Below average — CMS composite of the measures below.
The next survey window likely opens around July 2027
Estimate from public CMS data, current as of October 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.
Dietary staff failed to store, prepare, and serve food in a sanitary manner. Observations showed lemonade left on top of an ice machine, oatmeal placed on a serving area, sausage links without a date or label, chicken stored above potatoes without a date, and a refrigerator without a thermometer. During meal service, staff touched the inside of bowls and handled grilled cheese sandwiches and other food items with gloved hands without changing gloves or performing hand hygiene.
Failure to Notify Providers and Families of Resident Changes in Condition: Staff did not document or complete required notifications for multiple residents after new skin tears, wound care needs, refusal of ADL care, and falls/accidents. Records showed an LPN and RN assessed and dressed wounds, but provider and family notification was not documented; one resident repeatedly refused bathing without physician or RP notification, and another resident’s falls were not consistently reported to family as required.
A resident’s discharge MDS was not encoded and transmitted to the State within the required timeframe. The transfer form showed the resident was discharged, but the MDS record did not include a discharge assessment for that discharge, and the Regional MDS Coordinator said the facility MDS representative missed it and the facility follows RAI without a policy.
The facility failed to develop and implement complete care plans for two residents. One resident on dialysis had a care plan for ordered diet and meal intake monitoring, but multiple meal percentages were not documented after dialysis meals. Another resident with a suprapubic catheter was observed with an exposed, uncapped attachment nozzle, and the care plan did not include the resident’s self-care of the catheter. Staff and the DON confirmed the resident ate after dialysis and that the catheter tip should be covered when switched.
The facility failed to meet professional standards for wound care and feeding tube management. Two residents with skin tears had wound care entered and carried out without proper provider notification and without documentation of assessments or family notification, while a cognitively intact resident with a feeding tube was documented as receiving Glucerna enterally even though staff and the resident stated it was being taken orally and no enteral supplies were observed.
Failure to provide grooming assistance: A resident with an ADL self-care deficit related to weakness, limited mobility, confusion, a compression fracture, and a hx of falls was observed with hair extending beyond his ears while resting in bed. He stated he wanted a haircut and that staff had never offered one, and the DON said there was no written record showing the resident had been receiving or refusing haircuts. The facility policy required ADL care, including grooming, based on the individual care plan.
Failure to follow wound care orders and dressing documentation requirements was cited for multiple residents. A resident had a skin tear dressed without a physician order, another resident had a knee dressing with no date or initials, and a third resident had a dated dressing and pain patch that did not reflect the ordered treatment schedule. The DON and wound care RN acknowledged that dressings and treatments should be completed as ordered and that dressings are expected to be dated and initialed.
Indwelling catheter care was not provided as needed for a resident with Foley tubing that had cream-colored sediment along the length of the tubing on repeated observations. The resident had orders for Foley care every shift and irrigation for blockage, increased sediment, or decreased output, but staff and hospice interviews showed the tubing remained unchanged and there was no formal order for routine tubing changes, only PRN changes based on clinical findings.
Incomplete Dialysis Communication Documentation: The facility failed to fully complete the dialysis communication sheet for a resident receiving dialysis services. An LPN stated staff completed assessments and communication sheets before dialysis and upon return, while the DON said staff were expected to complete the sheets completely. Review showed multiple return-from-dialysis sections were left blank, and no earlier communication sheets were provided.
The facility failed to keep the exterior dumpster area sanitary. An open dumpster lid was observed with clear plastic bags inside, and a nearby grease trap had dark buildup, liquid pooling onto the concrete pad, and debris, trash fragments, and paper clutter around its base. Staff T and the ADM stated the dumpster lid should always be closed, while the ADM also said no one had told staff to clean the grease trap. The facility policy required dumpster lids to remain closed and the area to be clean and free of debris.
Incomplete and inconsistent documentation was found for a resident’s bathing care and for multiple residents’ skin-related treatments. Shower/bath records did not match the EMR and lacked entries for several days, with no documentation of physician or resident representative notification for refusals. Wound care, dressing changes, and lidocaine patch documentation were also missing or inconsistent with observations, and one resident was observed without ordered compression stockings.
Failure to perform hand hygiene, clean resident-care equipment, and use EBP PPE occurred during resident care and medication administration. A CNA handled drinks for multiple residents without hand hygiene between contacts, a wound care nurse changed gloves and completed wound care without hand hygiene between steps, and an LPN picked up a dropped tablet from the med cart and used an unc cleaned BP cuff on another resident. Staff also provided IV and tracheostomy care for residents on EBP without wearing a gown as required.
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.
Unsafe Food Storage and Improper Food Handling
Penalty
Summary
The dietary department failed to store, prepare, and serve food in a sanitary manner during kitchen observations. During an initial tour, a pitcher of lemonade was observed sitting on top of the ice machine, a bowl of oatmeal was placed on top of the serving area for plates, and a clear bag of sausage links was sitting on a plastic cart without a date or label. Staff stated the sausage had been opened the day before and should have been dated and stored in the refrigerator when not in use. In the walk-in refrigerator, a plastic container covered with aluminum foil and labeled chicken had no date and was stored inside another pan with ice on the second shelf above potatoes. Staff stated the chicken would be used the next day and should have been stored on the bottom shelf and dated before being placed in the refrigerator. A refrigerator in [NAME] Hall did not have a thermometer, and staff confirmed none could be located. During meal service, staff were observed touching the inside of bowls while grabbing multiple bowls at a time, and another staff member touched grilled cheese sandwiches with a gloved hand while flipping them and then returned to food handling after touching a cooler and handling cheese without changing gloves or performing hand hygiene. The assistant dietary manager stated the lemonade should have been stored in the cooler, the sausage should have been labeled and dated, the chicken should have been dated and stored on the bottom rack, the refrigerator should have had a thermometer, and staff should have handled bowls by the outside and washed hands or changed gloves when handling food.
Failure to Notify Providers and Families of Resident Changes in Condition
Penalty
Summary
The facility failed to notify residents’ physicians and/or resident representatives of changes in condition for multiple residents, including new or worsening skin issues, refusal of ADL care, and accidents. The report identified failures involving Resident #2, Resident #37, Resident #28, Resident #11, and Resident #30. The deficiency was based on observation, interview, and record review showing that required notifications were not documented after these events occurred. Resident #37 was observed with a bandage on the lower right forearm, and records showed wound care orders for skin tears to the arms and right wrist. The resident’s progress notes from 6/1/2026 through 8/10/2026 contained no documentation of notification to a provider or the resident representative regarding the wounds or dressings. Staff A, RN, the wound care nurse, stated she assessed the resident, found wounds on both forearms with dressings already in place, cleaned and redressed them, entered wound care orders, but did not write a progress note or contact a provider or the family. The physician stated he could not recall receiving a call about the wound, and the DON stated the wound care nurse was expected to notify family and a provider if a new or worsening wound was identified. Resident #2 had a skin tear to the left lateral ankle/left lower leg with a wound care order entered as a verbal order from Physician #2. The resident was observed with a gauze bordered dressing on the left lower extremity, and the resident stated the wound nurse had changed the dressing and said she would return later. Review of progress notes showed no documentation of the skin tear, no notification to family or provider, and no treatment orders documented in the notes. Resident #11 refused bathing on multiple occasions, but the record contained no documentation that the physician or resident representative was notified of the refusals. Resident #28 had a new skin tear to the right wrist that was bleeding and was assessed and dressed by nursing staff, but there was no documentation that the provider was notified. Resident #30 had a history of falls and skin tears, and the DON stated the family should have been notified for the resident’s falls; the report cited a failure to notify the resident’s family of the accident/change in condition as required.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to encode and transmit the resident discharge assessment to the State within 7 days of assessment for one resident, Resident #9. Review of the EXCEL-SNF to Hospital Transfer form showed the resident was discharged on 7/15/2026, but review of the resident’s MDS assessments did not show a Discharge MDS Assessment for that discharge date. During interview, the Regional MDS Coordinator stated that the resident’s MDS was not updated because the facility MDS representative just missed it and that the facility does not have a policy, relying instead on the RAI.
Incomplete care planning and documentation for dialysis nutrition and catheter self-care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #6 related to dialysis and meal intake documentation. Resident #6’s care plan, initiated on 5/21/2026, included interventions to provide and serve diet as ordered and to monitor intake and record it every meal. However, the Task ADL Eating and Meal Percentage record did not document meal intake percentages for 7/16/2026, 7/17/2026, 7/18/2026, 7/23/2026, 7/25/2026, 7/30/2026, 8/1/2026, 8/3/2026, 8/4/2026, and 8/6/2026. The physician order dated 5/20/2026 specified a renal diet, regular texture, regular/thin liquids, and a 1000 ml fluid restriction. Staff stated that after dialysis the resident returned to the facility for lunch and that meal intake should be recorded in PointClickCare, and the DON stated the resident normally received a chef salad or new tray after dialysis and that staff should record what was given and what was eaten. The facility also failed to include Resident #18’s self-care of a suprapubic catheter in the care plan initiated on 06/07/2026. During observation on 08/09/2026, the resident’s Foley bag was hanging from the bedside frame and the attachment nozzle was exposed and lying on the bed. Staff stated the resident switches to the leg bag himself and that the tip should be covered. The resident stated he wears the larger bag at night and puts the leg bag on in the morning himself, and the ADON/Infection Control Nurse stated that when a new leg bag is opened it comes with a blue cap and it needs to be covered when he switches it and leaves it on the bed. The MDS for 06/07/2026 documented an indwelling catheter Foley, and the physician order read suprapubic catheter care every shift.
Failure to Document and Follow Ordered Wound and Tube Feeding Care
Penalty
Summary
The facility failed to provide services that met professional standards of quality for resident skin issues and feeding tube management. For one resident with metabolic encephalopathy, dysphagia, dementia, aphasia, and weakness, staff found a skin tear on the bilateral forearms with dressings already in place and entered wound care orders in the computer without documenting a progress note or contacting a provider to report the findings or confirm the order. The resident’s record showed prior and current wound care orders for skin tears, but there was no documentation in the progress notes from early June through mid-August regarding notification to a provider or the resident representative about the wounds or dressings. A second resident, admitted for orthopedic aftercare and with diagnoses including weakness, difficulty walking, COPD, anxiety, depression, heart failure, PTSD, and excoriation disorder, had a skin tear to the left lateral ankle. The wound care nurse entered a verbal order for wound care, and the MAR/TAR documented daily dressing care, but the progress notes contained no documentation of the skin tear, notification to family or provider, or treatment orders. The resident was cognitively intact, and during observation had a bordered gauze dressing to the left lower extremity. The facility policy required verification of the provider’s order and timely documentation of assessments, observations, and services provided. For a third resident with a feeding tube, intracerebral hemorrhage, cerebral edema, diabetes, morbid obesity, atrial fibrillation, gastrostomy status, and hypertension, the record showed an order for bolus Glucerna 1.5 by enteral route when meals were eaten at less than 75%, with water flushes before and after bolus feedings. However, staff documented the Glucerna as being administered enterally on the MAR/TAR while also stating that the resident was drinking the Glucerna orally. The resident stated she was taking medications and Glucerna by mouth and nothing was going through the feeding tube, and no feeding pump or enteral supplies were observed. The DON stated that if the resident preferred to take the feeding orally, the physician should be notified and the order updated, but the record showed the ordered route was not followed as documented.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to ensure assistance with ADLs for grooming, specifically haircuts, for Resident #7, who was reviewed for ADL care. During an observation on 8/09/2026 at 10:16 AM, Resident #7 was resting in bed and his hair extended beyond his ears. When interviewed at that time, he stated that he would like to get a haircut and that staff had never offered to do that for him. His care plan dated 6/16/2026 documented an ADL self-care performance deficit related to weakness, limited mobility, confusion, compression fracture, and a history of falls. During an interview on 8/11/2026 at 9:30 AM, the DON stated that the facility did not have anything in writing showing that Resident #7 had been receiving or refusing haircuts. The facility policy stated that the facility shall provide care and services for ADLs as needed based on the individual care plan, including hygiene, bathing, dressing, grooming, and oral care.
Failure to Follow Wound Care Orders and Dressing Documentation
Penalty
Summary
The facility failed to ensure physician orders and facility policy were followed for wound care for 3 of 10 residents reviewed for wounds. Resident #28 was observed with a gauze dressing to the right wrist dated 08/06/2026, and the nursing note documented that a CNA noticed a new skin tear to the right wrist that was bleeding, was assessed by the nurse, cleaned, and dressed. However, review of the physician orders showed no wound care order for the right wrist. The wound care RN stated the resident did not have any wounds to her knowledge and explained that when a resident gets a skin tear, the nurse should cleanse it, recover the skin, dress it, notify the physician and family, and enter new orders. The DON stated the resident did not have orders for wound care to the right wrist and that the LPN should have notified the provider and obtained orders. Resident #21 was observed with an island dressing on the right knee that had no date or initials. The DON stated dressings are expected to be dated, and the wound care RN stated it is her practice to date and initial every dressing change, with weekend and PRN dressing changes done by the nurse on the cart. The TAR directed daily cleansing and application of a long island dressing to the right knee surgical site, and the facility policy for clean/dry dressings required tape/labels with date and initials. Resident #113 was observed with a dressing dated 8/6 and a white pain patch on the left arm dated 8/6/2026. The physician order required cleansing the left arm skin tear and applying xeroform, honey gel, and border gauze every day shift, and another order directed Aspercreme Lidocaine Patch 4% to the left shoulder in the morning and night and to the left hip with removal at bedtime. The wound care RN stated she was not familiar with the resident's skin tear dressing orders and that wound care should be done as ordered, while the DON stated dressings and treatments should be done as ordered and a check mark in the treatment record means completed.
Indwelling Catheter Care Not Provided as Needed
Penalty
Summary
Failure to provide treatment and services for the care of a resident with an indwelling urinary catheter was identified for one of five residents reviewed. During observation of the resident on 08/09/2026, Foley tubing had cream-colored sediment along the length of the tubing, and the same sediment was still present and unchanged during a second observation on 08/11/2026. The resident’s record showed physician orders for Foley care every shift and for irrigation with 60 cc normal saline for blockage, increased sediment, or decreased output every 6 hours as needed, with notification of the physician for any abnormal observation from baseline. Staff interviews showed that the CNA would notify the nurse if something was wrong with the Foley when emptying it, and the hospice director stated the hospice aide documented care and would notify the RN and floor nurse if there were new findings or resident complaints. The ADON/Infection Control Nurse stated the Foley catheter tubing should be changed based on how it looked, but there was no formal order for routine tubing changes and it was only PRN. The DON stated a PRN Foley change would be needed if there was leakage, blockage, or sediment that could not be flushed out. The facility policy stated routine fixed-interval catheter changes are not recommended and that residents should be observed routinely for complications and new complications reported to the provider as indicated.
Incomplete Dialysis Communication Documentation
Penalty
Summary
The facility failed to complete the dialysis communication sheet for one resident who required dialysis services. The resident had a physician order dated 5/20/2026 for dialysis at a third-party dialysis provider on Tuesday, Thursday, and Saturday, with a 7:00 AM pickup time and 7:30 AM chair time, transported by wheelchair. Review of the resident’s dialysis communication forms showed that the section for facility completion upon return from dialysis was not completed on 8/8/2026, 8/6/2026, 8/4/2026, 8/1/2026, and 7/28/2026, and no other communication sheets were provided prior to 7/28/2026. Staff interviews indicated that an LPN completed assessments and communication sheets before dialysis and upon return, and the DON stated that staff were expected to complete the communication sheets completely and that progress notes would be on the communication sheet. The facility policy titled Clinical Dialysis Management stated that facility personnel will provide information useful or necessary for the resident’s care to the dialysis center as needed.
Exterior Dumpster Area Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to maintain the exterior waste area in a sanitary condition. During an observation of the dumpster area with Staff T, the dumpster lid was open and clear plastic bags were visible inside. Next to the dumpster, a grease trap had dark buildup and liquid pooling outward from the base of the grease container across the concrete pad, with loose debris, trash fragments, and paper clutter accumulated around the base. During interviews, Staff T stated the dumpster lid should be closed at all times and was unsure who was responsible for cleaning the grease trap. The Assistant Dietary Manager stated the garbage container lid should always be closed and said no one had ever told staff to clean the grease trap. The Administrator stated the dumpster lid should be closed at all times and said they would look at the grease trap and speak to maintenance. The Maintenance Director stated the area needed to be clean and appeared to have some sort of spillage. The facility policy stated dumpster lids must remain closed when not in use and that dumpster areas must be clean and free of debris, with immediate cleanup for spills, leaks, and loose trash.
Incomplete and Inconsistent Documentation of ADL Care and Skin Treatments
Penalty
Summary
The facility failed to maintain complete and accurate documentation in the medical record for ADL care and skin-related treatments. For one resident, shower/bath documentation from 7/01/2026 through 8/10/2026 showed multiple dates with no entries, and the task list contained bathing refusals that did not consistently match the printed shower/bath sheets. The record also lacked documentation that the resident’s physician or resident representative was notified about refusals of ADL care. Staff stated that residents who refused bathing were to be offered care multiple times, the outcome documented, and the nurse notified, but those steps were not reflected in the record. For another resident, the TAR did not document ordered wound care on several dates for a right lower extremity wound and on two dates for a left lower extremity wound. The wound care orders required cleansing, ointment, dressings, and wrapping, but the TAR showed missing documentation on multiple days in July 2026. An LPN stated that the wound care had been completed but was not documented. For a third resident, observation showed a dated dressing on the left arm and dated lidocaine patches, while the TAR reflected dressing completion and patch application/removal on different dates. Staff involved stated they were not familiar with the resident’s skin tear dressing orders or could not recall the care provided, while the DON stated that a check mark in the MAR meant the care was completed and nurses were expected to document care accurately. During observation, one resident was seen without compression stockings despite an order for daily compression stockings to both lower extremities. The DON stated that doctor’s orders were expected to be carried out and refusals charted. The report also included facility policies requiring accurate, timely documentation of assessments, observations, and services provided, and stating that documentation should reflect actual resident experiences and be completed at the time of service or by the end of the shift.
Failure to Perform Hand Hygiene, Clean Equipment, and Use EBP PPE
Penalty
Summary
The facility failed to perform hand hygiene during resident care and medication-related activities. During dining service, a CNA handled resident drinkware and beverages for multiple residents, including filling a tumbler, delivering drinks, and then moving to other tables without performing hand hygiene between resident contacts. During wound care for a resident with a right groin wound, a wound care nurse removed gloves and donned new gloves multiple times without hand hygiene between glove changes while removing the dressing, cleaning the wound, packing the wound, and applying a new dressing. The DON and ADON both stated that hand hygiene should have been performed between glove changes and between resident interactions. During medication preparation and administration, an LPN dropped a multivitamin tablet onto the top of the medication cart, picked it up with gloved hands without hand hygiene, and placed it into a medication cup for administration to a resident. The same LPN later obtained a resident’s blood pressure using a cuff that had been used on another resident without cleaning the cuff between residents, and she did not perform hand hygiene after obtaining the blood pressure and before preparing and administering oral medications. The DON stated that a pill dropped on the medication cart should have been discarded, hand hygiene was required before preparing medications and after administration, and blood pressure cuffs were to be cleaned after each use between residents. The facility also failed to follow Enhanced Barrier Precautions for residents with indwelling devices. An LPN disconnected and flushed a resident’s IV line and later accessed the resident’s PICC line and administered IV antibiotics without wearing a gown. Another staff member performed tracheostomy care for a resident on EBP while wearing gloves and a mask but no gown. The DON stated that residents on EBP required staff to wear appropriate PPE, including a gown and gloves, during direct care such as IV care and tracheostomy care. Facility policies reviewed addressed hand hygiene, clinical equipment cleaning, medication administration, and EBP for residents with wounds or indwelling medical devices.
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 18 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 | ★★★★★ | 4 | 0 |
| Live Oak Healthcare And Rehabilitation Center | 20.4 mi | ★★★★★ | 11 | 0 |
| Surrey Place Nursing Center | 20.9 mi | ★★★★★ | 0 | 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 October 2026) and official state health department websites.