Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Lakeland Hills Center during CMS and state inspections, most recent first.
A resident with severe hypoxic ischemic encephalopathy and Full Code status experienced cardiac arrest, and staff initiated CPR prior to EMS arrival, as confirmed by an EMS report and the RN assigned to the resident. However, review of the medical record showed no documentation of CPR in progress notes or assessments, and no code blue sheet could be located in the facility’s binder, despite policy requiring use of a Code Blue Worksheet and transcription of the event into the medical record. The ADON, DON, and RN all acknowledged that required CPR documentation was missing for this event.
Medication storage and administration were not maintained according to professional standards. A resident kept OTC meds at bedside, another resident had a pill left in a medication cup on the bedside table, and multiple carts contained mixed storage of topical and oral meds, expired medication, and insulin products with missing or inconsistent labels/dates. Staff also found an uncapped Tubersol vial in an unlocked conference room and acknowledged several items were stored or labeled incorrectly.
Resident Council meetings were held in a dining room area open to staff, residents, visitors, and hallway traffic instead of a private space, and a family member and staff were observed present during the meeting. Review of council minutes and grievance logs showed multiple resident concerns were either not clearly documented or not tied to grievances, including requests related to activities for visually impaired residents, access to personal money, community outings, and a smoking-area canopy. The NHA stated residents should be able to meet in private and that voiced concerns would be written up as grievances and investigated.
Comfortable Water Temperatures Not Maintained: A resident reported that water did not get hot and that she frequently washed up with cold water. Surveyors found the back hall hot water heater at 108 degrees F, and water in two resident rooms measured 102.3 degrees F and 101.8 degrees F after running for five minutes. The MDS said he did not have a key to the water heater room, did not know why temperatures were low, and did not know why some heaters lacked mixing valves or temp gauges; the NHA said she expected hot water and higher temps for resident comfort.
The facility failed to obtain PASARR Level II evaluations for two residents before admission. One resident had diagnoses including depression, schizoaffective disorder, bipolar disorder, and a history of suicidal ideation and attempts, while another resident had PTSD, MDD, anxiety, seizures, and other brain disorders. PASARR Level I screens identified mental illness for both residents, but Level II screens were not submitted. Interviews showed the SSD and DON had differing understandings of PASARR triggers, and the DON stated she was the only staff member auditing and evaluating residents for Level II PASARR.
Incomplete Care Planning for Psychotropic Medications: Two residents had psychotropic medication-related care planning gaps. One resident with Alzheimer’s disease, schizoaffective disorder, bipolar disorder, depression, and anxiety had no care plan for antipsychotic, antidepressant, anti-anxiety, or anticonvulsant medications, despite MDS and staff interviews confirming those medications and diagnoses. Another resident with anoxic brain damage, depression, bipolar-type schizoaffective disorder, and cognitive communication deficit was receiving mirtazapine, trazodone, and Depakote ER, and the care plan was not fully aligned with the medication-related needs and timing of interventions.
A resident with spinal stenosis, neurogenic claudication, and low back pain did not receive timely incontinence care. The resident reported waiting about two hours after using the call light and later again waiting after telling the SSD she needed to be changed. The SSD asked CNAs to assist, but the CNAs did not provide care at that time, and one CNA later stated the resident was changed after lunch and had redness in the perineal area. Documentation also showed long gaps between incontinence care entries.
Failure to provide individualized activities for a dependent resident with CVA-related deficits, aphasia, trach, G-tube, and an indwelling catheter. The resident was observed lying in bed and non-responsive or minimally responsive, with no music playing and no meaningful activity engagement documented. The care plan and family preferences identified music, outdoor time, religious services, reading, and group activities, but CNA task records showed no activity participation, and staff reported there was no current Activity Director and limited in-room activity provision.
Improper enteral feeding management was identified for two residents with feeding tubes. One resident was observed without nutrition running, and an LPN used a syringe plunger to push contents into the GT despite the RN/UM stating the facility policy was to gravity feed, not push. Another resident had repeated tube feed interruptions, kinked tubing, air bubbles in the line, and periods when the pump was off or the bottle was not connected, resulting in the resident not receiving the ordered amount of Jevity and showing weight loss.
Failure to provide medically-related social services for a resident with intact cognition who reported not receiving a Social Security check for over a year and having no money for needed items. SSD notes showed limited contact with the prior facility and verbal follow-up with the business office, while the resident said he kept being told the issue was being worked on without any follow-through.
Pharmacist recommendations were not implemented within the expected timeframe for two residents. One resident with HTN, AFib, and HF had PRN Midodrine ordered for SBP <100, but BP and pulse monitoring was not documented as ordered and q shift vitals were not numerically recorded. Another resident with multiple acetaminophen-containing orders had a pharmacist recommendation to add a daily acetaminophen limit from all sources and clarify PRN pain orders by severity, but the limit was not added to all applicable orders and the pain orders lacked mild, moderate, and severe pain parameters.
Failure to Obtain Ordered Laboratory Tests: A resident had physician orders for a STAT UA C&S, BMP, stool occult testing, salt tablets, potassium, and Depakote monitoring, but the BMP was not documented as obtained or rescheduled and no Depakote level results were found in the chart. The TAR and lab monitoring sheets did not direct the lab vendor to obtain the BMP, and staff, the psychiatry NP, and the DON all noted missing or inconsistent lab monitoring for Depakote.
QAA Committee Failure With Unresolved Care Plan, Medication Storage, and Pest Control Deficiencies: A resident with mood disorder, depression, anxiety, and suicidal ideations had a care plan calling for removal of self-harm items, yet knives, scissors, disposable razors, and nail care products were found at the bedside. Medication storage was also deficient, with meds left at bedside, expired and unlabeled items on carts, and staff reporting no education on storage. Live flies were observed throughout hallways, resident rooms, and common areas, and staff and the NHA acknowledged the pest problem remained unresolved.
Pest control was ineffective, with live flying insects observed in resident rooms, hallways, the conference room, and bathrooms, including flies on walls, curtains, ceilings, and a resident’s washcloth. A resident and family member reported ongoing flies, and staff including the DON, NHA, RHD, and Maintenance Director stated the problem had persisted for weeks to years and that treatments were not working. Pest control invoices and sighting logs documented repeated service calls for gnats and flies in rooms, drains, and the kitchen, with notes that the issue was worsening and likely tied to an underlying source.
The facility failed to accurately reconcile hospital discharge medications and follow physician orders for several residents, resulting in missed or incorrect medication administration, lack of follow-up on laboratory and outpatient orders, and failure to document or notify physicians as required. These failures led to serious harm, including seizures, falls, hospitalization, and death. Staff interviews confirmed lapses in medication reconciliation, order verification, and adherence to prescribed protocols.
Nursing staff failed to demonstrate competency in medication reconciliation, laboratory follow-up, and adherence to physician orders, affecting multiple residents. Deficiencies included lack of proper training, failure to document or report G-tube malfunctions, unauthorized medication administration, and inadequate follow-up on lab orders. These failures resulted in worsened resident conditions and led to an Immediate Jeopardy determination.
Three residents experienced significant medication errors due to failures in medication reconciliation and administration. One resident with a seizure disorder and G-tube did not receive the correct dose and form of anti-seizure medication, leading to multiple seizures, a fall, and death. Another resident with epilepsy and a feeding tube did not receive all prescribed seizure medications after readmission, resulting in seizure-like activity and hospital transfer. A third resident with diabetes received unauthorized insulin doses from an LPN, contrary to physician orders, and was hospitalized for hyperglycemia. These incidents were linked to failures in communication, documentation, and adherence to medication protocols.
The QAPI committee failed to ensure effective diabetes management for two residents, resulting in nursing staff not following physician orders for insulin administration, lack of required physician notifications for high blood sugar readings, and inadequate documentation of care. These deficiencies were not effectively identified or addressed through the facility's QAPI process.
The facility failed to maintain essential laundry equipment, resulting in a shortage of clean linen for resident care. One of two industrial dryers was non-functional due to a trunnion bearing assembly failure, leading to delays in repairs and communication issues with the vendor. CNAs reported linen shortages and resorted to using the remaining dryer after hours, which was against protocol.
Two residents experienced a deficiency in their shared bathroom, which had a strong odor and improperly sized toilet seat. A CNA used towels to soak up water, concerned for a resident with sight challenges and fall risk. The Maintenance Director was unaware of the issue due to a lack of communication and absence of an electronic work order system, leading to the deficiency.
A resident with hemiplegia and heart failure was unable to reach the call light due to improper implementation of the care plan. Despite being cognitively intact, the resident reported difficulty in accessing the call light, which was observed to be out of reach. The facility's policy mandates that care plans be followed to ensure residents' well-being, which was not done in this instance.
The facility failed to ensure proper food labeling, storage, and sanitation in the kitchen. Observations revealed unlabeled food items, dirty cookware, and improper glove use by staff. Additionally, the facility did not maintain accurate sanitizer logs or calibrate thermometers correctly, leading to multiple deficiencies in food safety and handling practices.
Failure to Document CPR Event in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to accurately document a CPR event in accordance with its own policy and accepted professional standards. Resident #2, who had severe hypoxic ischemic encephalopathy and an advanced directive of Full Code, experienced a cardiac arrest. An EMS county Fire Rescue report showed that staff initiated CPR at 00:55 and EMS arrived at 01:37:48, continued CPR, provided medication support, and transferred the resident to a local hospital. However, review of Resident #2’s clinical chart, including the face sheet, progress notes, and assessments, revealed no indication that CPR had been performed on the resident on the date of the event. During interviews, the ADON and Regional Nurse Consultant confirmed that staff were required to complete a code blue sheet when CPR was conducted and that these sheets were kept in a binder, but no code blue sheet for Resident #2 was found. The DON, after reviewing the paper medical file, also confirmed there was no documentation in the medical record related to CPR being performed. A phone interview with the RN assigned to the resident that night confirmed that CPR had been administered and that she had participated in the code. The RN stated she had filled out the code blue sheet but did not know what happened to it and acknowledged that documentation in the clinical record “would be on me,” explaining that there had been a lot going on that night. The facility’s CPR-Code Status Orders and Response policy requires use of a Code Blue Worksheet to notate the timeline and activity, with transcription of those notes into the medical record upon resolution of the event, and completion of a 24-hour and nurse’s note, which did not occur for this resident.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in accordance with current professional standards for two residents and in four medication carts. Resident #57 had medications at the bedside, including a box of Cold & Flu medication in a partially open dresser drawer, and later staff removed two daytime cold & flu tablets and a bottle of antacid tablets from the resident’s bedside dresser. The resident stated no one had told her she could not keep medications at bedside and reported her spouse had brought the medication in when she had a cold the prior week. Multiple medication storage problems were observed in the medication carts and other storage areas. In the 100-hall cart, a round blue pill was found in the bottom of a drawer and staff did not know what it was; topical lidocaine patches were stored with oral medications. In the 200-hall cart, no-sting skin protectant was stored with liquid wound care supplements, lidocaine patches were stored with an oral laxative granule and liquid wound care supplements, and several insulin products were improperly labeled or dated, including an insulin glargine vial with an open date later than the box date, insulin lispro vials with inconsistent or missing open dates, a Novolog insulin pen labeled for emergency use without a resident name, and another insulin pen that was undated with an unclear bag date. A box of employee Tubersol was also observed in an unlocked conference room with the vial uncapped, no date opened, and no discard date. In the 400-hall cart, lidocaine patches were stored with bleach wipes without a divider, and in the 300-hall cart an opened bottle of chloraseptic spray was expired. Resident #128 was also observed with a medication cup containing a white pill on the bedside table, and the resident said he did not know the pill was still there or what it was for. Staff stated the nurse had given the medication cup and would return later to gather it, and the DON stated nurses are expected to remain at bedside until medications are taken. The facility policy stated medications must be accessible only to authorized staff, outdated medications must be removed from stock, medications are to be administered at the time they are prepared, and the resident is always observed after administration to ensure the dose was completely ingested.
Resident Council Meetings Held Without Privacy and Concerns Not Properly Addressed
Penalty
Summary
The facility failed to honor residents’ right to organize and participate in resident/family groups by not providing a private space for Resident Council meetings and by not consistently responding to council concerns and suggestions. On 3/10/26, the resident council meeting was held in the dining room between the 100/200 halls and the 300/400 halls, an area open between units with a half wall, a hallway used by staff, residents, and visitors, and a screened porch leading to the smoking patio. Residents were seated at several tables, a family member of Resident #83 attended, and the president stated this was the location used for council meetings. Residents and the family member reported the facility did not have a private space for them to meet. During the meeting, a corporate staff member was observed standing behind part of the wall next to the dining room, and numerous staff members were observed at the nearby nursing station and walking through the area using the dining room as a hallway. Review of Resident Council Meeting Minutes and grievance/concern logs showed repeated concerns were not clearly documented or linked to grievances. The 10/8/25 minutes noted a vision-impaired resident wanted games for the blind, but the resident was not identified and the minutes did not specify what games were provided; the grievance log also did not reflect that concern. The 11/19/25 minutes stated previous concerns were resolved without explanation and noted residents were frustrated about not being able to get their money, but no resident council grievance was documented. The 12/20/25 minutes stated prior concerns were resolved without identifying them and recorded requests for community outings by bus or van and a new canopy for the smoking area, but no council grievance was shown. The 1/14/26 minutes did not identify any concerns or issues voiced, and no grievance was documented for that meeting. The 2/11/26 minutes noted prior concerns were resolved and recorded comments about food being hotter and faster, but the record still did not show consistent follow-through on council concerns. The policy stated the council would be provided a private area to hold meetings and that staff or visitors would attend only at the council’s invitation. The NHA stated residents should be able to meet in private and that concerns voiced during council meetings would be written up as grievances and investigated.
Comfortable Water Temperatures Not Maintained
Penalty
Summary
The facility failed to ensure water temperatures were comfortable for one resident on the 400 hall. A resident stated that the water does not get hot even when left on and that she frequently washes up with cold water. During observation, the back hall hot water heater showed a temperature gauge beyond the mixing valve at 108 degrees Fahrenheit, and staff had to use a flathead screwdriver to break the lock to enter the water heater room because the Maintenance Director did not have a key. In two resident rooms, water was run for five minutes and measured 102.3 degrees Fahrenheit at one sink and 101.8 degrees Fahrenheit at a bathroom sink; the water was described as not cold but not warm either. The Maintenance Director stated he had not checked the temperature because he did not have a key, said the temperature should be between 110 and 112 degrees Fahrenheit, and confirmed the 108-degree reading. He also stated he did not know why the temperatures were reading low, did not know why the front hot water heaters did not have a mixing valve or temperature gauges, did not have a schedule for flushing the hot water heaters, and did not know the manufacturer specifications. The Nursing Home Administrator stated she expected the rooms to have hot water, did not know the temperature range, and expected the back hall water to be at a higher temperature for resident comfort. A policy reviewed by surveyors stated hot water temperatures would be heated to 140 degrees Fahrenheit before reaching the mixing valve and that water heaters would be flushed per manufacturer specifications.
Failure to Obtain PASARR Level II Evaluations for Two Residents
Penalty
Summary
The facility failed to obtain PASARR Level II evaluations for two initially sampled residents before admission. Resident #8 was admitted with diagnoses including anoxic brain damage, unspecified depression, bipolar-type schizoaffective disorder, and cognitive communication deficit. The resident’s PASARR Level I screening, completed by the facility’s current DON, identified mental illness diagnoses of depressive disorder, schizoaffective disorder, and insomnia, but concluded that a Level II evaluation was not required. A psychiatry note later documented that Resident #8 had a past psychiatric history of insomnia, major depressive disorder, bipolar disorder, and bipolar-type schizoaffective disorder. The resident’s care plan also identified risk for self-harm and suicidal ideation with a history of suicide attempts. During interviews, the SSD stated she assisted with sending information to the State Mental Health Authority and that the DON reviewed the audit sheets, while the DON stated Resident #8 had been audited but a Level II had not yet been requested. Resident #9 was admitted with diagnoses including PTSD, chronic seizures, major depressive disorder, generalized anxiety disorder, and other specified disorders of the brain. The resident’s PASARR Level I screen, electronically signed by an RN, identified confirmed or suspected mental illness including anxiety disorder, schizoaffective disorder, substance abuse, and chronic PTSD, and noted the resident was receiving services for mental illness, but a Level II screen was not submitted. Interviews with the SSD and DON showed differing understandings of when a Level II was triggered, and the DON stated she was the only staff member auditing and evaluating residents for Level II PASARR along with other DON responsibilities.
Incomplete Care Planning for Psychotropic Medications
Penalty
Summary
The facility failed to create resident-centered care plans for medications for two residents. One resident had diagnoses including Alzheimer's disease, schizoaffective disorder, bipolar type, bipolar disorder, depression, and generalized anxiety disorder. The resident's MDS showed use of antipsychotic, antidepressant, anti-anxiety, and anticonvulsant medications, but the care plan dated 11/26/25 did not include care plans for those medications. During interview, the RN/CRD stated the resident should have care plans for anti-anxiety, depression, and psychotropic medications, and the SSD stated the care plan was missing the schizoaffective, depression, and anxiety diagnoses. The DON stated the resident should have been care planned for bipolar disorder, schizoaffective disorder, depression, and anxiety, and that there should be a psychotropic care plan including those diagnoses. Another resident was observed lying in bed and did not respond to introduction. The resident's record showed diagnoses including anoxic brain damage, depression, bipolar-type schizoaffective disorder, and cognitive communication deficit. Psychiatry documentation noted a history of insomnia, major depressive disorder, bipolar disorder, and bipolar-type schizoaffective disorder, and physician orders included mirtazapine for depression, trazodone for depression, and Depakote ER for bipolar disorder. The care plan focus, initiated and revised on 3/11/26, addressed psychotropic medication use and potential adverse effects, but the goal had a target date earlier than the interventions and the interventions were not initiated until 3/11/26.
Delayed Incontinence Care and ADL Assistance
Penalty
Summary
The facility failed to ensure timely ADL care for Resident #139, who was admitted with spinal stenosis of the lumbar region with neurogenic claudication and low back pain. During interviews, the resident stated she used the call light after urinating and having a bowel movement, was answered by staff, and then waited about two hours to be changed. She also stated that later, after telling the Social Services Director she had a bowel and bladder movement and needed to be changed, she heard the SSD ask two CNAs to assist, but the care was not provided at that time. The SSD stated she asked Staff I, CNA, to assist the resident, but Staff I said she was busy assisting another resident with a shower. The SSD then asked Staff J and Staff K to help, but the SSD did not see anyone go into the resident’s room. Staff J stated she did not assist and walked off after seeing Staff K go into the room, while Staff K stated she did not assist the resident. Staff I later stated she changed the resident after lunch and that the resident was red in the perineal area at that time. The CNA Kardex showed incontinence care documented at 05:55 AM on 03/09/2026, with the next entry not until 12:20 PM, and on 03/11/2026 the resident was changed at 10:00 AM and not again until 12:29 PM.
Failure to Provide Individualized Activities for a Dependent Resident
Penalty
Summary
The facility failed to provide life enriching activities for one dependent resident who was sampled for activities. The resident had a tracheostomy, gastrostomy tube, indwelling urinary catheter, aphasia, hemiplegia and hemiparesis following a CVA, dysphagia following cerebral infarction, seizures, and impaired cognitive function. The care plan identified that the resident was non-verbal, dependent for ADLs, required staff assistance with involvement in activities because of cognitive deficits, preferred to stay in the room, and needed physical assistance to and from activities. Observations on multiple days showed the resident lying in bed and non-responsive or minimally responsive, with no music playing in the room. One observation noted the resident in bed with three roommates, two televisions off, one with a solid blue screen, and no music playing. Another observation noted a leaking urinary drainage bag on the floor, which an LPN confirmed. The resident’s record and MDS showed the resident was rarely or never understood, dependent for hygiene and care needs, and required assistance with all mobility and transfers. The resident’s documented preferences included listening to music, going outside for fresh air, participating in religious services or practices, reading books/newspapers/magazines, keeping up with the news, doing things with groups, and favorite activities. However, CNA task documentation for the 30-day lookback showed no data for self-directed, individual, or group activities, and no documentation of involvement in activities such as music listening, sensory stimulation, spiritual guidance, current events, or other listed programs. Staff interviews confirmed there was no current Activity Director, that activities were mainly bingo, games, movies, and popcorn, and that in-room visits were not clearly identified. The NHA stated that activities for low cognitive and bedbound residents should be provided per resident or family preference and that something should be occurring for the resident, even music.
Improper Enteral Feeding Management
Penalty
Summary
The facility failed to ensure appropriate management of enteral feeding for two residents with feeding tubes. One resident was observed lying in bed, unresponsive to verbal stimuli, with a nutrition pump beside the bed and no bottle of liquid nutrition hanging, showing the resident was not receiving nutrition at the time of the observation. The resident’s record showed diagnoses including unspecified sequelae of cerebral infarction, aphasia, dysphagia following cerebral infarction, tracheostomy status, and gastrostomy status. During a later observation, an LPN connected the resident’s liquid nutrition to the gastrostomy tube and used a 60 cc syringe and plunger to push the contents of the tubing into the stomach, then pushed 60 cc of water through the tubing before connecting the feeding tubing and starting the pump. The LPN stated she was a brand-new nurse and did not know what gravity or push meant. The RN/UM stated the policy was to gravity feed and not push, explaining that staff cannot see what they are pushing into and that pushing could indicate an abscess or placement issue. A second resident with anoxic brain damage and gastrostomy status was observed multiple times with problems involving the tube feeding setup. The feeding bottle and pump were seen with air bubbles and gaps in the formula line, and at one point the bottle was not connected to the resident while the pump was off. Later observations showed the bottle reconnected, but the pump had been off for part of the time and the resident had not received the full ordered amount. Staff interviews identified recurring issues with a kinked feeding line and a pump that would run and then stop. The resident’s order was for Jevity 1.5 cal continuous at 85 mL/hr with 200 mL water flushes every 4 hours, and the record showed weight loss from 176.4 pounds to 170.2 pounds. The DON stated the resident had received only 3 mL since 2:00 p.m., that the tubing had kinked again, and that staff should have identified the tube feeding issue.
Failure to Provide Follow-Through on Resident’s Social Security Check Issue
Penalty
Summary
Medically-related social services were not provided to help a resident achieve the highest possible quality of life when Resident #11 reported that he had not received a Social Security check in over a year and had no money to buy needed items. The resident was cognitively intact on the MDS, with a brief interview mental status score of 15 out of 15. During the interview, he stated that he had spoken with several people about the missing check and was told they were working on it, but he was never followed up with. The record showed social services involvement beginning in June 2025, when the SSD contacted the business office manager and then another facility about the resident’s belongings and any funds, with a note that social services would continue to follow. A later note in December 2025 stated the resident was waiting for Social Security to fix a problem with his check and that he was working with the Business Manager. In interviews, the Office Manager stated the facility had been trying to resolve the resident’s Social Security check issue since she started in November, including repeated calls to the other facility and Social Security, but the facility could not be the rep payee. The SSD stated she was responsible for advocating for services and benefits, but said she did not help with the check because the business office was handling the money-related issue, and she acknowledged that follow-up with the business office was verbal and not documented.
Pharmacist Recommendations Not Implemented and Medication Orders Not Properly Clarified
Penalty
Summary
The facility failed to initiate consulting pharmacist recommendations within the expected 30-day time frame for two residents sampled for unnecessary medications. One resident had diagnoses including essential hypertension, atrial fibrillation, and heart failure, and had a consultant pharmacist recommendation dated 12/2/25 asking staff to review medication errors and correct the lack of blood pressure documentation every 8 hours for Midodrine ordered PRN for SBP less than 100. Review of the resident’s March 2026 MAR showed the Midodrine order included a place to document blood pressure and pulse, but no blood pressure and/or pulse had been obtained during the month of March, and the MAR also showed a q shift vital signs order without numerical documentation of vital signs until 3/12/26. The resident’s blood pressure summary showed readings only on 1/30/26, 2/10/26, 2/23/26, and 3/10/26. The care plan did not show a focus for hypertension and/or hypotension episodes. During interview, the DON stated that if there are parameters for hypotension, staff should be getting vital signs every 8 hours, and confirmed staff were not obtaining blood pressure every 8 hours. A second resident, admitted with diagnoses including multiple rib fractures, type 2 diabetes mellitus, and hemiplegia/hemiparesis following cerebral infarction, had a Medication Regimen Report dated 1/5/26 with recommendations related to acetaminophen use. The pharmacist noted the maximum recommended chronic dose of acetaminophen is 4 g per day without liver impairment and asked the facility to add a daily limit of acetaminophen from all sources to the resident’s orders, and to clarify PRN pain orders with specific dosing parameters for mild, moderate, or severe pain. Review of the resident’s active orders showed multiple acetaminophen-containing medications, including PRN acetaminophen, Percocet, and Fioricet/Codeine, but the daily acetaminophen limit was not added to all applicable orders and the pain orders did not include parameters for mild, moderate, or severe pain. The consultant pharmacist stated that recommendations going past 60 days were reported to corporate, and later stated that the scheduled Percocet did not need the daily limit added.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide laboratory services for one resident who had physician orders dated 1/27/26 for a STAT urinalysis culture and sensitivity, a BMP in one week, stool occult x2, salt tablets, and potassium. The resident was observed on 3/9/26 lying atop a low air loss mattress and did not respond to the surveyor’s introduction. Review of the February TAR showed the BMP was scheduled for 2/3/26, but the TAR did not show it was administered and did not show the BMP had been obtained or rescheduled. The lab monitoring sheets dated 2/2/26 and 2/3/26 listed other tests, including vitamin B12, folate, and occult stool, but did not instruct the laboratory vendor to obtain the BMP on 2/3/26. The resident’s laboratory results did not include BMP results from 2/3/26, and the chart also did not include Depakote level results despite an order for Depakote ER 250 mg three times daily for bipolar disorder. The psychiatry note dated 2/26/26 listed Depakote 250 mg three times daily on the medication list. Staff M, LPN, reviewed the records and could not locate any Depakote level results, stating the level should be drawn at baseline and then every 3 or 6 months. The psychiatry NP stated that when Depakote is started, ammonia and valproic acid levels are obtained after 7 days and then every 6 months if prescribed for mood, and the DON stated a Depakote level is obtained when a resident starts Depakote and every 3 months, but the facility did not have a standing order for psychotropics.
QAA Committee Failure With Unresolved Care Plan, Medication Storage, and Pest Control Deficiencies
Penalty
Summary
The facility did not maintain a functioning QAA Committee to review quality deficiencies and develop corrective plans of action. The report states the facility was involved in creating, implementing, and monitoring the plan of correction for deficiencies cited during a recertification survey ending 3/12/2026, including F656, F761, and F925, but the plan was not comprehensively implemented by the revisit survey on 4/16/2026. The facility’s QAPI policy stated the QAA&C Committee would implement the QAPI program through individual and committee assignments, including tracking performance, analyzing problems, developing corrective actions, and monitoring the effects of those actions. For F656, Resident #3 had diagnoses including unspecified mood disorder, depression, and anxiety disorder, and was cognitively intact with a BIMS score of 14. The resident’s care plan initiated on 4/15/2026 identified a risk of hurting self with suicidal ideations and included removing objects that could be used for self-harm. However, on 4/16/2026, the resident’s bedside table contained several knives, scissors, disposable razors, and nail care products. Staff members, including an LPN, CNAs, the DON, and the NHA, stated disposable razors should not be in resident rooms, and the DON later stated the focus had only been on psychotropic medications and that no other care plan audits had been completed. For F761, Resident #3 had medication on the bedside table, including a tube of prescription pain medication and a full box containing another tube of medication, despite no physician order, assessment, or care plan for self-administration. Medication cart observations showed multiple storage problems: unopened insulin bottles not refrigerated, opened insulin without an open or expiration date, an allergy medication bottle with a worn-off expiration date, loose medications in a drawer, expired fish oil, inhalers and albuterol products without open or expiration dates, and chemical wipes stored next to medications in cart drawers. Staff members stated they had not received education on medication storage and did not know where certain items should be stored. For F925, live flies were observed throughout the 100 hallway and in multiple resident rooms, including around a urinal, on ceilings, and on a curtain, as well as in the conference room. Residents reported the flies were bothersome, and staff acknowledged the flies were still present. The pest control log showed a gnats sighting in the dining room, and the NHA stated the flies were still an issue and that the pest control company only treated areas of high concern.
Pest Control Program Ineffective With Ongoing Fly and Gnat Infestation
Penalty
Summary
The facility failed to ensure its pest control program was effective on four of four hallways, with observations showing live flying insects in multiple resident areas. Surveyors observed three live flying insects on the wall of the headboard in one room, a live flying insect on the curtain in the same room, a live flying insect on the ceiling in another room, and four live flying insects on the wall of a third room. A resident in one room stated there was a fly on the ceiling, and a resident family member reported having spoken with the NHA about flies and being told the bug guy would be out the following week. Staff also reported seeing flies in the facility for at least two months, with spraying occurring three times the prior week, and the DON stated flies had been seen within the last 6 weeks and had been treated for the past month. Additional observations and records showed fruit flies and gnats throughout the facility, including in the conference room, a resident room, and the bathroom between resident rooms, as well as flies around a resident bedside table and on a washcloth hanging on a headboard. The resident stated the flies had been in the room for a long time and were annoying and irritating. Pest control invoices documented repeated treatments for gnats and flies in resident rooms, drains, the kitchen, and other areas, with notes that the problem was getting worse, may have an underlying drain issue, and appeared to be a "Band-Aid" rather than addressing the source. The pest sighting logs showed fruit flies and gnats had been reported dating back to 2021, and the NHA, RHD, and Maintenance Director each stated the flies were widespread and that nothing was working.
Failure to Reconcile Medications and Follow Physician Orders Resulting in Resident Harm
Penalty
Summary
The facility failed to protect residents from neglect by not accurately reconciling medications, failing to follow up on physician orders for laboratory testing, medical equipment, and outpatient services, and not administering medications as ordered. One resident was readmitted from the hospital with a history of seizures and a G-tube, requiring a specific dose and form of seizure medication. The facility did not accurately reconcile the hospital discharge medication orders, resulting in the resident receiving an incorrect dose and form of medication. Despite multiple notifications to the physician and pharmacy about the need to change the medication to a solution for G-tube administration, the correct order was not implemented in a timely manner. The resident subsequently experienced multiple seizures, a fall with head trauma, and ultimately died from his injuries. Laboratory orders for seizure medication levels were not completed as ordered, and follow-up on outpatient cardiology appointments and equipment was not performed. Another resident with epilepsy and a feeding tube was readmitted to the facility, but the hospital discharge medication list was not properly reconciled. Several medications, including a seizure medication, were omitted from the facility's orders, and the resident did not receive these medications. The resident experienced seizure-like activity and required transfer to a higher level of care. Staff interviews revealed that the admitting nurse did not verify the medication list with the physician, and the correct discharge medication list was not obtained until after the incident. The facility initiated an investigation after being notified by the resident's family that the resident had not received her seizure medications since her last hospitalization. A third resident with diabetes and epilepsy was not managed according to physician orders for blood sugar testing and insulin administration. An LPN administered large doses of insulin without a physician's order after observing high blood sugar readings, and failed to document the blood sugar readings or notify the physician as required. The resident was subsequently sent to the hospital for hyperglycemia and influenza A. Staff interviews confirmed that the nurse did not follow the prescribed sliding scale insulin orders and acted without proper authorization or documentation.
Failure to Ensure Nursing Staff Competency and Adherence to Physician Orders
Penalty
Summary
Licensed nursing staff failed to demonstrate knowledge and competency in several critical areas of resident care, affecting six out of ten sampled residents. Deficiencies included failure to accurately reconcile medications upon admission, failure to follow up on laboratory orders, administration of medication without a physician's order, failure to report and document gastrostomy tube (G-tube) malfunctions, practicing outside the nursing scope of responsibility, failure to follow physician orders for blood sugar testing, and failure to implement hospice consultation orders. These failures resulted in worsened conditions for residents and created the likelihood of serious injury or death, leading to a determination of Immediate Jeopardy. For one resident with a history of seizures and a G-tube, there were multiple failures in medication reconciliation and laboratory follow-up. Orders for seizure medication levels were entered as completed, but no lab results were found in the medical record. Interviews revealed that nurses lacked access to the lab portal, had not received formal training on the lab process or the admission process, and often relied on informal guidance from coworkers. The DON confirmed that the process for lab follow-up was not followed, and that staff were not supposed to reconcile medications or enter orders without physician communication. Additionally, the emergency drug kit did not contain necessary anti-seizure medications, and some nurses lacked access to the electronic medication dispensing system. In another case, staff failed to report and document a G-tube malfunction for a resident with multiple complex diagnoses. Nurses cut the G-tube without physician orders or documentation, and there was no facility policy on G-tube care. Staff interviews confirmed that cutting the tube was done without proper notification or documentation, and that education on this issue was lacking. In a separate incident, an LPN administered insulin to a resident with diabetes without a physician's order and failed to document blood sugar readings or the amount of insulin given. These actions were only discovered during shift handoff, and the resident required transfer to the emergency room for further care.
Failure to Prevent Significant Medication Errors and Ensure Accurate Medication Reconciliation
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the areas of medication reconciliation upon admission and the administration of physician-ordered medications. In one case, a resident with a history of seizures and a gastrostomy tube was readmitted from the hospital with orders for a specific dose and form of seizure medication (Levetiracetam/Keppra). The facility did not accurately reconcile the hospital discharge medication orders, resulting in the resident receiving an incorrect dose and form of the medication. Documentation showed confusion and delays in changing the medication from tablet to solution for G-tube administration, and there was a lack of clear communication and documentation regarding dose changes. The resident subsequently experienced multiple seizures, a fall with head trauma, and was transferred to a higher level of care, where he later died. Additionally, physician-ordered laboratory tests for seizure medication levels were not implemented as ordered, with no results found in the medical record. Another resident, also with a history of seizures and a feeding tube, was readmitted with hospital discharge orders for multiple medications, including two anti-seizure drugs and other critical medications. The facility failed to obtain and reconcile the correct hospital discharge medication list, resulting in the omission of key medications, including a prescribed seizure medication. The resident did not receive the ordered anti-seizure medication, and there were multiple missed doses of another seizure medication due to unavailability. The resident subsequently experienced seizure-like activity and required transfer to a higher level of care. Interviews revealed that the admitting nurse did not verify the medication list with the physician, and the correct discharge medication list was not obtained until after the incident. A third resident with diabetes and epilepsy was affected by improper medication administration when an LPN administered two large doses of insulin without a physician's order, contrary to the resident's sliding scale insulin protocol, which required physician notification for high blood sugar readings. The nurse did not document the blood sugar readings or the insulin administration and failed to notify the physician as required. The resident was later sent to the hospital for hyperglycemia and influenza A. Interviews confirmed that the nurse acted outside the scope of practice and did not follow established protocols for medication administration and physician notification.
Failure to Implement Effective QAPI Plan for Diabetes Management
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Committee (QAPI) failed to implement an effective Performance Improvement Plan (PIP) for diabetes management, as evidenced by multiple incidents involving two residents with diabetes. In one case, a resident with Type 2 Diabetes Mellitus, legal blindness, epilepsy, and acute kidney failure was admitted and later discharged to an acute care hospital after experiencing uncontrolled hyperglycemia. Nursing staff failed to follow physician orders for insulin administration, with one LPN administering two separate 20-unit doses of insulin without a physician's order and without documenting the blood sugar readings or the insulin given. The nurse also failed to notify the physician as required when the blood sugar was above the specified threshold, and there was no documentation of these actions in the resident's medical record. Another resident with Type 2 Diabetes Mellitus and other complications had physician orders specifying that the physician should be notified if blood sugar exceeded a certain level. Despite multiple documented instances of blood sugar readings above this threshold, there was no evidence that the physician was notified as ordered. The medication administration records showed repeated high blood sugar readings and insulin administration, but the required notifications to the physician were not documented. The facility's QAPI policy outlines a process for tracking, measuring, and correcting performance issues, including the use of the Plan-Do-Study-Act (PDSA) cycle and regular reporting to the QA&A Compliance Committee. However, the events described demonstrate that the QAPI process was not effectively implemented or monitored in relation to diabetes management, as evidenced by the lack of adherence to physician orders, failure to document critical care actions, and absence of systematic follow-up on identified deficiencies.
Deficiency in Laundry Equipment Maintenance
Penalty
Summary
The facility failed to ensure that essential laundry equipment was in safe operating condition, specifically one of the two industrial dryers, which impacted the availability of clean linen for resident care. On the morning of January 14, 2025, a Certified Nursing Assistant (CNA) reported a shortage of linen, stating that she was unable to complete resident care due to the lack of towels, flat sheets, chuck pads, and washcloths. Another CNA confirmed that one of the dryers was not working, leading to competition among staff for available linens. The Laundry Aide confirmed that one of the dryers had been non-functional since the previous month, and the Housekeeping/Laundry Supervisor acknowledged that the dryer had been down for about three weeks, attributing the delay to the need for parts and technician availability. The Maintenance Director stated that the dryer had stopped working some time ago due to a failure in the trunnion bearing assembly, which caused the drum to lock up. Despite placing a service call to the vendor, there was a delay in diagnosing the problem and ordering the necessary parts. The Maintenance Director noted that two technicians visited the facility to diagnose the issue, confirming the initial diagnosis, but there was a lack of communication regarding the ordering of parts. A package containing the part arrived without paperwork, and the Maintenance Director was attempting to arrange for technicians to install the parts. This situation led to CNAs using the remaining functional dryer after hours to meet linen needs, which was against protocol and further slowed laundry production.
Failure to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable environment for two residents, resulting in a deficiency. Observations revealed that the shared bathroom of two residents had a strong ammonia and urine odor, with wet towels placed around the base of the toilet. The toilet seat was improperly sized, being two inches shorter than the commode base. Staff A, a CNA, acknowledged the use of towels to soak up water, expressing concern for Resident #7, who has sight challenges and is at risk for falls. Resident #7, who has a history of hemiplegia, muscle weakness, and blindness, confirmed her ability to use the bathroom independently. Resident #8, who is cognitively intact, reported the persistent odor and expressed discomfort. Interviews with the Housekeeping/Laundry Supervisor and the Maintenance Director revealed lapses in communication and maintenance procedures. The Housekeeping/Laundry Supervisor stated that bathrooms should be cleaned daily and issues reported to the Maintenance Director, who was unaware of the bathroom's condition due to the absence of an electronic work order system. The Maintenance Director confirmed the toilet's instability and the incorrect toilet seat size, acknowledging that he had not been informed of the issue. The lack of communication and proper maintenance reporting contributed to the deficiency, as the Maintenance Director was not aware of the problem and therefore could not address it.
Failure to Implement Care Plan for Resident with Mobility Issues
Penalty
Summary
The facility failed to implement the care plan for a resident who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, weakness, and heart failure. The resident, who was cognitively intact, reported being unable to move her left arm and reach the call light, which was observed to be out of her reach. Despite the care plan specifying that the call bell should be within reach and that the resident required assistance for bed mobility, these interventions were not properly implemented. During an observation, the call light was found hanging on the left side of the bed, inaccessible to the resident. The Maintenance Director acknowledged the issue and suggested obtaining a clip to position the call light better. The facility's policy requires that each resident receives necessary care and services according to their comprehensive assessment and care plan, which was not adhered to in this case.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food and beverages were labeled and stored correctly, as observed during a kitchen tour. Three containers of red juice in the walk-in cooler were found without labels or dates, and two plates of food covered in plastic wrap were also unlabeled. Additionally, a box of frozen broccoli and a box of frozen pepperoni were found open to the air in the freezer. The Certified Dietary Manager (CDM) acknowledged these issues and stated that staff were expected to label and date all foods and beverages. The facility also did not maintain cleanliness and proper sanitation in the kitchen. A drying rack had an unknown black residue, and a pot and pan on the drying rack were found dirty with a greasy white substance and flaky reddish-brown spots. The three-compartment sink used for washing, rinsing, and sanitizing was not properly logged for sanitizer solution checks, with missing entries for multiple dates. The CDM and Senior Registered Dietitian (Sr RD) confirmed these observations and stated that logs should be filled out. Furthermore, staff did not adhere to proper glove use and thermometer calibration procedures. Staff A used the same gloves for multiple tasks, including handling food, writing in a logbook, and stirring food, without changing them. Additionally, Staff A's method of calibrating a digital thermometer was incorrect, as it involved running it under hot water instead of using an ice bath or boiling water method. Staff B was observed placing lids on bowls without wearing gloves initially. The Sr RD confirmed that gloves should be worn when handling ready-to-eat food and should be changed when soiled or ripped.
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What surveyors actually found near you
We read the 157 citations issued within 25 miles in the last 12 months — including the 9 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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lakeland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vivo Healthcare Lakeland | 0.1 mi | ★★★★★ | 2 | 0 |
| Charming Lakes Rehab | 0.5 mi | ★★★★★ | 11 | 0 |
| Valencia Hills Health And Rehabilitation Center | 2.2 mi | ★★★★★ | 28 | 0 |
| Manor At Carpenters, The | 2.3 mi | ★★★★★ | 0 | 0 |
| The Club At Lake Gibson | 2.3 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.