Below 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 Lake City Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not ensure proper wound care and medication management for several residents. Two residents had wound dressings that were not changed or documented according to physician orders and facility policy, with missing dates and initials on dressings and incomplete skin assessments. Another resident's medication was held by nursing staff without appropriate parameters or physician clarification, contrary to prescriber orders. These deficiencies were confirmed through observations, record reviews, and staff interviews.
Surveyors found that staff failed to properly store respiratory equipment, did not consistently use required PPE for residents on enhanced barrier precautions, and neglected hand hygiene and equipment cleaning protocols. Staff also handled medications with bare hands and administered pills that had dropped onto unclean surfaces, all in violation of facility infection control policies.
The facility did not ensure the accuracy of MDS assessments for three residents, including incorrect documentation of vision status, use of a feeding tube, and oral/dental status. Staff interviews and resident records confirmed that the MDS entries did not accurately reflect the residents' actual conditions.
A resident was admitted with multiple mental health diagnoses, but the facility failed to ensure the Level I PASRR assessment accurately reflected all relevant conditions as documented in the medical record. The Administrator confirmed the facility did not follow its process to review and correct the PASRR upon admission, resulting in noncompliance with federal screening requirements.
The facility did not develop or implement comprehensive care plans for two residents: one with mental health diagnoses requiring monitoring and another needing enhanced barrier precautions for wound care. Staff confirmed these care needs were not addressed in the residents' care plans, contrary to facility policy and federal requirements.
A resident did not receive a physician-agreed pharmacy recommendation for vitamin D3 supplementation, as the order was not entered into the electronic medical record despite documented agreement. Staff interviews confirmed the expectation that such recommendations be acted upon, but the process was not completed as required by facility policy.
A resident continued to receive an extended-release medication without a stop date, despite the consultant pharmacist's recommendation to evaluate the need and consider discontinuation. The physician's responses were inconsistent, and facility staff did not ensure that the medication orders were updated in the electronic medical record, leading to ongoing administration of the drug without adequate justification.
Surveyors found that several residents had unauthorized access to medications and biologicals in their rooms, including sprays, lubricants, powders, and an unattended pill. Staff confirmed that no residents were authorized to self-administer medications, and facility policy required secure storage and proper assessment before allowing self-administration. Medications and biologicals were not stored according to professional standards or facility policy.
A resident was not provided with timely dental services after losing dentures, resulting in the need for a mechanical soft diet. Delays were attributed to insurance and referral processes, and although staff documented the resident's ability to eat, the lack of dentures remained unresolved.
Surveyors found that food items in both the kitchen walk-in freezer and nourishment room refrigerator were not labeled or dated as required by facility policy. The Dietary Manager confirmed that these items should have been labeled and dated, indicating a failure to follow professional standards for food service safety.
A resident who previously participated in a restorative program did not receive required specialized rehabilitative services or evaluations after the program was discontinued, despite active physician orders and care plan interventions indicating ongoing need. Facility staff confirmed that the transition to a new functional maintenance program did not include proper evaluation or continuity of care for this resident, resulting in a lapse in required services.
Surveyors found that staff failed to maintain complete and accurate medical records for several residents, including improper documentation of behavioral monitoring, medication administration, and wound care. Errors included incomplete behavioral documentation, incorrect transcription of a medication order, lack of provider notification documentation when medications were held, and false documentation of wound care based on unverified reports from other staff.
The facility did not maintain an effective QAPI program for monitoring and documenting significant weight loss, as two residents identified for weight loss were not weighed according to the required weekly schedule, and there was no documentation of required risk meetings or monitoring. The DON confirmed the absence of documentation and a set plan during the transition to a new program, resulting in a lack of evidence that the QAPI processes were followed.
The facility did not establish or follow an effective antimicrobial stewardship program, as evidenced by two residents receiving antimicrobials without proper assessment, documentation, or diagnostic testing. Staff interviews indicated that providers often prescribed antimicrobials without required testing or review, and facility policy requirements for monitoring and review were not met.
Surveyors found that the generator annunciator panel, located behind the central nurses station, was not powered and appeared disconnected or disabled. This issue was confirmed by the Maintenance Director and acknowledged by facility leadership.
Surveyors found that the facility did not have documentation showing its Emergency Preparedness Program (EPP) was reviewed and updated annually, as required. Both the Administrator and Maintenance Director acknowledged the lack of annual review records during the survey.
The facility did not maintain the kitchen hood fire suppression system as required, failing to provide documentation for a semiannual inspection and leaving previously noted discrepancies uncorrected. This was confirmed by both the Administrator and Maintenance Director.
The facility did not ensure all fire alarm system devices, including duct detectors, were tested and maintained as required, and lacked documentation of biennial smoke detector sensitivity testing. Additionally, a smoke detector was found improperly placed near an HVAC supply vent. These issues were confirmed by facility leadership.
Surveyors found that the facility could not provide documentation of the required 5-year internal backflow inspection for the sprinkler system, and the fire backflow device was observed to be 'Red Tagged' and inoperable. These deficiencies were confirmed by facility leadership.
The facility did not provide documentation of annual inspections or evidence of a trained, certified individual responsible for fire and smoke door assemblies, as required by NFPA standards. This deficiency was confirmed by facility leadership during interviews and record review.
The facility did not maintain required documentation for the emergency generator engine and failed to perform annual diesel fuel testing as required by NFPA standards. These deficiencies were confirmed by the Maintenance Director and acknowledged by facility leadership.
The facility did not provide adequate documentation for the four-year fire and smoke damper inspection, as required by NFPA 80, with vendor records lacking details on the number, locations, and type of dampers. This deficiency was acknowledged by facility leadership.
Failure to Provide Proper Wound Care and Medication Management
Penalty
Summary
The facility failed to provide appropriate care and treatment for multiple residents, as evidenced by observations, interviews, and record reviews. For one resident with multiple abdominal and limb dressings, there were inconsistencies and omissions in wound care documentation and execution. The resident reported that dressings were last changed several days prior, and staff were unaware of all wound sites. Physician orders for wound care were not consistently followed, and some dressings lacked required labeling with date and initials. Staff interviews revealed a lack of clarity regarding responsibility for wound care on weekends and incomplete skin assessments upon admission. Another resident was observed with a dressing on her limb that had a dried dark substance and was missing date and initials, contrary to facility policy and physician orders. The resident stated the dressing was due to an injury, but the required documentation and proper dressing maintenance were not evident during multiple observations. The Director of Nursing confirmed that all dressings should be dated and initialed, which was not done in this case. Additionally, a third resident's medication was held by nursing staff without appropriate parameters or physician clarification, as indicated by the Medication Administration Record and staff interviews. The DON acknowledged that the medication was held without proper orders, and the facility's policy requires medications to be administered according to prescriber orders and standards of practice. These findings demonstrate failures in following professional standards, care plans, and physician orders for both wound care and medication management.
Infection Control Deficiencies in Equipment Handling, PPE Use, and Hand Hygiene
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices. Staff failed to properly store respiratory equipment, such as passive masks and tubing, for several residents. In multiple instances, these items were left unbagged on surfaces or on the floor, contrary to facility policy and staff expectations that such equipment should be bagged when not in use. Additionally, disposable equipment was not consistently labeled or changed as required. Staff did not consistently adhere to enhanced barrier precautions (EBP) for residents with medical devices or those requiring such precautions. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) were observed providing direct care, including dressing, toileting, and medication administration, to residents on EBP without wearing the required gowns, and in some cases, staff were unaware that residents were on EBP. The Director of Nursing (DON) confirmed that staff are expected to wear both gloves and gowns when providing care to residents under EBP, and that some residents who met criteria for EBP did not have appropriate orders in place. Hand hygiene and equipment cleaning protocols were not followed during resident care and medication administration. Staff were observed changing gloves multiple times without performing hand hygiene in between, despite facility policy and DON statements that hand hygiene is required between glove changes. Medical equipment, such as blood pressure cuffs and pulse oximeters, was used on multiple residents without cleaning between uses. Additionally, staff handled oral medications with bare hands and administered medications that had dropped onto unclean surfaces. These actions were inconsistent with facility policies and accepted standards for infection prevention and control.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents. For one resident, the MDS inaccurately documented that the resident had adequate vision without corrective lenses, despite both the resident's son and a registered nurse confirming the resident's vision was impaired and required corrective lenses. The optometry evaluation also indicated the use of corrective lenses, and the MDS Coordinator acknowledged the inaccuracy in the assessment. Another resident was reported to be using a tube for medication administration, but the MDS assessment did not reflect the presence of the tube or any related nutritional approaches. The MDS Coordinator confirmed this was incorrect. Additionally, a third resident, who was on a mechanical soft diet due to a broken dental appliance, was not accurately represented in the MDS under the oral/dental status section. The resident expressed frustration about not having the dental appliance, and the MDS Coordinator admitted the annual assessment was marked incorrectly.
Failure to Complete Accurate PASRR Assessment for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed for one resident who was reviewed for unnecessary medications. The resident was admitted with diagnoses including major depressive disorder and other mental health conditions. The Level I PASRR for this resident listed certain mental illnesses but omitted others, despite documentation in the hospital discharge summary and the Minimum Data Set (MDS) assessment indicating additional relevant diagnoses. The facility's policy requires that all individuals being admitted have a completed PASRR Level I prior to admission, and that the PASRR be reviewed for accuracy and corrected if necessary. During an interview, the Administrator acknowledged that the facility did not follow its process to review and correct the PASRR upon the resident's admission from the hospital. The resident's medical records, including a visit note and hospital discharge summary, documented a history of multiple mental health conditions that were not fully reflected in the PASRR. This failure to ensure an accurate PASRR assessment resulted in noncompliance with federal requirements for preadmission screening for individuals with mental illness or intellectual disability.
Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents as required by federal regulations. For one resident with diagnoses including generalized anxiety and post-traumatic stress disorder, the care plan did not include a focus or interventions addressing these mental health conditions, despite physician orders and clinical notes indicating the need for monitoring and documentation of related symptoms. Staff interviews confirmed that these diagnoses and their associated care needs were not incorporated into the resident's care plan and needed to be added. For another resident, physician orders and clinical documentation indicated the need for enhanced barrier precautions due to a medical device and wound care requirements. However, the resident's care plan did not address enhanced barrier precautions, and staff interviews, including those with the LPN Unit Manager, DON, and MDS Coordinator, confirmed that this omission was inconsistent with facility expectations and policy. The facility's policy requires the identification of problem areas and the development of targeted interventions, which was not followed in these cases.
Failure to Implement Physician-Agreed Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that a physician-agreed medication regimen recommendation from the consultant pharmacist was implemented for one resident. The consultant pharmacist recommended that the resident receive vitamin D3, 1000 IU once daily, based on clinical guidelines for elderly individuals to maintain bone health. The attending physician reviewed this recommendation and documented agreement with the plan, indicating, "Agree; will do." However, a review of the resident's current physician orders revealed that no order for vitamin D3 had been entered. Interviews with facility staff, including the DON and a nurse practitioner, confirmed that the process for addressing pharmacy recommendations involves unit managers and the ADON updating the electronic medical record when a provider agrees to a recommendation. Despite this expectation, the agreed-upon order was not entered. The facility's policy requires that drug regimen review recommendations be acted upon, but in this case, the necessary follow-through did not occur, resulting in the deficiency.
Failure to Address Pharmacist's Recommendation for Unnecessary Drug
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary drugs, as required by federal regulations. Specifically, the consultant pharmacist identified that the resident was receiving a long-acting medication without a stop date and recommended evaluating the current need and considering adding a stop date. The physician initially agreed to discontinue the medication but later disagreed, stating the medication was to be given as needed (PRN). Despite these recommendations and responses, the resident continued to receive the extended-release medication twice daily, as documented in the Medication Administration Records over an extended period. Interviews with facility staff, including the DON and a Nurse Practitioner, revealed that the process for addressing consultant pharmacist recommendations involved dividing the recommendations among unit managers and the ADON, with the expectation that any provider orders should be updated in the electronic medical record. The facility's policy required that drug regimen reviews be conducted monthly and that any irregularities be reported and acted upon, with documentation of the physician's review and actions taken. However, the records showed that the recommendations regarding the medication were not properly addressed or documented, resulting in the continued administration of the medication without adequate justification or a stop date.
Improper Storage and Unauthorized Access to Medications
Penalty
Summary
Surveyors observed multiple instances where drugs and biologicals were not stored in accordance with professional standards and facility policy. In one case, a resident had a bottle of spray at their bedside, which the resident reported using at night. Staff confirmed that residents are not permitted to self-administer medications without an evaluation, care plan, and physician order, none of which were in place for this resident. Another resident had a bottle of lubricant and powder on their bedside table and air conditioning unit, stating that they used these items as needed, sometimes with nurse assistance. A third resident had a tube of an unidentified substance at their bedside, which staff confirmed was not ordered and was brought in by family without staff knowledge or approval. In each case, staff acknowledged that the residents were not authorized to self-administer medications and that such items should not be accessible without proper assessment and documentation. Additionally, a medication cup containing a white pill was found unattended in a resident's room. The resident was unaware of the medication's purpose, and the LPN stated they believed the resident had already taken all medications. The DON confirmed that no residents in the facility were authorized to self-administer medications and that medications should not be left unattended in resident rooms. Facility policies reviewed by surveyors required that medications be stored securely and that self-administration only occur following interdisciplinary assessment and physician order, which was not followed in these instances.
Failure to Provide Timely Dental Services for Lost Dentures
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, specifically the replacement of lost or damaged dentures. The resident reported being on a mechanical soft diet solely due to the absence of dentures, expressing dissatisfaction with the inability to eat properly. Interviews with facility staff revealed that the process for obtaining dental services was delayed due to insurance requirements and the need for a referral from the resident's primary office to a dental clinic. Documentation in the medical record indicated that dental referrals were sent and that attempts were made to locate the resident's dentures for evaluation, but the dentures were not found, and the resident remained without them. Further review of the resident's records showed that dental consultations noted the absence of dentures and the resident's interest in obtaining a new set. Staff documented that the resident was able to obtain adequate nutrition and was not experiencing discomfort, but the only reason for the mechanical soft diet was the lack of dentures. The facility's policy required referral for dental services within three days of loss or damage of dentures, or documentation of actions taken and reasons for delay, but the report indicates ongoing delays and lack of resolution for the resident's dental needs.
Failure to Label and Date Stored Food Items
Penalty
Summary
Surveyors observed that the facility failed to ensure proper food storage practices in both the kitchen walk-in freezer and the nourishment room refrigerator. During an initial kitchen tour with the Dietary Manager, a plastic see-through bag containing unidentified food items was found in the walk-in freezer without any label or date. The Dietary Manager confirmed that the item should have been labeled and dated, in accordance with the facility's food storage policy, which requires all frozen foods to be covered, labeled, and dated. Additionally, in the nourishment room refrigerator on Desota Hall, a bag containing wrapped crackers and a bowl of covered food were found without dates. The Dietary Manager again acknowledged that these items should have been dated. The facility's policy for foods brought in by family or visitors also requires perishable foods to be stored in resealable containers with tight-fitting lids, labeled with the resident's name, item name, and a use-by date, with nursing staff responsible for discarding perishable foods on or before the use-by date. These observations indicate that the facility did not follow its own policies and professional standards for food service safety regarding labeling and dating stored food items.
Failure to Provide Required Specialized Rehabilitative Services After Program Discontinuation
Penalty
Summary
The facility failed to provide or obtain specialized rehabilitative services as required for one resident who was previously participating in a restorative program. The resident reported that after the facility discontinued the restorative program, no further rehabilitative services or evaluations were provided, despite active physician orders for evaluation and treatment. The resident's care plan indicated a need for a functional maintenance program due to self-care performance issues following an infraction affecting the left dominant side, but no current interventions were implemented after the program was discontinued. Interviews with facility staff, including the Functional Maintenance Coordinator, DON, and Rehabilitation Director, confirmed that the restorative program was ended and replaced with a functional maintenance program. However, the resident in question was not evaluated or included in the new program, and quarterly assessments were not conducted as required. Staff acknowledged that there was no process in place to ensure continuity of care for residents transitioning from the discontinued program, and the lack of evaluation was attributed to oversight or human error.
Deficient Medical Record Documentation and Incomplete Medication and Wound Care Records
Penalty
Summary
Surveyors identified multiple deficiencies related to the maintenance of complete and accurate medical records for several residents. For one resident with behavioral monitoring orders, staff failed to document required observations as specified by the physician, instead marking an 'X' rather than indicating 'yes' or 'no' for the presence of behaviors, and did not provide corresponding progress notes when behaviors were observed. The Director of Nursing confirmed that the documentation was incomplete and did not follow the order's requirements. For two residents receiving medication management, there were errors in both the transcription and documentation of medication orders and administration. One resident's medication order was transcribed incorrectly, using the wrong symbol for a critical parameter, which was acknowledged by both the DON and an Advanced Practice Registered Nurse. Another resident had insulin doses held due to low blood sugar readings, but staff failed to document provider notification or the rationale for withholding the medication in the nurses' notes, as required by facility policy and standard practice. Additionally, for a resident requiring daily wound care, staff documented that care was provided on days when it was actually performed by another nurse, without verifying completion. The responsible nurse admitted to documenting care based on verbal reports rather than direct observation or confirmation, and a unit manager confirmed that documenting care not personally completed constitutes false documentation. Facility policy requires detailed documentation of wound care, including date, time, and wound appearance, which was not consistently followed.
Failure to Maintain Effective QAPI Program for Weight Loss Monitoring
Penalty
Summary
The facility failed to maintain an effective, data-driven Quality Assurance and Performance Improvement (QAPI) program as required by federal regulations. Specifically, the facility did not provide evidence of ongoing monitoring and documentation for a performance improvement plan (PIP) related to weight loss among residents. The QAPI program was expected to include systematic identification, reporting, investigation, analysis, and prevention of adverse events, as well as documentation of corrective actions and performance improvement activities. However, the facility was unable to demonstrate that these processes were consistently followed for residents experiencing significant weight loss. A review of the facility's Loss Performance Improvement Plan indicated that residents who experienced significant weight loss were to be reviewed weekly in risk meetings until their weight stabilized for four weeks. The plan also required appropriate notifications, Registered Dietitian consults, care plan updates, and consistent weighing practices. Despite these outlined procedures, documentation revealed that two residents identified for monitoring were not weighed according to the prescribed weekly schedule, and there was no proof of weekly risk meetings or adequate monitoring as required by the plan. During interviews, the Director of Nursing (DON) acknowledged the lack of a set plan for transitioning from restorative to a Functional Maintenance Program and admitted that documentation for weekly monitoring and meetings was not available. The facility's QAPI policy required identifying issues, developing and implementing corrective actions, and reviewing and analyzing data, but the facility was unable to provide evidence that these steps were followed for the residents in question.
Failure to Implement Effective Antimicrobial Stewardship Program
Penalty
Summary
The facility failed to establish and implement an effective stewardship program to monitor the use of antimicrobials for two residents. For one resident, a physician ordered a preventative antimicrobial regimen without documented consideration of a 'time out' or pause to reassess the need for continued therapy. The Advanced Practice Registered Nurse (APRN) admitted to not having considered a time out and was unable to provide documentation of the clinical assessment that led to the order, citing issues with transitioning records. The Assistant Director of Nursing (ADON) also could not provide documentation of discussions with providers regarding antimicrobial use. For another resident, antimicrobials were ordered without any diagnostic testing to confirm the need for such treatment. The Director of Nursing (DON) confirmed that no test was ordered and that the provider prescribed the medication without testing. Staff interviews revealed that a physician frequently prescribed antimicrobials based on symptoms alone, such as coughing, without ordering diagnostic tests, and that staff felt unable to discontinue these medications once the provider had spoken to the resident. Review of the facility's stewardship policy indicated that regular review of antimicrobial utilization and laboratory reports was required, but these practices were not followed in the cases reviewed.
Generator Annunciator Panel Found Disconnected
Penalty
Summary
During a facility tour, surveyors observed that the generator annunciator panel, which is required to be powered and located in a place readily observed by operating personnel, was found to have no power. The panel was located on the wall behind the central nurses station near the central hallway. Testing of the annunciator revealed it was disconnected or disabled, and this was confirmed by the Maintenance Director during the tour. The deficiency was acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information regarding residents or their medical conditions was included in the report.
Failure to Annually Review and Update Emergency Preparedness Program
Penalty
Summary
The facility failed to review and update its Emergency Preparedness Program (EPP) as required by federal regulations. During a record review with the Administrator and the Maintenance Director, surveyors found that there was no documented evidence showing the EPP had been reviewed and updated annually. This deficiency was identified during the survey process when the facility was unable to provide records demonstrating compliance with the annual review and update requirement for the EPP. Both the Administrator and the Maintenance Director acknowledged the absence of documentation regarding the annual review and update of the EPP during the exit conference. The Maintenance Director also concurred with the findings during the interview. No information was provided in the report regarding specific residents or their conditions at the time of the deficiency.
Failure to Maintain Kitchen Hood Fire Suppression System
Penalty
Summary
The facility failed to maintain the kitchen hood cooking fire suppression system in accordance with required inspection and maintenance protocols. During a record review with the Administrator and Maintenance Director, it was found that the facility could not provide documentation for one of the required semiannual maintenance inspections. The last available semiannual inspection, dated 7/29/24, indicated discrepancies that had not been corrected, and this was confirmed during the facility tour. Both the Administrator and Maintenance Director acknowledged these findings during the exit conference. No information regarding specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Fire Alarm System Testing and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with NFPA 72 standards. During a record review with the Administrator and Maintenance Director, it was found that not all fire alarm devices had been tested, inspected, and maintained as required. Specifically, 5 out of 12 duct detector devices were missed during testing and were reported as not accessible by the fire alarm vendor. Additionally, the facility could not provide documentation showing that biennial sensitivity testing of smoke detectors had been conducted, with no records available to indicate when the last such testing occurred. During a facility tour, a smoke detector was observed to be within 36 inches of an HVAC supply vent in the main service hallway, which does not comply with placement requirements. These deficiencies were acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information about specific residents or their conditions was provided in relation to these deficiencies.
Failure to Maintain Sprinkler System and Provide Required Inspection Documentation
Penalty
Summary
The facility failed to maintain its automatic sprinkler system in accordance with NFPA 101 requirements. During a record review with the Administrator and Maintenance Director, the facility was unable to provide documentation of the required 5-year internal backflow inspection report. Additionally, during a facility tour, surveyors observed that the fire backflow device located at the main entrance was 'Red Tagged,' indicating that the system was in failure and inoperable. These findings were confirmed by the Maintenance Director during the interview and acknowledged by both the Administrator and Maintenance Director at the exit conference. No information about residents or their medical conditions was included in the report.
Failure to Maintain and Inspect Fire and Smoke Door Assemblies
Penalty
Summary
The facility failed to provide regular inspections, testing, and maintenance of fire and smoke door assemblies as required by NFPA 80 and NFPA 105. During a record review with the Administrator and Maintenance Director, the facility was unable to produce documentation of annual inspections for smoke doors or evidence of training for a competent, certified individual responsible for fire and smoke doors. This lack of documentation and training was confirmed during interviews with facility leadership. The deficiency was acknowledged by both the Administrator and the Maintenance Director during the exit conference. No information was provided regarding specific residents or patient conditions related to this deficiency. The report focuses solely on the absence of required inspection records and training for fire and smoke door assemblies.
Failure to Maintain Emergency Power System and Annual Diesel Fuel Testing
Penalty
Summary
The facility failed to maintain its Emergency Power System (EPS) in accordance with NFPA 80 and NFPA 110 requirements. During a record review with the Administrator and Maintenance Director, it was found that the emergency generator engine manufacturer's recommendations were not available for reference. Additionally, the facility did not conduct the required annual testing of the generator's diesel fuel as specified by the relevant codes. These deficiencies were confirmed during interviews with the Maintenance Director, who concurred with the findings. The lack of documentation and failure to perform the mandated fuel testing were acknowledged by both the Administrator and Maintenance Director during the exit conference. No information about residents or their conditions was provided in the report.
Failure to Document Fire and Smoke Damper Inspections per NFPA Standards
Penalty
Summary
The facility failed to maintain proper documentation for the four-year fire and smoke damper inspection, testing, and maintenance as required by NFPA 80. During a record review with the Administrator and Maintenance Director, it was found that the vendor documentation only indicated that the fire and smoke dampers were functioning, but did not specify the number of dampers, their locations, or the type of system installed. This lack of detailed documentation meant the facility could not demonstrate compliance with the required standards for maintaining the integrity of the fire alarm system to ensure proper alarm and safe relocation of residents, staff, or other building occupants in the event of a fire. These findings were confirmed by both the Administrator and the Maintenance Director during the exit conference.
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 19 citations issued within 25 miles in the last 12 months — 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 Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Montgomery Health And Rehabilitation Center | 0.5 mi | ★★★★★ | 3 | 0 |
| Solaris Healthcare Lake City | 0.7 mi | ★★★★★ | 0 | 0 |
| Baya Pointe Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 9 | 0 |
| Live Oak Healthcare And Rehabilitation Center | 20.4 mi | ★★★★★ | 1 | 0 |
| Surrey Place Nursing Center | 20.9 mi | ★★★★★ | 6 | 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.