then assisting a resident into a wheelchair without changing gloves or washing hands. The CNA also brushed the resident's hair without performing hand hygiene. The Director of Nursing confirmed that the expectation is for staff to perform hand hygiene before and after resident contact and medication handling, and to clean blood pressure cuffs before and after each use. The facility's hand hygiene policy emphasizes the importance of hand hygiene in preventing infection spread.
Failure to Maintain Sanitary Conditions in Shower Room
Penalty
Summary
The facility failed to maintain a sanitary and orderly environment in the 200-hall shower room, as observed during multiple inspections. The ceiling, walls, and tiles surrounding the shower area were found to be cracked and had holes. Additionally, the walls were streaked with a darkened green and brown substance, and dirty linen and personal items were left in the shower room. These observations were made over several days, with staff continuing to wheel residents into the shower room for showers despite the unsanitary conditions. Interviews with facility staff revealed a lack of effective communication and oversight regarding the cleaning and maintenance of the shower room. The Maintenance Director acknowledged the need for repairs but indicated it was on a list of tasks to be completed. The Housekeeping Lead stated that cleaning was reported as completed daily but admitted to not routinely checking the work. The Director of Nursing expressed that staff should not leave personal items or linens in the shower room and expected the area to be ready for the next user. The facility's policy on maintaining a clean and sanitary environment was reviewed, highlighting the importance of cleanliness for resident safety.
Deficiency in Respiratory Care Services
Penalty
Summary
The facility failed to provide respiratory care services consistent with professional standards for two residents. Resident #591 was observed multiple times with varying oxygen levels administered through a nasal cannula, despite a physician's order specifying oxygen at 2 liters. The resident stated they did not adjust the oxygen settings, while a Licensed Practical Nurse (LPN) suggested the resident might be changing the settings themselves. However, the LPN admitted to checking the oxygen settings daily, indicating a lack of adherence to the prescribed oxygen level. Resident #80 was observed receiving oxygen at 2.5 liters with an empty humidified water bottle on two occasions. The humidification bottle and tubing were dated from a week prior, contrary to the physician's order to change them weekly or as needed. An LPN admitted to not assessing the oxygen delivery system, and the Director of Nursing confirmed the oversight. The facility's policy required weekly changes of oxygen tubing, which was not followed, leading to a deficiency in maintaining infection control standards.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by a 7.14% error rate observed during a medication pass. During the observation, 28 medication administration opportunities were reviewed, and two errors were identified involving one resident. Specifically, a registered nurse administered Midodrine HCL and Vitamin D3 to a resident, contrary to the physician's orders. The resident's blood pressure was recorded at 140/88, which exceeded the prescribed parameter for administering Midodrine, which should only be given if the systolic blood pressure is less than 110. Additionally, the resident was given 5000 IU of Vitamin D3 instead of the ordered 3000 IU. Interviews with staff revealed a lack of adherence to the facility's medication administration policy. Staff D, an RN, acknowledged that Midodrine should not have been administered due to the resident's blood pressure being outside the specified range. The Director of Nursing confirmed that medications should be administered as ordered, emphasizing the importance of following physician instructions. The facility's policy mandates that medications be given in accordance with physician orders and that any discrepancies or concerns should be addressed with the physician or Medical Director. However, these protocols were not followed, leading to the identified medication errors.
Unsecured Medications Left Unattended
Penalty
Summary
The facility failed to ensure the security of medications, allowing unauthorized access by personnel, residents, and visitors. During an observation, a medication cup containing seven pills was found unattended on a resident's bed. The resident was not present in the room, but the roommate and two family members were, and the unsecured medication was visible from the hallway. The medications included lisinopril, diltiazem, apixaban, fluoxetine, memantine, pantoprazole, and nitrofurantoin. Staff E, an LPN, confirmed that the medications had been left unattended since 10:30 AM that morning. She admitted to being distracted by the resident's roommate and their family, which led to forgetting the medications in the room. The Director of Nursing stated that the expectation is for the nurse to ensure the resident takes the medications and to never leave them unsecured. The facility's policy requires medications to be stored securely in cabinets, drawers, carts, or automatic dispensing systems.
Deficiencies in Medication Administration and Record-Keeping
Penalty
Summary
The facility failed to ensure the accuracy of medical records and proper medication administration for two residents. In the first case, a medication cup containing seven pills was left unattended on a resident's bed, with the resident absent from the room. The medications, which included treatments for elevated blood pressure, depression, dementia, gastroesophageal reflux disease, and infection, were documented as administered in the Medication Administration Record (MAR), despite not being given to the resident. The Licensed Practical Nurse (LPN) responsible for the medication pass admitted to being distracted and forgetting the medications in the room. There was no documentation of the medications being destroyed, administered late, or any notification to the physician about the missed doses. In the second case, the facility failed to maintain accurate and complete records for a resident who was hospitalized twice. The resident experienced a large laceration after losing control of her motorized chair and was transported to the hospital. On another occasion, the resident was sent to the emergency room due to a change in condition, presenting with systemic twitching and non-responsiveness. In both instances, the medical record lacked documentation of transfer forms or change in condition forms, which are expected to be completed when residents are sent to a higher level of care. The Director of Nursing confirmed the absence of these forms in the resident's chart.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure accurate nurse staffing information was posted daily for three out of six days. Observations on July 14, 2024, revealed that the nurse staffing information displayed in the front lobby area was for July 12, 13, and 14, 2024. However, a comparison review with the Staffing Coordinator showed that the posted information did not accurately reflect the total number and actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides on those dates. During an interview, the Staffing Coordinator admitted that the displayed nurse staffing information was based on projections and did not accurately reflect the actual staffing. She stated that she posted the projected staffing sheets on Thursday evenings for the upcoming days, including Fridays, Saturdays, Sundays, and Mondays. The facility's policy, last reviewed on January 25, 2024, requires the posting of actual staffing data daily at the beginning of each shift, which was not adhered to in this instance.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were labeled and stored in accordance with professional standards of practice in six medication carts. Observations revealed multiple instances of opened insulin and eye drops without dates of opening or expiration dates. Specifically, Medication Cart #1 contained opened Humalog and Lispro insulin, olopatadine and Prednisolone eye drops, and artificial tears without proper labeling. Medication Cart #2 had opened Humalog, Lantus, and Humulin N insulin without dates or with expired dates. Similar issues were found in Medication Carts #3, #4, and #6, with various opened medications lacking proper labeling and storage instructions. Additionally, Medication Carts #5 and #6 were found unlocked and unattended, posing a security risk for the medications stored within them. Interviews with the staff, including LPNs and an RN, confirmed that they were aware of the labeling and storage requirements but failed to adhere to them. The Director of Nursing also acknowledged the expectation that all medication carts should be locked when unattended and that medications should be labeled and discarded if expired. The facility's policy and procedure on medication storage were reviewed, which outlined the requirements for safe, secure, and orderly storage of medications, including the need for proper labeling and locking of compartments containing medications when not in use.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 203 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lady Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villages Healthcare And Rehabilitation Center, The | 1.6 mi | ★★★★★ | 10 | 0 |
| Freedom Pointe Health Center | 1.7 mi | ★★★★★ | 7 | 0 |
| Chatham Glen Healthcare And Rehabilitation Center | 1.7 mi | ★★★★★ | 5 | 0 |
| Club Healthcare And Rehabilitation Center At The V | 5.1 mi | ★★★★★ | 0 | 0 |
| Buffalo Crossings Healthcare & Rehabilitation Cen | 5.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lady Lake Specialty Care Center And Rehab.
100% money-back within 48 hours.
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.