Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
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 Port Square Health Center during CMS and state inspections, most recent first.
Inaccurate resident assessments were identified for multiple residents when MDS coding did not match the clinical record, observations, or staff statements. One resident was coded as having a restraint-related chair device despite no restraints being observed or ordered, another was coded as not receiving antibiotics despite MAR documentation of mupirocin use, and two other residents had missing or incorrect MDS entries for diagnoses, ROM status, and skin/wound conditions based on admission records, physician notes, wound care documentation, and staff interviews.
PASRR assessments were not updated for two residents after new mental health diagnoses were documented. One resident had records showing brief psychotic disorder, major depressive disorder, and later delusional disorder, with psychotropic orders for quetiapine and trazodone, while the PASRR did not reflect mental illness. Another resident had documented depression and anxiety, later behavioral health notes identifying major depressive disorder and decline-related concerns, and an escitalopram order for depression, but the PASRR also did not reflect mental illness.
An LPN administered only one tablet of methotrexate instead of the ordered six-tablet dose for a resident with RA. The facility also failed to maintain ordered midline IV care for another resident receiving IV abx, with observations showing a soiled dressing, site discoloration, and later no midline or IV pump present despite orders for ongoing site monitoring, dressing changes, and line removal after tx completion.
Failure to Provide Ordered Nutritional Supplement: A resident at risk for malnutrition did not receive a physician-ordered frozen nutritional treat with lunch and dinner. Observations showed the meal trays contained food and drinks but no supplement, and the resident stated she was not getting any frozen nutrition treat. Staff interviews revealed the order was not communicated to the kitchen program and was not appearing on the meal ticket; the kitchen manager said changes depended on nursing communication, and the DON said the CDM typically ensured items were on the tray.
Missing Oxygen Order and Improper Nebulizer Storage: A resident receiving oxygen for sleep apnea had no physician order specifying the oxygen delivery rate, even though staff were setting the rate. In a separate observation, a resident’s nebulizer mask was left unbagged on the nightstand while not in use. An LPN and the DON both stated respiratory equipment should be stored in a bag when not in use, and the facility policy required bagged storage between uses.
Unlabeled medication cups and supplies were left unattended at the bedside of two residents. A CNA stated cream was left in one resident’s room and later applied, while another resident had a clear cup with a spoon and cream on the nightstand. Staff confirmed neither resident had an order to self-administer medications, and an LPN and the DON stated the residents did not have self-administration orders. The facility policy required medications and biologicals to be stored in locked compartments.
Unsafe food storage was identified in the main kitchen and in 1 of 2 nourishment rooms. The walk-in freezer had no stand-alone thermometer, and the 300 Hall nourishment room freezer registered 30 degrees Fahrenheit with 7 thawed ice cream bars stored inside. The Kitchen Manager acknowledged the missing thermometer and confirmed the thawed items.
Improper Garbage and Refuse Disposal: Surveyors observed a large lidless dumpster containing exposed facility trash bags and a small dumpster with an open lid exposing its contents to pests and wildlife. The Kitchen Manager acknowledged the conditions, and the Interim Certified Dietary Manager stated the large dumpster was a construction dumpster and should not have contained facility trash.
A resident receiving PT had multiple scheduled therapy sessions with no documentation in the service log matrix. The resident said therapy had been inconsistent, and the DON of Therapy acknowledged missed sessions without recorded reasons, stating the therapist should have documented why the sessions were not completed. The resident later said he had missed therapy when he was not feeling well and that the therapist had been sick once.
A facility failed to ensure accurate MDS assessments for a resident with a feeding tube. An LPN administered medications via a gastric tube, but the resident's MDS inaccurately indicated no feeding tube. Physician orders confirmed the presence of a gastric tube and enteral feeding instructions. The MDS Coordinator admitted the error, acknowledging the resident did have a feeding tube.
A facility failed to develop comprehensive care plans for a resident with atrial fibrillation and two residents requiring respiratory services. The first resident, on anticoagulant medication, lacked a care plan for monitoring complications. The second resident, using CPAP for sleep apnea, and the third resident, receiving inhalation treatments and oxygen therapy, both lacked care plans for respiratory services. The DON confirmed these omissions, which should have been addressed shortly after admission.
A facility failed to provide appropriate CPAP therapy for a resident with sleep apnea. Observations showed the CPAP nose piece was not in use, and there was no physician's order for the CPAP documented. The resident had multiple diagnoses, including sleep apnea, requiring CPAP use, but the facility did not have the necessary order in place.
The facility failed to properly store medications, as observed with a resident's menthol gel and antifungal powder left unsecured on bedside tables. Another resident had Latanoprost eye drops left unattended. Staff confirmed that medications should be secured unless a physician orders self-administration, in which case they must be locked in the bedside table.
The facility failed to ensure proper food storage, labeling, and cleanliness in the kitchen. Observations revealed unlabeled open food condiments, debris on the freezer floor, and a dietary aide without hair covering. Breakfast items were placed on the tray line too early, and there was excessive buildup on kitchen equipment. The CDM and FSD confirmed these issues, which violated facility policies on equipment cleanliness, food storage, and personal cleanliness.
The facility failed to accurately document medication administration for three residents, leading to discrepancies in the Medication Administration Record (MAR). A resident's hypertension medications were held without proper documentation of vital signs or physician notification. Another resident's insulin was held without documenting communication with the provider. Additionally, a resident's refusal of insulin was incorrectly documented as held due to low blood sugar. Staff interviews revealed inconsistencies in following documentation policies, highlighting the need for accurate record-keeping and communication with physicians.
The facility failed to adhere to infection control protocols, with staff not donning required PPE during high-contact care and improper storage of respiratory equipment. A CNA entered a resident's room without a gown despite contact precautions, and an LPN forgot to wear a gown while administering medication via a gastric tube. Additionally, respiratory equipment was not stored in bags as per policy, and a CNA assisted a resident on contact isolation without PPE. These lapses indicate non-compliance with infection control standards.
The facility failed to change central venous catheter dressings according to professional standards for two residents. One resident had an outdated dressing with gauze underneath, and the other had a dressing with gauze that should have been changed earlier. Staff did not notice or address these issues during their assessments and medication administrations.
Inaccurate Resident Assessments
Penalty
Summary
Resident assessments were not completed accurately to reflect resident status for 4 of 9 residents reviewed. For one resident, the quarterly MDS dated 5/8/2026 indicated under Section P that a chair prevented rising and was used less than daily, yet observations on 6/8/2026 and 6/9/2026 showed the resident sitting in a wheelchair with no restraints observed, and the resident stated she did not use any restraints. The physician orders also did not document any restraint use, and staff, including the LPN, MDS Coordinator, and DON, stated that no restraints were used in the facility. For another resident, the quarterly MDS dated 5/23/2026 marked Section N Medications as no antibiotics, but the physician order and MAR showed Mupirocin External Ointment 2% was administered from 5/16/2026 through 5/22/2026 for a fungal rash on the left pointer and middle fingers. The MDS Coordinator stated that the assessment should have reflected antibiotic use and said it would be corrected. The DON stated the facility follows the RAI. For a third resident, the admission record listed a left humerus fracture, ventral hernia, and schizophrenia, but the MDS dated [DATE] coded Section GG as no impairment of upper or lower extremity, omitted schizophrenia from Section I, and marked Section M skin conditions as none. Observation showed the resident wearing a black sling on the left arm, and the resident stated she had a hernia surgery in 2010 and had been dealing with the surgical site since then. The wound care nurse described a large weeping abdominal hernia being treated with dressings, and the MDS Coordinator acknowledged the coding was incorrect. For a fourth resident, the admission record and physician documentation showed a history of TIA and cerebral infarction without residual, but the MDS Section I did not include those diagnoses. The MDS Coordinator stated the resident had a TIA and stroke history and that it needed to be added to Section I.
PASRR Assessments Not Updated After New Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure PASRR assessments were updated after new mental health diagnoses were documented for two residents. For one resident, the admission record showed diagnoses including brief psychotic disorder and major depressive disorder, while the Florida AHCA PASRR dated 11/11/2025 did not document mental illness. Subsequent records included physician orders for quetiapine for brief psychosis and trazodone for insomnia related to depression, along with psychology notes listing adjustment disorder, major depressive disorder, and delusional disorders. The DON stated in interview that the resident was being monitored in March because he was having a hard time after learning his cancer had returned. For the second resident, the admission record showed diagnoses including major depressive disorder and anxiety disorder, but the Florida AHCA PASRR dated 10/24/2025 did not document any mental illness. Later behavioral health documentation identified a past psychiatric history of depression and assessed major depressive disorder, recurrent, unspecified, and a subsequent progress note documented treatment concerns related to condition decline and limiting behaviors. A later physician order for escitalopram was written for depression with monitoring for isolation and sadness. The Social Services Assistant stated both PASRRs needed to be updated, and the DON stated psychology provides Social Services a list of residents seen and attends meetings where resident changes are discussed.
Medication Dose Error and Midline IV Care Failure
Penalty
Summary
The facility failed to administer the correct dosage of Methotrexate Sodium for a resident with rheumatoid arthritis. During medication administration, an LPN poured only one 2.5 mg tablet into the medication cup and then administered the medications, even though the physician order required six tablets by mouth every Wednesday for a total dose of 15 mg. The LPN later stated that she should have given six tablets and not one, and the DON stated that the nurse reported the error to her and was instructed to call the provider and notify the resident. The facility policy stated that medications are to be administered in accordance with prescriber orders. The facility also failed to provide IV device care as ordered for a resident receiving midline therapy and IV antibiotics. Observation showed the resident’s midline dressing dated 5/30/2026 with visible purple discoloration at the insertion site and dry blood under the clear dressing, while an empty antibiotic bag remained in the room. On a later observation, the midline and dressing were no longer present, and the IV pump was also absent. The resident’s orders included weekly dressing changes, every-shift site monitoring, and removal of the midline after treatment was complete. The Medical Director stated that the line is to be removed immediately after the last antibiotic dose, and the DON stated that after a verbal order is obtained it is to be entered into PCC by the end of the shift.
Failure to Provide Ordered Nutritional Supplement
Penalty
Summary
The facility failed to provide a physician-ordered frozen nutritional treat with lunch and dinner for one resident who was identified as at risk for malnutrition. During observations on 6/8/2026 and 6/9/2026, the resident was eating lunch in her room and the meal trays contained food and beverages, but no frozen nutritional treat was present. The resident stated she did not get any additional nutrition treat and nothing that was frozen. The resident’s physician order dated 11/26/2025 directed a frozen nutritional treat with lunch and dinner two times a day for risk for malnutrition. The medical record showed weights of 187.4 lbs on 5/23/2026, 194.6 lbs on 4/13/2026, 189.8 lbs on 2/22/2026, and 196.1 lbs on 11/30/2026, and the dietary/nutrition evaluation dated 6/4/2026 documented weight as stable and listed current nutritional supplements as magic cup BID. Staff interviews indicated the treat was normally sent from the kitchen, but the order had not been communicated to the kitchen program and was not appearing on the meal ticket. The kitchen manager stated the change would be made only if nursing sent the communication form, and the DON stated the CDM typically pulled the order and ensured everything was on the tray.
Missing Oxygen Order and Improper Nebulizer Storage
Penalty
Summary
The facility failed to ensure that Resident #11’s oxygen delivery rate was specified in the clinical record. Resident #11 was observed semi reclined in bed receiving oxygen from a concentrator via nasal cannula at 2 liters per minute. The resident’s care plan, initiated 1/2/2026, identified risk for complications related to sleep apnea and included oxygen as needed to promote lung expansion and improve air exchange, with positioning at 45 degrees if tolerated. The physician orders included oxygen-related maintenance and respiratory orders for oxygen at night for sleep apnea, but the clinical record did not contain a physician’s order establishing the ordered oxygen delivery rate. An LPN confirmed the record did not show an ordered delivery rate, and the DON agreed the oxygen delivery rate should be included as a physician’s order. The facility also failed to ensure nebulizer equipment was properly stored for Resident #85. During observations, a nebulizer mask was seen lying on top of the nightstand and was not bagged while the resident was sitting in a wheelchair and later while lying in bed with eyes closed. Resident #85 had physician orders for levalbuterol nebulization every 8 hours and ipratropium-albuterol inhalation solution every 6 hours as needed for shortness of breath. An LPN stated the nebulizer mask and oxygen tubing should be stored in a bag when not in use, and the DON stated the nebulizer mask and tubing should be stored in a dated bag when not in use. The facility policy stated oxygen cannula and tubing used PRN should be kept in a plastic bag when not in use, and nebulizer circuits should be stored in a plastic bag marked with the date and resident’s name between uses.
Unlabeled Medications Left at Bedside
Penalty
Summary
The facility failed to follow standards for medication storage for 2 of 6 halls reviewed for unattended medication. During observation, a clear medication cup containing cream was found at the bedside of Resident #86, and the cup was not labeled. Two normal saline flush syringes were also observed on top of the resident’s nightstand. In interviews, the resident’s representative stated staff came in and applied the cream when they changed the resident, and a CNA stated the wound care nurse gave her the cream that morning, she left it in the resident’s room, and later applied it. An LPN stated she was not aware of any cream or normal saline flushes and had not done any of it. A similar observation was made at the bedside of Resident #38, where a clear medication cup with a spoon and cream was left on the nightstand. The resident stated staff apply the cream when they change him. A CNA confirmed the cup with the spoon was at the bedside and said it was cream to apply when the resident was changed, but it should not have been left there. An LPN stated the resident did not have an order to self-administer medication, and the DON later stated that Residents #86 and #38 did not have orders to self-administer medications. The facility policy titled Medication Labeling and Storage stated that medications and biologicals are stored in locked compartments under proper controls and only authorized personnel have access to keys.
Unsafe Food Storage in Kitchen and Nourishment Room Freezer
Penalty
Summary
Food was not stored in a safe manner in the main kitchen and in 1 of 2 nourishment rooms. During the initial tour of the main facility kitchen, there was no thermometer in the walk-in freezer, and the Kitchen Manager acknowledged that a stand-alone thermometer was not present. In the 300 Hall nourishment room freezer, the thermometer registered 30 degrees Fahrenheit, and there were 7 thawed ice cream bars stored inside. The Kitchen Manager confirmed the freezer temperature and agreed the ice cream bars were thawed. The facility policy titled Food & Beverage Standards of Excellence stated that food will be purchased, stored, prepared, and served in a sanitary manner and that proper food temperature is required.
Improper Garbage and Refuse Disposal
Penalty
Summary
The facility failed to ensure garbage and refuse were disposed of properly. On 6/8/2026 at 9:51 AM, surveyors observed a large dumpster with no lid containing exposed filled household-style plastic garbage bags, and the bags were not secured from pests or wildlife. In the same area, a small dumpster had its left side top lid open, exposing the contents of the dumpster to pests and wildlife. During interviews, the Kitchen Manager acknowledged that the large dumpster with no lid should not contain garbage and confirmed the small dumpster lid was open. On 6/9/2026 at 9:09 AM, the Interim Certified Dietary Manager stated the large dumpster was a construction dumpster and should not contain facility trash. The facility policy titled Sanitization, last reviewed 1/22/2026, stated that kitchens, kitchen areas, and dining areas are to be kept clean, free from garbage and debris, and protected from rodents and insects, and that garbage and refuse containers are to be in good condition with waste properly contained in dumpsters/compactors with lids or otherwise covered.
Missing Documentation for Scheduled Therapy Sessions
Penalty
Summary
The facility failed to document therapy sessions for one resident receiving rehabilitation services. The resident stated during interview that he wanted to know whether he would have therapy that day and reported that the physical therapist had been on vacation and that he had not received therapy in weeks. Review of the physician order showed a PT recertification order for treatment every day, one time per week for 60 days, including therapeutic exercise, therapeutic activity, gait training, and caregiver education for diagnosis R53. The resident’s service log matrix showed no documentation for therapy visits on 4/14/2026, 4/28/2026, and 5/19/2026. During interviews, the Director of Therapy acknowledged that the resident missed the listed dates and stated there was no documentation explaining why the sessions were not completed. The Director of Therapy said the resident was on the assignment board for functional maintenance and that, for whatever reason, if the resident refused or was not feeling well, it was not documented. The Director also stated the therapist was in Thailand and could not communicate about what happened, and that the therapist should have documented the reasons the therapy sessions were not completed. The resident later stated he had missed therapy once or twice because he was not feeling well and that his therapist had been sick once, with someone else sent in that time. The facility policy required resident care documentation to be maintained in a complete, timely, and orderly fashion.
Inaccurate MDS Assessment for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident reviewed for nutrition. During an observation, a Licensed Practical Nurse (LPN) administered medications to a resident via a gastric tube. However, the resident's quarterly MDS inaccurately indicated that the resident did not have a feeding tube under Section K - Swallowing/Nutritional Status. A review of the resident's physician orders dated December 6, 2024, confirmed the presence of a gastric tube and specified enteral feeding instructions. During an interview, the MDS Coordinator acknowledged that the section was coded in error, confirming the resident did have a feeding tube. The facility's policy on resident assessments assigns responsibility to the resident assessment coordinator to ensure timely and appropriate assessments by the interdisciplinary team.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #26, who was admitted with diagnoses including atherosclerotic heart disease, cardiac pacemaker, prosthetic heart valve, and atrial fibrillation. Despite having a physician's order for Eliquis, an anticoagulant medication, there was no focus area or interventions for anticoagulant medication or atrial fibrillation in the resident's care plan. The Director of Nursing and the MDS Coordinator both acknowledged the absence of a care plan for monitoring anticoagulant complications, which should have been initiated upon admission. Resident #265, who was admitted with multiple diagnoses including sleep apnea, did not have a care plan for respiratory services. During an observation, the resident was seen with a CPAP nose piece on the bedside table, indicating the use of CPAP for breathing at night. The Director of Nursing confirmed the lack of a care plan for respiratory services, which should have been developed within 72 hours of admission. Similarly, Resident #266, admitted with conditions such as sepsis, pneumonitis, acute respiratory failure, and obstructive sleep apnea, did not have a care plan for respiratory services. The resident was observed with an inhalation mask and had physician orders for inhalation treatments and oxygen therapy. The Director of Nursing acknowledged the absence of a care plan for respiratory services, which was required to be developed promptly after admission.
Failure to Provide Appropriate CPAP Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #265, who required the use of a CPAP machine for sleep apnea. Observations on multiple occasions revealed that the CPAP nose piece was consistently left on the bedside table, indicating it was not in use. Despite the resident's acknowledgment of using the CPAP to breathe better at night, there was no physician's order for the CPAP documented in the resident's records. The resident was admitted with several diagnoses, including sleep apnea, which necessitates the use of a CPAP machine. The Director of Nursing confirmed that there should have been an order in place for the resident to receive CPAP therapy at the facility. The facility's policy on CPAP/BiPAP support requires a physician's order to determine the necessary settings for the machine, which was not adhered to in this case.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly stored, as evidenced by several observations. In one instance, a tube of menthol pain-relieving gel was found on the bedside table of a resident's room on two separate occasions. The resident confirmed using the gel for shoulder pain a couple of times a week. In another case, a bottle of antifungal powder was observed on the bedside table of a different resident, who stated they used it under their breast. Interviews with staff, including an LPN and the Director of Nursing, confirmed that medications should not be left unsecured at the bedside unless there is a physician's order for self-administration, in which case the medication must be locked in the bedside table. Additionally, a bottle of Latanoprost eye drops was found on the bedside table of another resident who was not able to self-administer medications. The resident mentioned that the eye drops were left behind by someone and needed to be discarded. The Director of Nursing confirmed that medications should not be left unattended in residents' rooms. The facility's policy on medication labeling and storage requires that all medications and biologicals be stored in locked compartments and that only authorized personnel have access to the keys. The policy also states that compartments containing medications should be locked when not in use, and transport trays or carts should not be left unattended if open.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper food storage, labeling, and cleanliness in the kitchen, leading to several deficiencies. During a walk-through tour, it was observed that several containers of open food condiments in the reach-in cooler were not labeled with an open date. Additionally, the freezer floor was littered with trash and debris, and open box flaps were exposing food items. A dietary aide was observed working without a hair covering or beard guard, which was confirmed during an interview. The Certified Dietary Manager (CDM) acknowledged the issues, stating that he was unaware of the need for open dates on condiment containers and agreed that the freezer floor should be cleaned and lids should be closed. The CDM also confirmed that all staff should use hair restraints in the kitchen. Further observations revealed that breakfast food items were placed on the tray line earlier than the facility policy allowed. There was a large buildup of food bits and dried debris on the floor mixer, and the convection ovens had excessive dirt and debris buildup. The food/grease trap drawer on the regular stove was also found to have excessive food particles and burnt debris. The Food Service Director (FSD) confirmed these observations, noting that the cook had placed food on the tray line too early and that the covered mixer was not cleaned as required. The facility's policies and procedures, which were reviewed, outlined the expectations for equipment cleanliness, food storage, and personal cleanliness, all of which were not adhered to, leading to these deficiencies.
Documentation Errors in Medication Administration
Penalty
Summary
The facility failed to accurately document notifications of medication parameters for three residents reviewed for medication administration. For Resident #27, there were discrepancies in the documentation of blood pressure and pulse readings in the Medication Administration Record (MAR) for medications prescribed for hypertension. The MAR indicated that medications were held due to vital signs being outside of parameters, but there was no documentation of blood pressure or pulse readings on specific dates. Interviews with staff revealed that while they used their nursing judgment to hold medications when blood pressure was low, they did not consistently document communication with the physician in the resident's medical record. For Resident #163, the MAR showed that insulin was held due to vital signs being outside of parameters, but there was no documentation of physician notification. Staff interviews indicated that the nurse did not document the communication with the provider when insulin was held, citing a busy admission process as the reason for the oversight. The facility's policy requires that all services provided to the resident, including changes in medical condition, be documented in the medical record to facilitate communication among the interdisciplinary team. Resident #26's case involved a documentation error where insulin was coded as held due to low blood sugar, but the resident had actually refused the medication. The nurse did not notify the physician of the refusal, and the documentation did not accurately reflect the resident's refusal. The facility's policy on medication administration requires that reasons for withholding, not administering, or refusing medication be documented accurately. The Director of Nursing acknowledged the documentation errors and emphasized the importance of proper documentation and physician notification.
Infection Control Deficiencies in PPE Usage and Equipment Storage
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple instances of non-compliance with infection control standards. During a medication administration observation, a CNA entered a resident's room without donning the required personal protective equipment (PPE) such as a gown, despite the resident being on contact precautions due to an ESBL infection. The CNA mistakenly believed that a gown was only necessary if the resident had a contagious illness. The Director of Nursing (DON) later clarified that staff should wear gloves and a gown when providing high-contact care for residents on enhanced barrier precautions. In another instance, an LPN failed to wear a gown while administering medication via a gastric tube to a resident on enhanced barrier precautions. The LPN acknowledged forgetting to don the gown, which was required by the facility's policy for high-contact resident care activities. Additionally, the facility's policy on storing respiratory care equipment was not followed, as observed with two residents. One resident's CPAP nose piece was repeatedly left unbagged on the bedside table, and another resident's inhalation mask was not stored in a bag after use, contrary to the facility's infection prevention policy. Furthermore, a CNA assisted a resident on contact isolation for C. diff without wearing a gown or gloves, despite clear signage indicating the need for such precautions. The CNA admitted to not paying attention to the signage and failing to don the appropriate PPE. The DON confirmed that staff are expected to wear a gown and gloves before entering rooms with contact precautions. These observations highlight lapses in adherence to infection control protocols, potentially compromising resident safety.
Failure to Change Central Venous Catheter Dressings as Per Standards
Penalty
Summary
The facility failed to ensure central venous catheter dressings were changed in accordance with professional standards of practice for two residents. Resident #3 had a PICC line with a transparent dressing dated 4/1/2024, which was observed curling at the edges and had gauze underneath. The resident's physician order required weekly dressing changes, but the dressing had not been changed for 10 days. Staff A, an RN, and Staff B, an LPN, both failed to notice and address the outdated dressing and the presence of gauze during their assessments and medication administrations. Resident #4 had a PICC line with a transparent dressing dated 4/6/2024, which also had gauze underneath. The resident's physician order required dressing changes every seven days and PRN, but the gauze should have prompted a change after two days. Staff A and Staff B admitted to not realizing the presence of gauze and the need for a dressing change. The Director of Nursing confirmed that the facility's policy required dressings with gauze to be changed every two days, which was not followed in these cases.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 136 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Leesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Campus Care Center And Rehab | 0.4 mi | ★★★★★ | 11 | 0 |
| North Campus Rehabilitation And Nursing Center | 1.2 mi | ★★★★★ | 12 | 0 |
| Avante At Leesburg, Inc | 2.1 mi | ★★★★★ | 0 | 0 |
| Chatham Glen Healthcare And Rehabilitation Center | 8.5 mi | ★★★★★ | 5 | 0 |
| Villages Healthcare And Rehabilitation Center, The | 8.6 mi | ★★★★★ | 10 | 0 |
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