Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manor At Carpenters, The during CMS and state inspections, most recent first.
Infection control practices were not followed for a resident’s respiratory equipment, medication handling, and soiled laundry. A resident’s oxygen concentrator, nasal cannula, suction canister, and suction tube were repeatedly observed uncovered and unprotected; an LPN was seen pushing tablets from blister packs into a bare hand before placing them in a med cup; and a laundry aide transferred soiled linen without demonstrating a protective apron or other clothing barrier.
Inaccurate PASRR Level I screenings were completed for four residents with diagnoses including dementia and serious mental illness. For each resident, the PASRR identified mental illness or suspected MI, but question 6 regarding dementia-related diagnoses was marked “no,” and no Level II referral was made. The DON reviewed the records and stated the responses were inadvertent mistakes.
Incomplete Care Plans for High-Risk Medications: The facility did not develop comprehensive person-centered care plans for several residents receiving high-risk meds. Residents with dementia, depression, bipolar disorder, anxiety, seizures, and psychotic disorders had MDS entries and physician orders for antipsychotics, antidepressants, anticoagulants, anticonvulsants, diuretics, opioids, and antianxiety meds, but their care plans lacked related focus areas, goals, or interventions. The MDS Coordinator and DON stated that meds should be included on the care plan.
Failure to provide ADL assistance for toenail care: A resident with intact cognition, a history of falls, unsteadiness, and polyneuropathy reported long toenails made walking difficult and said she had told staff without results. Observation showed a 1/4 inch long yellow toenail and other nails curved into the skin, while the chart had no podiatry notes and staff could not confirm when podiatry last saw the resident.
A resident with intact cognition reported that the call light in the room had been broken for an extended period and that a horn provided as backup was not reliably heard when the door was closed. Maintenance records showed repeated service calls, ongoing faults, and continued malfunction despite troubleshooting and replacement of a dome light, while staff confirmed the issue had persisted for weeks and surveyors observed the call light ringing constantly with unresolved timers.
A CNA physically abused a dependent resident with dementia by slapping her in response to the resident's combative behavior during care. The incident was witnessed by another CNA, and the facility's abuse prevention policy was not effectively implemented to prevent this occurrence.
A facility failed to follow its abuse prevention policy by not contacting a CNA's previous healthcare employer, as revealed by a background check, resulting in the hiring of an individual with a history of resident abuse. This oversight led to the physical abuse of a dependent resident with dementia and depression during care, as witnessed by another CNA.
Infection Control Failures With Respiratory Equipment, Medication Handling, and Soiled Laundry
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed for respiratory equipment used by Resident #72. On 06/08/2026, 06/09/2026, and 06/10/2026, the resident’s oxygen concentrator was observed with a long clear tube and nasal cannula hanging uncovered and unprotected from environmental contamination. During the same observations, the suction machine canister remained approximately one quarter full of a clear, thick liquid, and the disposable oral suction tube was also uncovered and unprotected. Staff F, CNA, stated the nasal cannula should be in a bag when not in use, the suction canister should be cleaned after each use, and the suction tube should also be bagged. Staff E, RN, stated oxygen cannulas, nebulizer masks, and suction equipment must be cleaned daily and placed in a protective barrier after each use. The facility also failed to follow infection control practices during medication administration and laundry handling. On 06/08/2026, Staff A, LPN, was observed at the medication cart pushing medication tablets through blister packages into a cupped bare hand and then placing the tablets into a medication cup, and this was observed on three separate occasions during the tour. On 06/10/2026, Staff B, laundry aide, demonstrated transferring soiled linen from designated bins into washing machines while wearing gloves but did not identify or demonstrate use of a designated apron or other protective covering for clothing, and stated the laundry staff used to have white disposable aprons for clothing protection. The ADON/ICP stated additional staff education was needed and provided a binder of infection control training conducted daily, weekly, monthly, and annually.
Inaccurate PASRR Level I Screenings
Penalty
Summary
The facility did not ensure PASRR Level I screenings were completed accurately for four residents with diagnoses that included dementia and serious mental illness. For Resident #39, the admission summary listed paranoid schizophrenia, major depressive disorder, persistent mood disorder, unspecified dementia, and generalized anxiety disorder, but the PASRR Level I marked question 6 as “no,” and the resident was not referred for a Level II screening. Similar findings were identified for Resident #1, whose diagnoses included unspecified dementia, persistent mood disorder, brief psychosis disorder, and major depressive disorder, with the PASRR Level I also marking question 6 as “no” and no Level II referral made. Resident #7’s record showed diagnoses of unspecified dementia and depression, and the PASRR Level I again marked question 6 as “no,” with no Level II referral. Resident #18’s record showed mood disorder due to known physiological conditions, bipolar disorder, major depressive disorder, and unspecified dementia with behavioral disturbances, yet the PASRR Level I also marked question 6 as “no,” and the resident was not referred for a Level II screening. In each case, the records showed mental illness or suspected mental illness was identified on the Level I PASRR, but the dementia-related question was answered “no.” During interview, the DON stated the initial PASRR screening was completed by the SSD and then reviewed by her, and that PASRRs would be updated with new diagnoses or medication changes. The DON reviewed the four residents’ PASRRs and stated the question 6 responses were inadvertent mistakes and would be corrected. The facility policy stated that residents with newly evident or possible serious mental disorder, intellectual disability, or related condition are to be referred for Level II resident review upon a significant change in status assessment.
Incomplete Care Plans for High-Risk Medications
Penalty
Summary
The facility did not ensure the development of comprehensive person-centered care plans related to the use of high risk medications for five residents. Review of records showed that Resident #18 had diagnoses including mood disorder due to known physiological conditions, bipolar disorder, major depressive disorder, and unspecified dementia with other behavioral disturbances, and had orders for risperidone, trazodone, behavioral monitoring for antipsychotic medication every shift, behavioral monitoring for antidepressant medication every shift, and an antipsychotic nursing alert every shift. Despite these orders and the MDS indicating use of a high-risk antipsychotic drug class, the care plan contained no focus area related to behaviors or psychotropic medication use. Resident #1 was admitted with diagnoses including unspecified dementia, persistent mood disorder, brief psychotic disorder, and major depressive disorder. The MDS indicated use of a high-risk antipsychotic drug class, and physician orders included behavioral monitoring for antipsychotic medication every shift, Seroquel for brief psychotic disorder, mirtazapine for depression, Depakote for mood disorder, and an antipsychotic nurse alert every shift. The care plan did not include a focus area related to psychotropic medication use. Resident #7 had diagnoses including unspecified dementia and depression, and the MDS indicated use of a high-risk antipsychotic drug class. Physician orders included sertraline and trazodone for depression, but the care plan had no focus area related to psychotropic medication use. Resident #37 had diagnoses of major depressive disorder, seizures, and anxiety disorder, and the MDS showed use of antianxiety, antidepressant, anticoagulant, opioid, and anticonvulsant medications in the last seven days; however, the care plan had no focus, goal, or interventions related to antipsychotic, opioid, or anticoagulant medications. Resident #5 was admitted with dementia, major depressive disorder, and anxiety, and the MDS showed use of antidepressant, anticoagulant, diuretic, and anticonvulsant medications, but the care plan had no focus, goal, or interventions related to those medications. The MDS Coordinator and DON stated that medications should be on the care plan, and the facility policy addressed comprehensive resident-centered care plans.
Failure to Provide Toenail Care and ADL Assistance
Penalty
Summary
The facility failed to provide activities of daily living assistance for one resident who was unable to maintain toenail care. During an observation and interview, the resident stated her toenails were so long that she had a hard time walking, said she had told everyone and nothing had been done, and reported she used to see the podiatrist but could not remember when she was last seen. The resident, who had diagnoses including history of falling, need for assistance with personal care, unsteadiness on feet, and polyneuropathy, was observed with a 1/4 inch long yellow toenail on the first toe and the remaining toenails curved into the skin of the second and third toes. Record review showed the resident had intact cognition with a BIMS score of 15 out of 15 and required partial moderate assistance with self-care. The chart contained no notes regarding a podiatry visit. Staff interviews indicated nurses performed skin assessments and were expected to report long toenails so residents could be added to the podiatry list, and the SSD stated podiatry came every other month and residents were added on admission or as needed. The SSD reviewed the record and could not find when the resident was last seen by podiatry, and the DON stated the resident had not told her she needed her toenails trimmed despite seeing her daily.
Nonfunctioning resident call light system
Penalty
Summary
The facility failed to ensure a functioning call system was available in a resident’s room bathroom and bathing area for one resident. Resident #64, who had an original admission date of 12/24/2024 and a BIMS score of 15 out of 15, reported that the call light had been broken for a while and that the problem had been ongoing. The resident stated the facility could not figure out why it kept going out and said a horn had been provided, but staff were not able to hear it most of the time if the room door was closed. Record review showed repeated outside maintenance service calls for the resident’s call light malfunction. Documentation reflected that the station had blinking lights, could not be reset, had an old configuration that caused the bed station to fault, and later continued to malfunction after the dome light was replaced. Staff interviews confirmed the call light had been worked on but was still not functioning, with one RN stating it had been broken for approximately one to one and a half months. Survey observations also found the call light ringing constantly with unresolved timer readings, and the maintenance director stated he knew very little about the issue and planned to contact the outside company again. The facility’s policy stated each resident should have access to a functioning call light system at all times and that routine calls must be answered within 5 minutes.
Failure to Protect Resident from Physical Abuse by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) physically abused a resident during care. The resident, who had diagnoses including depression, senile degeneration of the brain, cerebral atherosclerosis, major depressive disorder, and dementia without behaviors, was dependent on staff for all activities of daily living and was rarely or never understood. During an incident, the resident became combative and pulled her arm away from the CNA. The CNA then grabbed the resident's arm and put it into her shirt. The resident slapped the CNA, and in response, the CNA slapped the resident back. This act of physical abuse was witnessed by another CNA, who reported both seeing and hearing the slap. The facility's policy on abuse, neglect, exploitation, and misappropriation of property, last reviewed on 1/1/24, states that the facility is responsible for developing and implementing procedures to prevent, identify, investigate, and report abuse. Despite these policies, the incident occurred, resulting in a failure to protect the resident from physical abuse by facility staff.
Failure to Screen CNA Led to Resident Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policies and procedures regarding the screening of potential employees, specifically in the case of a Certified Nursing Assistant (CNA) who was later involved in the physical abuse of a resident. The CNA, who had previously been terminated from another nursing facility for resident abuse, did not disclose this prior employment on her application. Human Resources only contacted the references listed on the application, which were two fast food restaurants, and did not cross-reference the Level II background screen that showed recent employment at another nursing home. As a result, no attempt was made to obtain information from the CNA's previous healthcare employer, where the abuse incident had occurred. The deficiency resulted in harm to a resident with significant cognitive and physical impairments, including dementia, depression, and dependence on staff for all activities of daily living. The resident was physically abused by the CNA during care, as witnessed and reported by another staff member. The facility's policy required screening potential employees for a history of abuse, including contacting previous employers, but this procedure was not followed, allowing the CNA with a known history of abuse to be hired and subsequently harm a resident.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
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Nursing homes near Lakeland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Club At Lake Gibson | 0 mi | ★★★★★ | 2 | 0 |
| Wedgewood Healthcare And Rehabilitation Center | 0 mi | ★★★★★ | 1 | 0 |
| Valencia Hills Health And Rehabilitation Center | 0.5 mi | ★★★★★ | 28 | 0 |
| Breezy Hills Rehab And Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Vivo Healthcare Lakeland | 2.2 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 October 2026) and official state health department websites.