Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Montgomery Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with type 2 DM, foot ulcers, and cognitive impairment had physician orders for HumaLOG sliding‑scale insulin before meals and at bedtime and Lantus insulin at bedtime. Over two consecutive months, the MAR showed multiple instances where blood glucose checks were not completed as ordered and numerous refusals of Lantus were documented, yet there was no documentation that the resident’s representative was notified of these refusals or missed monitoring. The resident’s representative later reported not being informed of the non‑compliance, an LPN acknowledged not notifying the family in this case, and the DON stated that the expectation per facility policy was to notify and document when residents refuse medications or treatments, including clinical complications requiring notification.
A resident was admitted with a Full Code advanced directive, and the care plan correctly reflected a CPR (Full Code) order at admission. Later, the resident’s code status was changed to DNR, but the care plan was not updated to reflect this change. The DON, MDS LPN, and Social Worker Director all confirmed in interviews that code status changes are normally discussed in morning clinical meetings and should trigger a care plan update, but in this instance the change was missed. This failure was not consistent with the facility’s written policy requiring documentation and care plan updates whenever code status/advanced directives are changed.
A resident with DM had physician orders for sliding-scale HumaLOG before meals and at HS and scheduled Lantus at HS, but the MAR over two consecutive months showed numerous entries where ordered blood glucose checks were marked as "NA," left blank, or marked with an "X," and multiple Lantus doses were coded as refused. The medical record lacked documentation that the provider was notified when blood sugars were not obtained to determine insulin needs or when insulin doses were refused. In interviews, an APRN and an LPN reported that the resident often refused accu-checks and insulin and that staff usually called the provider, while the LPN admitted there were times these calls were not documented. The DON stated that nurses are expected to notify the provider and document refusals, and facility policies require that reasons for not following physician orders and all refusals be recorded in the medical record, which did not occur consistently for this resident.
A resident's assessment failed to accurately reflect their use of oxygen therapy, as the MDS indicated no oxygen use despite multiple records and a physician order confirming ongoing oxygen administration. An LPN confirmed that documentation practices did not align with facility policy, leading to an inaccurate assessment.
The facility did not accurately complete PASRR screenings for two residents with multiple mental health diagnoses, omitting key conditions such as mood disorders, schizophrenia, and psychotic disorders from the required documentation. Despite psychiatric notes and MDS assessments indicating these active diagnoses, the PASRR forms were not updated accordingly, as confirmed by the DON.
Nursing staff failed to administer medications according to physician orders for two residents. One resident's blood pressure medication was withheld without provider notification or parameters, while another resident received insulin despite blood sugar levels below the ordered threshold. Staff interviews revealed lack of adherence to medication orders and facility policy.
Accurate nurse staffing information was not posted daily as required, with outdated information observed and delays attributed to the scheduler waiting for census data. The scheduler and administrative staff provided differing accounts regarding the timeliness of census information and expectations for posting, and there was no formal policy in place for the posting process.
The facility did not ensure that laboratory services and tests were provided in a timely and quality manner to meet resident needs, as identified during the survey.
Surveyors observed that food items in a nourishment room freezer and refrigerator were not labeled or dated as required. The Dietary Manager confirmed that these items should have been labeled and dated, in line with facility policy for food brought in by families or visitors.
The facility failed to maintain a clean and homelike environment, with multiple deficiencies observed in the laundry room and various hallways. Issues included a non-functional washing machine, buildup of garbage and debris, dirty air conditioning unit and dryer lint areas, and broken equipment. Additional deficiencies were found in the C-Hallway and B-Hallway, including improper storage of cleaning supplies, buildup of ice in a specimen refrigerator, and a broken wash sink.
A resident with multiple diagnoses, including diabetes and pressure injuries, experienced significant weight loss due to the facility's failure to provide timely nutritional interventions. Despite consuming most of her meals, the resident's weight dropped significantly, and the Consultant Dietitian had not started supplements despite being aware of the weight loss.
Failure to Notify Resident Representative of Repeated Insulin Refusals and Missed Blood Glucose Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative when the resident repeatedly refused ordered insulin and when staff did not monitor blood sugar values as ordered. The resident was admitted with type 2 diabetes mellitus with a foot ulcer, difficulty in walking, and a non‑pressure chronic ulcer of the right foot with necrosis of muscle. A quarterly MDS documented a BIMS score of 9/15, indicating some cognitive impairment. The resident had orders for HumaLOG insulin per sliding scale before meals and at bedtime, and Lantus insulin at bedtime for diabetes management. Review of the MAR for November showed multiple instances where blood sugar monitoring was not completed as ordered and/or insulin was not administered. For HumaLOG, there were 16 occurrences in November where blood sugar values were either marked as not applicable or left blank at various times (0630, 1130, 1630, and 2100), indicating that blood sugar was not checked to determine if insulin was required. For Lantus, four doses in November were documented with the code "2" for drug refused. The medical record for this period did not contain documentation that the resident’s representative was notified of either the refusals or the missed blood sugar monitoring. In December, the pattern continued. The Lantus dose was increased to 25 units at bedtime, and the MAR documented five additional refusals of Lantus using the code "2". For HumaLOG, there were 15 occurrences in December where blood sugar values were not monitored, documented as not applicable or with an "X" at various scheduled times. Again, the medical record did not show that the resident’s representative was notified of the resident’s refusals of insulin or of staff not monitoring blood sugar values. The resident’s representative later stated they were not aware of the refusals and had not been told the resident was non‑compliant. An LPN reported that while they call the physician and sometimes family when refusals are frequent, they did not notify this resident’s family. The DON stated the expectation was that nurses notify family and the provider and document when a resident refuses medications or treatments, and that the resident’s refusals had been discussed in morning meetings. The facility’s Notification of Changes policy required notifying the resident’s representative of clinical complications and significant changes in health status.
Failure to Update Care Plan After Change in Advanced Directives
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan to reflect a change in advanced directives. Record review showed that the resident was admitted with an advanced directive of Full Code status, and the care plan documented a focus on advanced directives with an established CPR (Full Code) order and corresponding initiation and creation dates. However, the resident’s code status was changed in October to Do Not Resuscitate (DNR), and this change was not reflected in the resident’s care plan. During interviews, the DON acknowledged that the resident’s care plan was not updated after the code status changed from Full Code to DNR. The MDS LPN stated that when a code status order changes, the care plan should be updated and that this is typically discussed in morning meetings before care plans are revised, but in this case the update did not occur. The Social Worker Director reported attending morning clinical meetings where advanced directives are reviewed and stated that if the care plan was not updated, it was likely missed during this process. Review of the facility’s “Advanced Directives Code Status” policy confirmed that when code status changes, Social Services and nursing must document the change and update the code status/advanced directives care plan, which did not happen for this resident.
Failure to Maintain Complete Insulin and Blood Glucose Monitoring Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and to document required notifications related to insulin administration and blood glucose monitoring for one resident with diabetes mellitus. The resident had physician orders for HumaLOG KwikPen insulin on a sliding scale before meals and at bedtime, and for Lantus SoloStar insulin at bedtime. Review of the MAR for November 1–30, 2025, showed multiple entries where blood sugar values were recorded as “NA” or left blank at ordered times (0630, 1130, 1630, and 2100), and one entry marked with an “X,” resulting in 16 occurrences where the resident’s blood sugar was not monitored as ordered to determine if sliding-scale insulin was required. The medical record for that period did not contain documentation that the physician was notified when the medication was not administered due to resident refusal and/or staff not performing the ordered blood sugar checks. For the same resident, the MAR for November 1–30, 2025, documented Lantus SoloStar 100 UNIT/ML at bedtime with four doses marked with the chart code “2,” indicating drug refusal, on specific dates in November. The resident’s medical record did not contain documentation that the physician was notified of these refusals. In the subsequent period, December 1–20, 2025, the Lantus SoloStar order was changed to 25 units at bedtime, and the MAR documented five additional doses with the code “2” for refusal. Again, the medical record for this period did not show documentation that the physician was notified of the resident’s repeated refusals of the ordered insulin. During the same December period, the MAR for HumaLOG KwikPen continued to show missing or incomplete documentation of blood sugar monitoring. At ordered times, multiple entries were documented as “NA” or with an “X,” resulting in 15 occurrences where the resident’s blood sugar was not monitored to determine if insulin administration was required. Interviews with the APRN and an LPN indicated that the resident frequently refused blood sugar checks and insulin, and that staff usually called the provider, but the LPN acknowledged there were times these calls were not documented. The DON stated that the facility’s expectation is that nurses notify family and the provider and document when a resident refuses medications or treatments. Facility policies on Physician Services and Medication Administration require that all physician orders be followed, reasons for not following orders be recorded in the medical record during that shift, and that refusals be reported and documented, which was not consistently done for this resident.
Inaccurate Resident Assessment for Oxygen Therapy
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments for one resident receiving respiratory services. Specifically, the Minimum Data Set (MDS) quarterly assessment documented that the resident did not use oxygen therapy, despite multiple records showing the resident was receiving oxygen via nasal cannula on several occasions. Nurses' notes and vital sign records consistently indicated oxygen use, and a physician's order was in place for oxygen administration as needed for shortness of breath. During an interview, an LPN acknowledged that the MDS section regarding oxygen use needed updating and that nursing staff were not documenting oxygen therapy on the treatment record, instead recording it in nurses' notes and vital sign records. The facility's policy requires comprehensive and accurate assessments using the RAI process, which was not followed in this instance.
Failure to Accurately Complete PASRR for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) process was accurately completed for two residents. For one resident with a history of residual schizophrenia, unspecified mood disorder, adjustment disorder, major depressive disorder, generalized anxiety disorder, and paranoid schizophrenia, the PASRR did not reflect persistent mood disorder or suspected mental illness in the relevant section. This omission was identified despite the resident's psychiatric notes and Minimum Data Set (MDS) assessment indicating active diagnoses of mood and mental health disorders. The Director of Nursing (DON) acknowledged that the PASRR needed updating and was unaware that additional diagnoses could be added in the specified section. Similarly, another resident with diagnoses including brief psychotic disorder, major depressive disorder, other specified persistent mood disorders, and generalized anxiety disorder had a PASRR that did not list these mental health conditions under the mental illness or suspected mental illness section. The resident's psychiatric notes and MDS assessment documented these active diagnoses, but they were not reflected in the PASRR. The DON confirmed that the PASRR for this resident also required updating to include the missing diagnoses.
Failure to Administer Medications as Ordered by Physician
Penalty
Summary
The facility failed to ensure that medications were administered as ordered by physicians for two residents. For one resident, Metoprolol Tartrate was held multiple times by nursing staff due to perceived low blood pressure and pulse, despite the physician's order not including parameters for withholding the medication. The nurses did not notify the provider about their concerns or seek clarification before withholding the medication. Interviews with the DON and the physician confirmed that the medication should not have been held without a specific order or parameters, and that the provider was not informed of the nurses' actions. For another resident, insulin glargine (Lantus) was administered on several occasions even when the resident's blood sugar was below the ordered threshold for holding the medication. The physician's order specified to hold Lantus if blood sugar was less than 150, but the medication was still given at lower blood sugar readings. Nursing staff interviews revealed a lack of awareness or attention to the specific parameters in the order, with some staff admitting to not reading the full order or making errors in administration. The facility's policy required medications to be administered as ordered by the physician, but this was not followed in these cases.
Failure to Post Accurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that accurate nurse staffing information was posted daily as required. On observation, the staffing information displayed was for the previous day rather than the current day. Interviews revealed that the scheduler, who is responsible for updating the posting, typically arrives around 8 to 8:30 AM and sometimes delays updating the information while waiting for the current census from payroll or the Business Office Manager. The scheduler stated that on the day in question, the updated posting was prepared but not displayed because she was still finalizing the numbers. The Business Office Manager reported no delays in providing the census, and the Administrator confirmed there was no formal policy for posting the staffing information, but expected it to be posted by 9:00 AM.
Failure to Provide Timely, Quality Laboratory Services
Penalty
Summary
The facility failed to provide timely, quality laboratory services and tests to meet the needs of residents. This deficiency was identified during the survey process, indicating that the laboratory services did not meet the required standards for promptness or quality as needed for resident care. No additional details about specific residents, their medical history, or the exact nature of the laboratory service failures are provided in the report.
Failure to Properly Label and Date Food Items in Nourishment Room
Penalty
Summary
During an observation of the nourishment room on C Hall, surveyors found two unlabeled and undated plastic bags containing unknown food items in the freezer, as well as an unlabeled and undated cloth lunch box with an unknown food item in the refrigerator drawer. The Dietary Manager confirmed during an interview that these food items should have been labeled and dated. Review of the facility's policy indicated that all prepared food brought in by family or visitors must be labeled with content and date to ensure resident safety. The failure to label and date these food items was not in accordance with the facility's policy and professional standards for food storage.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for residents, as evidenced by multiple deficiencies observed in the laundry room and various hallways. During an inspection, one of the two washing machines was found to be non-functional, and there was a significant buildup of garbage, debris, and lint behind the machines. Additionally, a window screen was improperly placed on the floor, surrounded by garbage and debris. The air conditioning unit, dryer lint areas, and the drum of Dryer #2 were all found to be dirty, with Dryer #2's door not latching properly. The clean linen cart also contained garbage and debris, and the carts holding clean linens were uncovered. Interviews with the Director of Housekeeping and Laundry, the Maintenance Director, and a Laundry Assistant confirmed these issues, with the Director of Housekeeping and Laundry noting that the broken washing machine had been affecting their ability to keep up with laundry needs for a couple of weeks. The Maintenance Director admitted that the facility never cleaned and scraped the dryer drums, and the Laundry Assistant confirmed the broken latch on Dryer #2's door. Further observations revealed additional deficiencies in the C-Hallway and B-Hallway. In the shower room on the C-Hallway, a disinfectant cleaner with bleach spray was found lying near a stack of towels, a drink, a package of cookies, and a cell phone on the sink counter. The specimen refrigerator in the dirty utility room of the C-Hallway had a buildup of ice in the freezer section, and three ceiling vents on the C-Hallway had a buildup of dust, lint, and a black substance. In the Medication Room on the C-Hallway, supply boxes were stacked on top of the upper cabinets, reaching the ceiling. Additionally, the wash sink in the soiled room on the B-Hallway was broken. The Maintenance Director confirmed these findings and was unable to specify how long the wash sink had been broken.
Failure to Provide Timely Nutritional Interventions
Penalty
Summary
The facility failed to ensure timely nutritional interventions for a resident who experienced significant weight loss. The resident, who had diagnoses including diabetes, gastroesophageal reflux disease, and pressure injuries, reported that the food was often cold and over-seasoned, leading her to frequently request a substitute meal, usually a sandwich. Despite consuming 50-100% of her meals, the resident's weight dropped from 188 pounds to 150 pounds over a six-month period, indicating a 20.21% weight loss. The care plan noted the resident was at nutritional risk and experiencing weight loss, but the interventions, such as providing snacks, were not effective in preventing further weight loss. Additionally, the resident had a stage 4 pressure ulcer that showed signs of worsening over time, as documented by the Wound Nurse Practitioner. The Consultant Dietitian acknowledged being aware of the resident's significant weight loss but had not initiated any supplements. The dietitian only became aware of the most recent weight measurement the day before the interview. Despite the resident's consistent meal consumption and the documented weight loss, the facility did not implement timely and effective nutritional interventions to address the resident's needs, contributing to the deficiency in care.
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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 Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake City Healthcare And Rehabilitation Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Lake City | 0.6 mi | ★★★★★ | 0 | 0 |
| Baya Pointe Nursing And Rehabilitation Center | 0.8 mi | ★★★★★ | 9 | 0 |
| Live Oak Healthcare And Rehabilitation Center | 20.7 mi | ★★★★★ | 1 | 0 |
| Surrey Place Nursing Center | 21.2 mi | ★★★★★ | 6 | 0 |
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