Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Eustis Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Thickened Liquids Served at Incorrect Consistency: Two residents with dysphagia orders for nectar-thick fluids were served thin liquids instead of the ordered consistency. One resident with multiple cardiac, respiratory, and cognitive diagnoses was given thin apple juice on ice and thin coffee, and coughed after drinking. Another resident with dysphagia and post-CVA deficits was observed with thin clear liquid and thin apple juice labeled as nectar. Staff and the DON confirmed the drinks were not thickened, and dietary staff identified that the beverage machine was not producing the correct consistency.
A facility failed to serve ordered nectar thick liquids at the correct consistency. Two residents with dysphagia orders were observed receiving thin juice and coffee, and one resident coughed after sipping thin liquid. Staff and dietary leadership later observed that drinks labeled as thickened were actually thin, and the kitchen’s beverage equipment was identified as not producing the proper consistency.
A facility failed to secure medications when unattended after multiple residents were observed with nasal decongestant, saline nasal spray, a pain roller, Vicks VapoRub, and an analgesic sore throat spray on bedside tables or dressers without orders for self-administration. Staff and the DON stated these items should not be at bedside and that medications must be stored in locked compartments or a lock box/locked drawer when kept in a resident’s room.
Inaccurate MDS assessments were completed for two residents. One resident’s MDS did not reflect a significant 6-month weight loss, and another resident’s MDS incorrectly stated the resident was not receiving a scheduled pain med regimen despite an order for methocarbamol BID and MAR documentation showing administration. The MDS RN acknowledged both assessments were inaccurate.
PASARR screening was not updated for two residents with behavioral diagnoses. One resident’s PASARR did not reflect major depressive disorder despite orders and psych notes documenting depression and anxiety, and another resident’s PASARR omitted bipolar disorder even though the chart, care plan, med orders, and psych eval all referenced it. The SS Director acknowledged the omissions and stated the bipolar diagnosis had been missed.
A resident’s ordered antihypertensive medication was repeatedly held or not given, with staff stating they used nursing judgment, sometimes forgot to call the provider, and relied on parameters from other patients. The resident also had a weekly weight order related to pleural effusion, but weights were not documented as ordered, and the DON could not locate the weekly weights.
Enteral feeding was not administered per the physician order for a resident with a gastrostomy and dysphagia following cerebral infarction. The resident's Osmolite 1.5 tube feed was ordered at 50 mL/hr for 22 hours, but surveyors observed it running at 55 mL/hr with water flushes every 3 hours. An LPN said the wrong rate could cause GI symptoms and affect comorbidities, and the ADON confirmed the ordered rate was 50 mL/hr.
Oxygen was administered below the ordered flow rate for a resident with COPD exacerbation. The resident had an order for O2 at 3 L via NC continuously, but surveyors observed the oxygen running at 2 L on two occasions while the resident sat in a wheelchair in her room. The resident stated she was supposed to be at 3 L, and an RN later confirmed the flow rate needed to be adjusted.
Incomplete documentation of medication administration and provider notification was found for two residents. One resident with DM had multiple insulin doses coded as not required or held based on blood sugar results, but the record did not show provider notification or documentation of insulin refusal. Another resident had BP medications held for low BP, but the chart did not show that the provider was notified, despite staff stating they had called the NP.
An LPN failed to perform hand hygiene between dirty and clean steps during wound care for a resident with a left trochanter wound, including after glove removal and before repacking the wound. In a separate event, a housekeeper entered a room on contact precautions without gown or gloves and touched the curtain and bed despite PPE being available outside the room.
The facility failed to ensure food was safely stored, labeled, or discarded in the kitchen walk-in cooler. Surveyors found unlabeled and undated containers, expired food, and improperly labeled items. The Dietary Manager confirmed the labeling and dating requirements were not followed as per the facility's policy.
A resident with hemiplegia and hemiparesis was inaccurately assessed in their functional status. Despite being part of a restorative program and having documented impairments, the resident's MDS did not reflect these limitations, as confirmed by the MDS Coordinator and other staff.
The facility failed to implement a comprehensive care plan for a resident at risk for falls by not ensuring the use of bilateral floor mats as specified. Additionally, the facility did not develop a care plan for another resident with epilepsy, omitting necessary interventions for seizure management.
The facility failed to ensure staff used appropriate PPE while providing direct care to residents on enhanced barrier precautions. A CNA assisted two residents with wounds without wearing a gown, despite the facility's policy requiring gowns and gloves for high-contact care activities. The CNA stated they did not see the signage indicating enhanced barrier precautions on the residents' doors.
Thickened Liquids Served at Incorrect Consistency
Penalty
Summary
The facility failed to ensure that residents with physician-ordered thickened liquids received drinks at the ordered consistency. Resident #71 had diagnoses including metabolic encephalopathy, heart failure, COPD, atherosclerotic heart disease, hypertensive heart disease with heart failure, hyponatremia, NSTEMI, cognitive communication deficit, and altered mental status. The resident had a physician order for a regular diet with dysphagia mechanical soft texture and nectar thickened fluids, and speech therapy documented signs of dysphagia and aspiration concerns with a recommendation for a mechanical altered/nectar diet. During observation, Resident #71 was served apple juice on ice at a thin consistency and took sips that caused coughing. Staff C, the Scheduling Manager, also served thin coffee to the resident. Staff C later stated the resident had a nectar thickened diet and should not have received the juice or coffee. The DON also confirmed that Resident #71 was delivered thin consistency juice and coffee and should not have been given thin liquids. A change-in-condition assessment was completed for coughing while drinking thin liquids, with a recommendation for a chest x-ray. Resident #46 had diagnoses including dysphagia, oral phase, speech and language deficits following cerebral infarction, history of TIA, GERD, constipation, hypertension, and anemia. The resident had a physician order for a regular diet with dysphagia puree texture and nectar thicken fluids consistency. During observation, Resident #46 was served a cup with a straw containing ice and clear thin liquid, and also had a cup labeled as nectar apple juice that was observed to be thin when the lid was removed. The resident was observed taking a sip from the clear thin liquid. The DON stated the resident should not have thin liquids and confirmed the apple juice was not thickened. The report also documented that the facility’s thickened liquid machine was not functioning properly, with staff and dietary leadership observing that the juices were too thin and that the machine required adjustment.
Thickened Liquids Served at Incorrect Consistency
Penalty
Summary
The facility failed to provide thickened liquids in the ordered consistency for residents who had physician-ordered nectar thickened fluids. Resident #71 had an order for regular diet, dysphagia mechanical soft texture, and nectar thickened fluids, and Resident #46 had an order for regular diet, dysphagia puree texture, and nectar thicken fluids. Resident #46 also had a pulmonary progress note stating thickened liquid was needed to reduce any risk of aspiration. The report states the facility administration failed to use its resources effectively and efficiently to implement policy and procedures related to thickened liquids and failed to ensure residents were served liquids to meet their needs. During observation, Resident #71 was served apple juice on ice at a thin consistency and took sips of it, coughing afterward. Resident #71 then requested coffee, and Staff C, Scheduling Manager, served coffee at thin consistency. Staff C later stated the resident had a nectar thickened diet and should not have been given the juice or coffee. Resident #71’s change-in-condition record documented coughing while drinking thin liquids and recommended a chest x-ray. Staff D, CNA, stated she gave the resident thin liquid juice and did not give thickened liquids because those normally come on the tray. Resident #46 was observed with a cup containing ice and clear thin liquid and also a cup labeled as nectar apple juice that was observed to be thin consistency. Resident #46 took a sip from the clear thin liquid. The DON stated the resident should not have thin liquids and that the apple juice from the kitchen was not thickened. The FSM and CDM observed that the thickened liquids from the machine were not the same consistency as expected, and the FSM stated she did not know whether the machine was not working or whether ice was melting into the cups. Staff later observed multiple cups of drinks designated as thickened drinks on the tray line that were actually thin in consistency, and Staff B, Dietary Aide, stated she thought the drinks were already thickened and was not aware of a problem with the machine.
Unsecured Medications Found at Bedside Without Self-Administration Orders
Penalty
Summary
The facility failed to secure medications when unattended. During observation, a bottle of nasal decongestant and a bottle of saline nasal spray were found on a resident’s bedside table, and the RN stated the resident did not have an order to self-administer medications, that medications were supposed to be kept in the medication cart, and that the Afrin had come from the hospital and was no longer needed. Review of the resident’s physician orders did not show an order for self-administration, and the product information for Afrin stated not to use it for more than 3 days and to use only as directed. Additional observations found other residents with medications or medication-like products at bedside without orders for self-administration. One resident with MS had a pain roller containing avocado butter, hempseed oil, vitamin E, beeswax, and healing oils on the dresser; the resident said he used it for pain and sometimes had nursing help, while the RN stated the resident was not supposed to have any medication at bedside. Another resident had Vicks VapoRub on the bedside table, and a fourth resident had an analgesic sore throat spray container at bedside; staff stated neither resident had orders for self-administration and the items should not be at bedside. The DON stated medications are to be stored in a drawer or lock box, that residents should have a self-administration assessment and the doctor notified, and that medications should not be unattended. Facility policy required drugs and biologicals to be stored in locked compartments and, if stored at bedside, in a lock box or locked drawer.
Inaccurate MDS Assessments for Weight Loss and Scheduled Pain Medication
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for two residents reviewed for nutrition and medication management. For Resident #45, the quarterly MDS dated [DATE] coded Section K0300 Weight Loss as 0, or no/unknown, even though the resident’s weights showed 167 pounds on 12/10/2024 and 150 pounds on 6/1/2025, a 10.2% weight loss over six months. During interview, the Registered Dietitian stated the resident fluctuates in weight but that the most recent weight changes were significant and would have been coded differently, and the MDS RN stated Section K should be corrected because, based on the RAI, it was a weight loss. For Resident #72, the MDS dated [DATE] coded Section J Health Conditions as not receiving a scheduled pain medication regimen. However, the physician ordered methocarbamol 500 mg by mouth twice daily for pain on 7/29/2025, and the July 2025 MAR documented the medication was administered on 7/30/2025 at 9:00 AM and 9:00 PM. During interview, the MDS RN stated the resident had scheduled pain medication for the look-back period and that the MDS was inaccurate. The facility policy titled Minimum Data Set stated that each person completing a section or portion of the MDS signs the Attestation Statement indicating its accuracy.
PASARR Screening Not Updated for Behavioral Diagnoses
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not kept current for two residents with behavioral diagnoses. Resident #66 was admitted with major depressive disorder, and the record showed a PASARR dated 8/11/2025 that did not document a mental illness or suspected mental illness. However, a physician order dated 8/14/2025 identified sertraline for depressed, withdrawn behavior related to major depressive disorder, and a psychiatric admission note dated 8/19/2025 documented mild depression and anxiety related to adjustment to the facility, loss of independence, and the treatment plan. During interview, the Social Service Director stated the resident’s PASARR needed to be corrected because not all diagnoses were listed upon admission. Resident #80 was admitted with major depressive disorder, anxiety disorder, and bipolar disorder. The PASARR dated 7/30/2025 documented anxiety disorder and depressive disorder based on history and medications, but did not include bipolar disorder. A physician order dated 8/5/2025 identified divalproex for mood disorder related to bipolar disorder, the care plan referenced anticonvulsant medication related to bipolar disorder, and the psychiatry admission note stated the resident reported a history of bipolar disorder. The Social Services Director stated she was responsible for verifying PASARR completion, acknowledged bipolar disorder was listed among the resident’s diagnoses, and confirmed it was not included in the PASARR because it was missed and was not on the hospital discharge documentation used to complete it.
Failure to Follow Medication and Weight Monitoring Orders
Penalty
Summary
The facility failed to ensure that blood pressure medication and weekly weights were administered and monitored according to physician orders for Resident #51. The resident had an order dated 4/8/2025 for Valsartan 320 mg by mouth daily for hypertension, and the MAR showed multiple doses in July and August 2025 coded as held or otherwise not given. Staff interviews showed that an LPN stated the resident’s blood pressure sometimes went low and the medication was not given, and that she sometimes forgot to call the provider. An RN stated she used her nursing judgment and experience with other patients and had not called the doctor because she relied on the doctor’s parameters based on other patients. The resident also had a physician order dated 6/19/2025 for weekly weights, but the documented weights were only found on 7/7/2025, 7/21/2025, and 8/8/2025. The DON stated she was not able to find the weekly weights and did not know why the order was in place. The NP stated weekly weights were ordered because the resident had pleural effusion and she wanted to monitor for weight gain, and she had not received reports that the resident refused weights. The DON also stated that nurses needed to contact the doctor and document communication when holding a medication, and the facility policy stated medications should be administered safely and timely as prescribed and that weight monitoring schedules should be developed and weights recorded timely.
Enteral Feeding Ran at Incorrect Rate
Penalty
Summary
The facility failed to ensure enteral feeding was administered according to the physician order for Resident #7, who was admitted with diagnoses including gastrostomy status and had a physician order for enteral feeding related to dysphagia following cerebral infarction. The order dated 6/26/2025 specified Osmolite 1.5 to run at 50 mL/hr via pump for 22 hours, with a break from 7 AM to 9 AM, for a total of 1100 mL per 24 hours. A nutrition note later documented that the resident received tube feed and oral diet, with Osmolite 1.5 at 50 mL/hr for 22 hours and water flushes every 3 hours. During an observation on 8/25/2025 at 1:11 PM, Resident #7 was lying in bed with eyes open but did not respond to verbal stimuli, and the enteral feeding was observed running at 55 mL/hr with a 120 mL flush every 3 hours. An LPN stated that a tube feeding set to the wrong rate could cause side effects such as over or under eating, diarrhea, and other GI symptoms, and could affect comorbidities like diabetes. The ADON/Unit Manager stated that nurses were responsible for feeding tubes, had to double check the physician's order, and confirmed that the resident's ordered rate was 50 mL/hr, making the observed 55 mL/hr rate incorrect.
Oxygen Administered Below Ordered Flow Rate
Penalty
Summary
Failure to provide oxygen as ordered occurred for Resident #65, who had a physician order dated 7/28/2025 for oxygen at 3 liters per minute via nasal cannula continuously every shift related to chronic obstructive pulmonary disease with acute exacerbation. During observations on 8/25/2025 and 8/26/2025, the resident was sitting in a wheelchair in her room while oxygen was being administered at 2 liters per minute via nasal cannula. During an interview on 8/26/2025, the resident stated she was supposed to be at 3 liters. On 8/27/2025, an RN stated the resident's oxygen needed to be adjusted because it was running at 2 liters but the order was for 3 liters per minute. The DON stated nurses should notify the physician if the flow rate was incorrect and correct it, and that nurses should check oxygen at the beginning of the shift and periodically throughout.
Incomplete Documentation of Medication Holds and Provider Notification
Penalty
Summary
The facility failed to ensure resident medical records were complete and accurate for medication administration for two sampled residents. For one resident with diabetes mellitus and an order for Humulin N 36 units subcutaneously twice daily, the August 2025 MAR showed multiple entries where insulin was coded as not required or held based on blood sugar results, including readings of 85, 116, 110, 80, 66, 102, and 102. Nursing progress notes for the same period did not show documentation that the physician was notified of the blood sugar results or the resident’s refusal of insulin. Staff interviews indicated that the resident often refused insulin when blood sugar was low and that staff would normally notify the provider, but the refusals and notifications were not documented in the record. For another resident with orders for hydralazine, metoprolol, and diltiazem for hypertension, the eMAR showed the medications were held on one occasion when blood pressure was 98/54, and the progress note documented the medications were held for that blood pressure. However, the nursing progress notes did not show documentation that the provider was notified of the blood pressure results and the held medications. An LPN stated she called the nurse practitioner when blood pressure was low but forgot to document it, and the nurse practitioner stated she expected to be notified and believed she had been notified. The DON stated nurses should accurately document medication administration and provider notification when there was a concern with administering medication.
Hand Hygiene and PPE Use During Wound Care and Contact Isolation
Penalty
Summary
Staff failed to perform hand hygiene during wound care for Resident #7. During an observation, an LPN and the ADON entered the resident’s room, donned gowns and gloves, and began dressing care for a wound on the left lateral trochanter. After removing the soiled dressing and gloves, the LPN did not perform hand hygiene before donning a new pair of gloves and cleansing the wound. After cleansing the wound, the LPN again removed gloves and performed hand hygiene, then returned to the resident’s side, donned gloves, and cleansed continued drainage from the wound three times with different gauze. The LPN did not remove the gloves or perform hand hygiene before packing the wound with gentel blue foam and applying a clean dressing. During interview, the LPN stated she should have done hand hygiene between dirty and clean while doing the wound care. The ADON stated the nurse should have removed gloves and performed hand hygiene before putting on another set of gloves, and that hand hygiene should occur anytime staff touch dirty and move to clean during wound care. The DON stated staff should remove the old dressing and wash hands, then wash hands before putting on a new pair of gloves, with a break between dirty and clean tasks. Staff also failed to don appropriate PPE before entering a contact isolation room for Resident #2. The room door displayed a contact precautions sign and a PPE caddy with gloves and disposable gowns was available outside the room. A housekeeper entered the room without a gown or gloves and touched the curtain and bed even though she knew the resident was on contact precautions. The housekeeper stated she probably should have worn a gown and gloves, and the Director of Housekeeping stated housekeeping staff should wear a gown and gloves when a resident is on contact isolation and had been educated on the policy.
Failure to Properly Label and Store Food in Walk-In Cooler
Penalty
Summary
The facility failed to ensure food was safely stored, labeled, or discarded in the kitchen walk-in cooler. During an observation, surveyors found an unlabeled and undated large clear container with food items, a container labeled as pork with a use-by date that had already passed, and a sheet pan with 72 Styrofoam bowls containing food items with no labels or dates. The Dietary Manager confirmed that the products should have been labeled and dated before storing and that the pork should have been discarded by the labeled date. The facility's policy on Food Safety and Sanitation requires all leftovers to be labeled, covered, and dated when stored, and foods with expiration dates to be used prior to the date.
Inaccurate Functional Status Assessment
Penalty
Summary
The facility failed to ensure that Resident #32's functional status assessments were accurate. Resident #32, who was admitted with diagnoses including hemiplegia and hemiparesis following cerebrovascular disease, was observed wearing a splint on his right hand and reported using his left hand to assist with movement. Interviews with the Director of Nursing and the Director of Rehabilitation confirmed that the resident had impairments in all extremities and was part of a restorative program for range of motion and contracture management. However, the resident's Quarterly Minimum Data Set (MDS) did not document any impairment in the functional limitation of upper and lower extremities. The MDS Coordinator acknowledged that Resident #32 was incorrectly coded regarding his extremity impairments. The resident's physician orders also indicated the need for skilled occupational therapy and a restorative nursing program for contracture management. The facility's policy on MDS 3.0 Completion requires a comprehensive and accurate assessment of each resident's functional capacity, which was not adhered to in this case, leading to the deficiency.
Failure to Implement and Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to implement a comprehensive care plan for Resident #58, who was at risk for falls due to multiple diagnoses including chronic kidney disease, muscle weakness, lack of coordination, dementia, and repeated falls. Despite the care plan and physician's order specifying the use of bilateral floor mats when the resident was in bed, observations on multiple occasions revealed that the floor mats were not in place. Interviews with staff members, including a CNA and a Registered Nurse, confirmed that the floor mats were missing, and the Director of Nursing acknowledged that the care plan was not being followed as expected. Additionally, the facility failed to develop a comprehensive care plan for Resident #57, who had a diagnosis of epilepsy and was prescribed anticonvulsant medication. The care plan for this resident did not include any focus or interventions for managing the seizure disorder. The MDS/Care Plan Coordinator and the Director of Nursing both confirmed that the resident should have been care planned for seizures, but this was not done. The facility's policy on care plan meetings emphasized the importance of addressing new problems and ensuring that all relevant issues were included in the care plan, which was not adhered to in this case.
Failure to Use Appropriate PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff used appropriate PPE while providing direct care to residents on enhanced barrier precautions. During an observation, a CNA was seen assisting a resident with dressing and changing bed linen without wearing a gown, despite the resident being under enhanced barrier precautions for a wound on the right lateral ankle. The Wound Care Nurse, who was wearing gloves and a gown, asked the CNA to hold the resident's leg during wound care, but the CNA continued to assist the resident without a gown after the nurse left. The CNA stated that they did not know the resident was under enhanced barrier precautions because they did not see the signage on the door. In another instance, the same CNA provided incontinence care to another resident under enhanced barrier precautions without wearing a gown. The resident had a wound on the right leg. The Director of Nursing confirmed that staff are expected to wear gloves and a gown when providing high-contact care for residents with wounds and certain infections. The facility's policy on enhanced barrier precautions requires staff to wear a gown and gloves for all interactions that may involve contact with the resident or the resident's environment, especially during high-contact care activities. The CNA admitted to not wearing a gown because they did not see the signage indicating enhanced barrier precautions on the resident's door.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eustis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bayview Center | 0.3 mi | ★★★★★ | 7 | 0 |
| Ruleme Center | 1.5 mi | ★★★★★ | 9 | 0 |
| Solaris Healthcare Waterman | 2 mi | ★★★★★ | 1 | 0 |
| Avante At Mt Dora, Inc | 2.7 mi | ★★★★★ | 11 | 0 |
| Edgewater At Waterman Village | 3.2 mi | ★★★★★ | 9 | 0 |
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