Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Wales Health And Rehabilitation Center during CMS and state inspections, most recent first.
A deficiency occurred when a resident's room remained excessively hot, with temperatures near 90°F, due to an unrepaired rooftop A/C unit. The resident, who was nonverbal and medically complex, experienced physical discomfort for about a month while staff and maintenance were aware of the issue but did not routinely monitor or document room temperatures. Leadership lacked a formal process for temperature checks or maintenance reporting, and no policies were provided to ensure compliance.
A resident with severe disabilities was exposed to excessively high room temperatures due to a malfunctioning A/C unit, with temperatures reaching nearly 90°F. Multiple staff, including LPNs and CNAs, were aware of the issue for weeks, but no maintenance requests were documented and routine temperature monitoring was not performed. Facility leadership and maintenance staff were unaware of the ongoing problem, and the resident, who was unable to communicate discomfort, remained in the overheated room until the issue was discovered during a survey.
The facility failed to prevent neglect and medication errors, including not providing physician-ordered tube feeding and mobility assistance for a resident, leading to functional decline, and failing to administer medications as ordered for two residents. One resident missed multiple doses of IV antibiotics due to pharmacy and documentation issues, and another received the wrong IV medication due to staff error and lack of proper certification. Required assessments and investigations were not completed according to policy.
The facility did not keep nurse staffing postings current, as the displayed information was outdated for an extended period. The Staffing Coordinator, responsible for updating the postings, did not ensure they were updated, and the Nursing Home Administrator did not verify the postings as usual. There was no policy in place for posting nurse staffing data.
A resident with multiple complex medical conditions was given the wrong IV medication due to a medication error. Although the error was identified and reported, the facility did not conduct a thorough investigation or provide timely education to the involved LPNs on medication administration rights. The facility's documentation and staff interviews confirmed that required follow-up actions and staff training were not completed as per policy.
A resident with COPD and a physician's order for continuous oxygen was observed multiple times with an empty portable oxygen tank, resulting in a lack of oxygen delivery despite the nasal cannula being in place. Staff interviews revealed confusion over responsibilities for changing and initiating oxygen tanks, and the facility's policy limited initiation of oxygen therapy to licensed personnel. Full oxygen tanks were available in storage, but the resident did not receive the ordered therapy for an extended period.
Nurses and nurse aides failed to demonstrate appropriate competencies in medication administration, resulting in three residents not receiving medications as ordered. Errors included administering the wrong IV medication, missing multiple doses of an IV antibiotic due to supply and communication issues, and improper administration of eye drops and probiotics. Staff interviews revealed gaps in training, lack of policy adherence, and incomplete documentation.
Two residents did not receive their routine, physician-ordered medications upon admission due to the facility's failure to acquire and administer the medications in a timely manner. Despite the availability of some medications in the emergency drug kit, staff did not document attempts to access or administer them, and there was no clear communication with physicians regarding alternatives. Leadership confirmed the absence of policies guiding medication acquisition and use of the EDK, resulting in missed doses for newly admitted residents.
A medication pass observation revealed a 25% error rate when an LPN administered the wrong probiotic, failed to wait the recommended interval between two different eye drops, and gave both drops consecutively to a resident with diabetes and recent eye surgery. The MAR indicated the ordered probiotic was not given, and there was no facility policy for eye drop administration.
The facility's kitchen cooler was found in unsanitary condition, with peeling racks exposing rust and brownish-yellow stains. Various food items were stored improperly. The Dietary Director was aware of the issue but had not submitted a work order, and the Maintenance Director confirmed no work orders were received.
The facility did not have a qualified Infection Control Preventionist (ICP) with specialized training. The DON and an LPN were in training to become ICPs, but neither had completed the required training. Their training was assisted by a Regional Nurse Consultant who visits monthly. The previous ICP left in May, and the facility's policy mandates specialized training for the ICP role, which was not fulfilled.
The facility failed to maintain essential kitchen equipment safely, with a leaking reach-in cooler and steam table observed during a survey. Staff confirmed the issues and mentioned maintenance requests, but the Maintenance Director had not received any work orders. A review of work orders for May and June 2024 showed no records for the equipment, indicating a communication breakdown.
The facility failed to maintain accurate PASRR documentation for several residents, as their forms did not reflect current mental health diagnoses. This was confirmed through interviews and record reviews, revealing discrepancies between the PASRR forms and the residents' medical records and MDS assessments. The DON and SSD acknowledged their responsibility to ensure PASRR accuracy, but the process was not consistently followed.
The facility failed to complete MDS assessments on time for four residents, with delays attributed to other departments not completing their sections promptly. Two residents had their admission MDS assessments completed late, while two others had their Medicare 5-day MDS assessments delayed beyond the required timeframe.
A resident with unspecified hearing loss was inaccurately assessed in their MDS as having adequate hearing, despite requiring a dry erase board for communication. Facility staff, including the MDS Coordinator and DON, confirmed the error, acknowledging the resident's care plan for hearing difficulties. The facility's policy requires accurate assessments to meet residents' needs, which was not followed in this instance.
A resident's baseline care plan was not completed within the required timeframe after admission. Interviews with an LPN and the DON revealed confusion about the timeline for completing these plans, and the facility lacked a formal policy for baseline care plans.
The facility failed to update care plans for four residents, leading to deficiencies in care. One resident's care plan was not revised after transmission-based precautions were lifted. Another resident's laughing outbursts were not addressed in the care plan, despite a diagnosis of pseudobulbar affect. A third resident's care plan lacked interventions for skin-picking and wound care. Additionally, a resident receiving oxygen therapy had a care plan that did not include their oxygen, diabetes, or dysphagia needs.
The facility failed to provide proper oxygen therapy for four residents, with issues including lack of physician orders, improper documentation, and absence of signage indicating oxygen use. Residents were observed using oxygen at incorrect levels, and staff interviews revealed inconsistencies in monitoring and adjusting oxygen therapy according to physician orders.
A facility failed to limit PRN psychotropic medications to 14 days for a resident with mood disorder and dementia, and did not complete behavior and side effect monitoring for four residents as per physician orders. The MAR showed check marks instead of required documentation, indicating a lack of proper monitoring and documentation.
Failure to Maintain Safe Room Temperatures Due to Unrepaired A/C Unit
Penalty
Summary
A deficiency was identified when the facility failed to maintain safe and comfortable temperatures in a resident's bedroom due to an unrepaired rooftop air-conditioning (A/C) unit. Observations revealed that the resident's room had temperatures between 89.8 and 90.0 degrees Fahrenheit, with noticeable humidity and lack of cool airflow. The resident, who was nonverbal and dependent on staff for care, was found in a visibly uncomfortable state, with staff noting the room had been warm for about a month. Multiple staff members, including CNAs and LPNs, confirmed awareness of the persistent high temperatures in the room, and it was noted that the issue had not been formally reported or addressed in the facility's electronic communication log. The resident involved had significant medical conditions, including severe intellectual disabilities, acute and chronic respiratory failure, contractures, cognitive communication deficits, and generalized muscle weakness, necessitating assistance with personal care. The resident was unable to communicate preferences or discomfort regarding room temperature. Despite the resident's vulnerability, the maintenance staff had not routinely checked or documented room temperatures, and the Maintenance Director only measured the temperature after being prompted during the survey. The Maintenance Assistant and Director both expressed expectations for room temperatures to be significantly lower than what was observed, and acknowledged that the conditions were unsuitable for a resident. Interviews with facility leadership, including the DON and NHA, revealed a lack of awareness and formal process for monitoring and documenting room temperatures. The NHA stated that temperature checks were only performed in response to A/C outages and that staff were expected to report issues through an electronic system, though no such reports were found. The facility did not provide policies or procedures for temperature monitoring or staff communication regarding maintenance concerns. The deficiency was cited due to the failure to ensure the physical environment was maintained in a manner that assured resident safety and well-being, as required by regulation.
Plan Of Correction
Resident #5 was immediately moved to another room on 06/23/2025 with no adverse effects noted. Room #202 was closed on 06/23/2025. On 06/23/2025, a portable air conditioner was placed in room 202. An outside HVAC contractor detected a refrigerant leak on 06/26/2025; a recommendation for roof top unit (RTU) #3 replacement was received. A replacement unit was ordered on 06/26/2025. On 08/30/2025, an outside HVAC contractor added refrigerant to RTU #3. The new unit was installed on 07/11/2025 by an outside HVAC contractor. On 06/25/2025, the Maintenance Director tested room and hallway temperatures with no concerns identified. On 06/26/2025, an outside HVAC contractor completed a system check for the remaining RTUs to determine functionality. The recommendation was for the replacement of RTU #5, which was received. The replacement unit was ordered on 06/26/2025. No other recommendations were received for the remaining units. The NHA re-educated the Maintenance Director on 06/25/2025 on comfortable and safe temperature levels. Facility staff were re-educated on comfortable and safe temperature levels and submitting electronic work orders by 07/14/2025. Any staff not receiving education by 07/14/2025 will receive education prior to their next scheduled shift. The Maintenance Director/designee will complete random audits of temperatures in hallways and resident rooms 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month. Any concerns will be addressed at the time of audit. Audit results, along with any concerns related to compliance, will be presented to the QA Committee (Administrator, Director of Nursing, Medical Director, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Supervisor, Dietary Director) monthly at the Quality Assurance Performance Improvement meeting for review and any needed recommendations for 3 months. If non-compliance is identified, audits will start back at the beginning of the cycle occurring 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month.
Failure to Maintain Safe and Comfortable Room Temperatures
Penalty
Summary
A deficiency occurred when the facility failed to maintain safe and comfortable temperatures in a resident's bedroom, as required by federal regulations. The air conditioning (A/C) system serving the resident's room was not functioning properly, resulting in room temperatures measured between 89.8 and 90.0 degrees Fahrenheit. Observations confirmed excessive warmth and palpable humidity in the room, with no noticeable cool air flow from the ceiling vent. The resident, who was nonverbal and dependent on staff for care, was found in a visibly uncomfortable state, with staff noting that the room had been warm for about a month. Multiple staff members, including LPNs, CNAs, and housekeeping, were aware of the elevated temperatures in the room and reported that the issue had persisted for several weeks. Despite this, there was no evidence that maintenance staff or facility leadership had taken timely action to monitor or address the temperature problem. The maintenance director and assistant were unaware of any recent complaints or issues with the A/C unit, and temperature checks in resident rooms were not routinely performed unless the A/C system was known to be out of order. Staff reported that maintenance requests were to be submitted electronically, but no such requests regarding the temperature issue were found in the facility's communication log. The resident affected by the deficiency had significant medical needs, including severe intellectual disabilities, respiratory failure, contractures, and muscle weakness, and was unable to communicate preferences or discomfort. The facility did not have a documented policy or procedure for routine temperature monitoring or for staff to communicate environmental concerns to maintenance. Facility leadership, including the DON and NHA, were not aware of the temperature issue in the resident's room and had not noticed elevated temperatures in the affected area. The lack of routine monitoring and communication resulted in the resident being exposed to unsafe and uncomfortable temperatures for an extended period.
Plan Of Correction
Resident #5 was immediately moved to another room on 06/23/2025 with no adverse effects noted. Room #202 was closed on 06/23/2025. On 06/23/2025, a portable air conditioner was placed in room 202. An outside HVAC contractor detected a refrigerant leak on 06/26/2025; a recommendation for roof top unit (RTU) #3 replacement was received. A replacement unit was ordered on 06/26/2025. On 06/30/2025, the outside HVAC contractor added refrigerant to RTU #3. The new unit was installed on 07/11/2025 by an outside HVAC contractor. On 06/25/2025, the Maintenance Director tested room and hallway temperatures with no concerns identified. On 06/26/2025, an outside HVAC contractor completed a system check for the remaining RTUs to determine functionality. The recommendation was for the replacement of RTU #5, which was received. The replacement unit was ordered on 06/26/2025. No other recommendations were received for the remaining units. The NHA re-educated the Maintenance Director on 06/25/2025 on comfortable and safe temperature levels. Facility staff were re-educated on comfortable and safe temperature levels and submitting electronic work orders by 07/14/2025. Any staff not receiving education by 07/14/2025 will receive education prior to their next scheduled shift. The Maintenance Director/designee will complete random audits of temperatures in hallways and resident rooms 5 times a week for 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month. Any concerns will be addressed at the time of audit. Audit results along with any concerns related to compliance will be presented to the QA Committee (Administrator, Director of Nursing, Medical Director, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Supervisor, Dietary Director) monthly at the Quality Assurance Performance Improvement meeting for review and any needed recommendations for 3 months. If non-compliance is identified, audits will start back at the beginning of the cycle occurring 4 weeks, 3 times a week for 4 weeks, and 1 time a week for one month.
Failure to Prevent Neglect and Medication Errors
Penalty
Summary
The facility failed to protect residents from neglect by not providing physician-ordered tube feeding and failing to assist a resident in getting out of bed for 13 days, resulting in a decline in the resident's functionality. The resident, who was admitted with multiple serious diagnoses including sepsis, acute respiratory failure, and protein-calorie malnutrition, was supposed to receive enteral nutrition via a tube feed and assistance with mobility. Observations and interviews revealed that the tube feeding was inconsistently administered due to issues with the pump and lack of staff knowledge, and the resident was not assisted out of bed because staff were waiting on therapy and a wheelchair was missing. Documentation showed missed and undocumented feedings, and the resident experienced weight loss and a decline in physical function during this period. Additionally, the facility failed to administer medications in accordance with physician orders for two residents. One resident did not receive all prescribed doses of an IV antibiotic due to pharmacy supply issues and lack of proper tracking, resulting in missed doses and the premature removal of a PICC line before the antibiotic course was completed. Staff interviews confirmed confusion and lack of communication regarding the medication schedule, and documentation did not support that the full course was administered as ordered. Another resident received the wrong IV medication due to a medication administration error involving two LPNs, one of whom was not IV certified. The error was not fully investigated, and required neurological assessments were not completed as ordered. Facility policies on medication administration and abuse prevention were not followed, and staff involved did not receive appropriate education or oversight regarding medication rights and administration procedures.
Failure to Maintain Up-to-Date Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the posted nurse staffing data was up-to-date and current for the period from 4/18/25 to 4/30/25. Observations on 4/29/25 revealed that the Daily Nurse Staffing sheet displayed in the front lobby was dated 4/17/25 and had not been updated through at least 4/29/25. Interviews with the Staffing Coordinator confirmed she was responsible for posting the data but had not ensured it was done, citing changes in her work schedule and not realizing the postings were outdated. The Nursing Home Administrator also acknowledged that she typically checked the postings but had not done so during this period. It was further confirmed that the facility did not have a policy regarding the posting of Daily Nurse Staffing data. Photographic evidence was obtained to support these findings.
Failure to Investigate and Educate Staff After Medication Error
Penalty
Summary
The facility failed to thoroughly investigate and provide staff education following a medication error involving a resident who was admitted with multiple complex diagnoses, including intraspinal abscess, sepsis, and chronic myeloproliferative disease. The resident was inadvertently administered the wrong intravenous medication, Cefepime HCl, instead of the ordered Daptomycin. Documentation shows that the error was identified, the physician and family were notified, and neuro checks were initiated, but there was no evidence of adverse reactions at the time. However, the facility's progress notes lacked a follow-up entry for the day after the incident. Interviews revealed that the investigation into the medication error was incomplete. The DON, who was new to the position, provided only one investigation statement from the LPN involved and acknowledged that the form was not filled out correctly. The DON also stated that there was no proof that staff education on the seven rights of medication administration had been provided at the time of the incident. Other staff members confirmed that they had not received formal education related to medication rights or incident response until much later. The facility's policy requires immediate and thorough investigation of alleged neglect, including obtaining statements from all involved staff and providing education to prevent recurrence. In this case, the investigation did not include statements from all relevant staff, and there was no documentation of timely staff education. The lack of a comprehensive investigation and staff training following the medication error constituted a failure to respond appropriately to an alleged violation, as required by facility policy.
Failure to Provide Continuous Oxygen Therapy as Ordered
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and a physician's order for continuous oxygen at 2 liters via nasal cannula was observed multiple times throughout the day with an empty portable oxygen tank. The resident, who required oxygen due to asthma and reported episodes of wheezing, was seen in her wheelchair both in her room and on the patio with the nasal cannula in place but no oxygen being delivered, as the tank was empty. This was confirmed by several staff members, including CNAs and a registered nurse, who acknowledged that the oxygen tank had been empty since the morning and had not been replaced as required by the resident's care plan and physician's orders. Interviews with staff revealed confusion regarding responsibilities for changing and initiating portable oxygen tanks, with CNAs stating they typically changed the tanks and nurses indicating that only licensed staff should initiate oxygen therapy. The facility's policy specified that only physicians, RNs, LPNs, and respiratory therapists are authorized to initiate oxygen therapy. Despite the availability of full oxygen tanks in storage, the resident did not receive the ordered continuous oxygen therapy for an extended period, as evidenced by direct observation and staff interviews.
Medication Administration Competency Deficiencies
Penalty
Summary
The facility failed to ensure that nurses and nurse aides possessed the appropriate competencies and skills to administer medications as ordered for three residents. In one case, a resident with complex medical conditions, including sepsis and osteomyelitis, was given the wrong intravenous medication due to a lack of verification and proper handoff between two LPNs, one of whom was not IV certified. The medication error was not fully investigated, and required neurological assessments were not completed according to protocol, with documentation ceasing before the required monitoring period ended. Staff interviews revealed gaps in education regarding medication rights and incident response procedures. Another resident, admitted with sepsis and other serious diagnoses, did not receive all prescribed doses of an IV antibiotic due to medication unavailability and communication lapses. The MAR and progress notes showed that eight doses were missed, and documentation was inconsistent regarding physician notification and medication holds. Staff interviews confirmed difficulties in obtaining the medication and confusion about whether the full course was completed. The resident's PICC line was discontinued before the antibiotic regimen was finished, necessitating reinsertion for completion of therapy. A third resident experienced multiple medication administration errors during observation. An LPN administered a probiotic that was not the same as the one ordered, and two different eye drops were given consecutively without the recommended interval between administrations. The facility lacked a policy for eye drop administration, and staff were unclear about the equivalency of probiotics. These incidents demonstrate failures in medication verification, adherence to administration protocols, and staff competency in medication management.
Failure to Provide Admission Medications Due to Gaps in Acquisition and Documentation
Penalty
Summary
The facility failed to ensure that routine, physician-ordered medications were acquired and provided upon admission for two residents. For one resident with multiple diagnoses including a right femur fracture, chronic pain, asthma, fibromyalgia, and migraines, there was no documentation of medication reconciliation or communication with the physician at admission. Progress notes indicated that several ordered medications, including Lyrica, Eletriptan, Venlafaxine, and Senokot S, were not available or administered for up to three days after admission. The medication administration record confirmed these medications were not given, and staff documented that medications were pending pharmacy delivery or not available, with some offers of alternative pain relief being refused by the resident. Another resident, admitted with diagnoses such as spondylosis, type 2 diabetes with nephropathy, muscle spasm, bacteremia, and repeated falls, also did not receive ordered medications upon admission. The resident reported not receiving any medications, including those for diabetes, during the first night, which was corroborated by the medication administration record and progress notes. The facility's emergency drug kit (EDK) contained metformin and other relevant medications, but there was no documentation that these were accessed or administered. Staff interviews revealed inconsistent processes for obtaining and administering medications from the EDK and pharmacy, with some staff indicating that medications could be delayed depending on delivery schedules and lack of clear documentation or communication with physicians regarding alternatives. Further interviews with facility leadership, including the DON and NHA, confirmed gaps in the medication acquisition process, lack of documentation regarding medication availability, and absence of policies related to obtaining medications from pharmacy services or the EDK. The DON acknowledged that medications such as metformin and rosuvastatin were available in the EDK but could not confirm why they were not administered. The NHA stated there were no policies guiding the acquisition of medications or use of the EDK, contributing to the failure to provide necessary medications to residents upon admission.
Medication Administration Error Rate Exceeds 5% Due to Multiple Errors
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, as required. During an observation of medication administration for one resident, a total of twelve medication opportunities were reviewed, and three errors were identified, resulting in a 25% error rate. The errors included the administration of saccharomyces boulardii instead of the ordered lactobacillus probiotic, failure to wait the recommended interval between administering two different types of eye drops (latanoprost and timolol) in the same eye, and the administration of both eye drops consecutively without the required waiting period. The staff member involved confirmed the administration of the incorrect probiotic and did not follow the recommended procedure for eye drop administration. The resident involved had a history of diabetes mellitus and recent eye surgery, with orders for multiple oral medications, eye drops for glaucoma, and insulin. The medication administration record showed that the resident was to receive lactobacillus, but this was substituted with saccharomyces without a corresponding order at the time of administration. Additionally, the facility did not have a policy or procedure in place for the administration of eye drops, and staff were not following best practices for timing between different ophthalmic medications. These actions and omissions led to the identified medication errors.
Sanitation Deficiency in Kitchen Cooler
Penalty
Summary
The facility failed to maintain the reach-in cooler in a sanitary condition within the kitchen. During an inspection, the cooler was found to contain various food items, including a container of prepared food, an open carton of eggs, a container of turkey, half a head of lettuce, a cucumber, a package of meat, and a silver pan of corn, all covered with plastic wrap. The cooler's racks were observed to have peeling white coating, exposing rusted bars, and were stained with a brownish-yellow residue. The Dietary Director acknowledged the need to replace the racks and expressed a desire to replace the entire cooler. However, she was unaware of when a work order was submitted, despite the facility using an online system for such requests. The Maintenance Director confirmed that no work orders for the cooler had been received. A review of the facility's work order report for May and June 2024 showed no entries for the reach-in cooler.
Lack of Qualified Infection Control Preventionist
Penalty
Summary
The facility failed to ensure the presence of a qualified Infection Control Preventionist (ICP) with specialized training in infection control and prevention. During an interview, the Director of Nursing (DON) stated that both she and a Licensed Practical Nurse (LPN), referred to as Staff C, were in training to become the facility's ICPs. However, neither had completed the necessary specialized training. The DON mentioned that their training was being assisted by a Regional Nurse Consultant (RNC) who visits the facility once a month. The Nursing Home Administrator confirmed that the previous ICP left in May 2024, and currently, the DON and Staff C are undergoing training. The facility's policy requires that the ICP must have specialized training beyond initial professional education before assuming the role, which neither the DON nor Staff C had completed at the time of the survey.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in a safe operating condition, as observed during a survey. The reach-in cooler was found with a wet towel underneath and water pooling on the floor, indicating a leak. Additionally, the steam table was observed with wet towels and buckets on the lower shelf to catch water dripping from the upper shelf where food storage compartments were located. Staff E, a dietary staff member, confirmed the leaks and mentioned that a maintenance request had been submitted, although the drain was missing on the steam table, necessitating the use of buckets. The Dietary Director acknowledged that the reach-in cooler had been temporarily fixed by on-site maintenance and that the steam table did not leak consistently. However, the Maintenance Director stated that he had not received any work orders for either the reach-in cooler or the steam table. He only became aware of the issues when informed by the kitchen staff during the survey. A review of the facility's work order report for May and June 2024 showed no records of work orders for the problematic equipment, indicating a communication breakdown in the maintenance request process.
Inaccurate PASRR Documentation for Residents
Penalty
Summary
The facility failed to ensure the accuracy of admission diagnoses on the Level I Preadmission Screening and Resident Review (PASRR) forms and did not update these forms upon the addition of new diagnoses for thirteen residents. This deficiency was identified through interviews and record reviews, revealing that the PASRR forms for these residents were not accurately reflecting their current mental health diagnoses. For instance, Resident #43's PASRR form did not include updated diagnoses of vascular dementia and adjustment disorder with mixed anxiety and depressed mood, despite these being documented in the resident's medical records and medication administration records. Similarly, Resident #40's PASRR form was outdated and did not reflect the resident's current diagnoses of unspecified dementia and major depressive disorder. The review of the medication administration records and Minimum Data Set (MDS) assessments for several residents, including Residents #6, #59, and #37, showed discrepancies between the documented diagnoses and those listed on the PASRR forms. These inconsistencies indicate a failure to update the PASRR forms as required when new diagnoses were made or when residents were readmitted to the facility. Interviews with the Director of Nursing (DON) and the Social Services Director (SSD) confirmed that it was their responsibility to ensure the accuracy of the PASRR forms upon admission and to update them when new diagnoses were added. However, the review of the clinical records showed that this process was not consistently followed, leading to multiple residents having inaccurate PASRR forms. This oversight in maintaining accurate PASRR documentation could potentially impact the care and services provided to residents with mental disorders or intellectual disabilities.
Delayed Completion of MDS Assessments
Penalty
Summary
The facility failed to ensure the timely completion of the Minimum Data Set (MDS) assessments for four residents, which is a requirement for comprehensive resident assessment. Resident #47's admission MDS assessment was completed late, with an Assessment Reference Date (ARD) of 5/28/2024, but not completed until 6/5/2024. Similarly, Resident #273's admission MDS assessment was delayed, with an ARD of 6/12/2024, but not completed until 6/20/2024. These delays were acknowledged by Staff B, the Registered Nurse and MDS Coordinator, who attributed the lateness to other departments not completing their sections of the assessment on time. Additionally, the facility did not complete the Medicare 5-day MDS assessments for Resident #57 and Resident #17 within the required timeframe. Resident #57 was discharged on 2/3/2024, but the assessment was not completed until 3/20/2024. Similarly, Resident #17 was discharged on 1/4/2024, with the assessment also completed on 3/20/2024. Staff B was unable to provide reasons for these delays as she was not employed at the facility during that period. According to the Centers for Medicare & Medicaid Services guidelines, these assessments should have been completed within 14 days of the ARD.
Inaccurate MDS Assessment for Hearing Impaired Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a diagnosis of unspecified hearing loss. The resident was observed in a wheelchair watching television and communicated using a dry erase board, indicating a significant hearing impairment. Despite this, the resident's Quarterly MDS assessment inaccurately documented that the resident had adequate hearing with no difficulty in normal conversation, social interaction, or listening to TV. This discrepancy was identified during a review of the resident's care plan, which had interventions in place for hearing difficulties, such as using a dry erase board for communication. Interviews with the facility staff, including the MDS Coordinator and the Director of Nursing (DON), confirmed the inaccuracy in the MDS assessment. The MDS Coordinator acknowledged the error, noting that the resident was care planned for difficulty hearing, and the DON confirmed that the resident was unable to hear and required the use of a dry erase board for communication. The facility's policy on comprehensive care plans emphasizes the need for accurate assessments to meet residents' needs, which was not adhered to in this case.
Failure to Timely Complete Baseline Care Plan
Penalty
Summary
The facility failed to complete a baseline care plan in a timely manner for a resident, identified as #274, who was admitted on an unspecified date. The baseline care plan for this resident was not completed until 6/17/2024, which was beyond the expected timeframe. Interviews with staff revealed a lack of clarity regarding the timeline for completing baseline care plans. A Licensed Practical Nurse (LPN) indicated that unit managers typically initiate these plans, but could not specify when they should be completed. The Director of Nursing (DON) stated that baseline care plans should be completed by the admitting nurse within 48 hours of admission. However, the facility did not have a formal policy in place for baseline care plans, as confirmed by the DON.
Failure to Revise Comprehensive Care Plans
Penalty
Summary
The facility failed to revise the comprehensive care plans for four residents, leading to deficiencies in their care. For one resident with a history of ESBL in urine, the care plan was not updated to reflect the discontinuation of transmission-based precautions, despite the precautions being lifted weeks prior. The oversight was confirmed by the RN/MDS Coordinator, who acknowledged the care plan should have been updated when the precautions were no longer necessary. Another resident, diagnosed with Alzheimer's disease and other mental health conditions, exhibited sporadic outbursts of laughter, which were not addressed in the care plan. Despite a diagnosis of pseudobulbar affect and a recommendation for Nuedexta, there were no orders for the medication, and the care plan lacked any focus, goal, or intervention related to the laughing outbursts. Staff interviews revealed a lack of communication regarding the new diagnosis and the absence of documentation in the care plan. A third resident with a history of skin-picking disorder and venous ulcers had a care plan that did not address the behavior of removing dressings from wounds. The resident's care plan was also missing goals and interventions for the venous ulcers and did not include care for a toe wound. Staff interviews indicated a lack of awareness and communication about the resident's behavior and wound care needs. Additionally, another resident receiving oxygen therapy and diagnosed with diabetes and dysphagia had a care plan that did not include these conditions, highlighting a failure to update the care plan to reflect the resident's current needs.
Oxygen Therapy Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with professional standards for four residents. Resident #47 was observed using oxygen without proper documentation in the medication administration record, and there was no signage indicating oxygen use outside the resident's room. Despite having a physician's order for PRN oxygen, the administration was not recorded, indicating a lack of adherence to the prescribed treatment plan. Resident #274, who has chronic obstructive pulmonary disease and is dependent on supplemental oxygen, was observed using oxygen without a physician's order in place. The staff, including an LPN and the Director of Nursing, confirmed the absence of an order and acknowledged the lack of signage indicating oxygen use. This oversight highlights a failure in ensuring that physician orders are documented and followed, as well as a lack of communication regarding oxygen therapy protocols. Resident #14 was receiving oxygen therapy at a higher rate than prescribed, with no documentation of the administration in the medication record and no signage indicating oxygen use. Similarly, Resident #29 was observed using oxygen at a lower rate than ordered, with the resident unaware of the prescribed oxygen level. Interviews with staff revealed inconsistencies in monitoring and adjusting oxygen levels according to physician orders, further demonstrating a systemic issue in managing oxygen therapy for residents.
Failure to Limit PRN Psychotropic Medications and Monitor Side Effects
Penalty
Summary
The facility failed to ensure that physician-ordered psychotropic medications used on an as-needed basis were limited to 14 days for one resident. This resident was admitted with diagnoses of mood disorder and dementia and had an order for Lorazepam without an end date. The Director of Nursing acknowledged that psychotropic medications should be limited to 14 days and reviewed by the physician if continued use is necessary. The facility's policy requires that PRN orders for psychotropic drugs be limited to 14 days unless the physician documents a rationale for extension. Additionally, the facility did not complete behavior and side effect monitoring of psychotropic medication use in accordance with physician orders for four residents. For one resident, the Medication Administration Record (MAR) showed check marks instead of the required 'Yes' or 'No' documentation for monitoring behaviors and side effects. This resident had a history of Alzheimer's disease, mood disorder, and other psychiatric conditions, and was observed having sporadic outbursts of laughter. Staff interviews revealed a lack of documentation and communication regarding the resident's behavior and medication administration. For another resident, the MAR also showed check marks instead of the required documentation for monitoring behaviors and side effects. This resident had a diagnosis of depression and was observed sleeping frequently. The care plan indicated a risk for adverse reactions to psychotropic medications, but the required monitoring was not documented. Similar issues were found with two other residents, where the MAR showed check marks instead of the required documentation, indicating a failure to monitor and document behaviors and side effects as per physician orders and facility policy.
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 75 citations issued within 25 miles in the last 12 months — including the 5 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
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 Wales
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Groves Center | 1.9 mi | — | 19 | 0 |
| Astoria Health And Rehabilitation Center | 8.8 mi | ★★★★★ | 0 | 0 |
| Palm Garden Of Winter Haven | 9.5 mi | ★★★★★ | 0 | 0 |
| Lake Mariam Health And Rehabilitation Center | 9.5 mi | ★★★★★ | 4 | 2 |
| Life Care Center Of Winter Haven | 9.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lake Wales Health And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.