Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Scott Lake Health And Rehabilitation Center during CMS and state inspections, most recent first.
Improper medication storage was identified in multiple medication carts, medication rooms, and central supply. Surveyors found loose pills, expired meds, opened inhalers and test strips without dates, and chemical wipes stored with medications and supplies without dividers. An RN, LPNs, the DON, and central supply staff verified several items were expired or improperly stored, including narcotics, insulin pens, inhalation products, and OTC medications.
Call Lights Not Kept Within Reach: Multiple residents were observed with call lights tangled around bed rails, dangling out of reach, or stuck under the bed frame. One resident tried for over two minutes to reach the call light and gave up, while others stated they did not know what the call light was used for or yelled out for help instead. Records showed several residents had weakness, difficulty walking, cognitive impairment, dementia, or needed assistance with toileting and mobility, and staff confirmed call lights should be within reach.
Inaccurate PASRR screening for a resident with schizoaffective disorder, depression, anxiety, and insomnia led to a deficiency when the Level I PASRR marked mental illness diagnoses but indicated no serious MI or ID and no Level II was submitted. The resident was taking an antidepressant and antipsychotic, and psychiatric documentation described chronic psychosis with emotional and behavioral disturbance. The DON stated the diagnoses could potentially be considered serious MI and that she was not aware of the resident’s functional limitations when completing Section II.
Malfunctioning Resident Call Light: A resident’s call light in one room was observed not working, and the resident reported it had broken multiple times in the past few days. The NHA said she had been notified, while the DOM stated he only performed monthly audits unless a malfunction was reported. CNAs said they were trained to keep call lights within reach, answer them immediately, and report defects, and facility documents referenced testing the nurse call system and promptly reporting defective call lights.
Two residents with significant mobility and cognitive impairments did not have individualized care plans specifying the required number of staff for transfer assistance. Care plans and documentation were unclear or outdated, leading to staff confusion and inconsistent transfer practices, including an incident where a CNA used a mechanical lift alone. The facility did not ensure care plans were promptly updated or clearly communicated to staff.
A resident with diabetes and cognitive impairment was admitted without proper reconciliation of her hospital discharge medications, resulting in critical medications like insulin not being ordered or administered. Facility staff failed to notify the provider of abnormal blood glucose and blood pressure readings, and did not perform necessary blood sugar checks until the resident's condition became critical, leading to a hospital transfer for severe hyperglycemia.
A resident with diabetes and hypertension was admitted in a confused state and did not receive required insulin or proper medication reconciliation due to nursing staff errors. Blood glucose monitoring was not performed, abnormal labs and high blood pressure readings were not consistently reported or addressed, and the resident's condition worsened, resulting in emergency hospitalization. Staff interviews revealed confusion about admission protocols and inconsistent use of checklists.
A resident with diabetes and cognitive impairment was admitted with clear hospital orders for insulin, but due to failures in medication reconciliation and provider review, the correct medications were not entered or administered. The resident did not receive insulin or blood glucose monitoring, resulting in severe hyperglycemia and hospitalization. Staff interviews and record reviews confirmed that the facility's medication entry and review processes were not followed, and critical provider notifications were missed.
A facility failed to maintain a medication error rate below 5%, resulting in a 27.27% error rate during observations. An LPN administered incorrect dosages of Fish Oil and probiotics to a resident, while an RN gave another resident incorrect forms and dosages of Magnesium and Vitamin D, nearly administered expired nasal spray, and withheld Metoprolol based on incorrect parameters. The DON confirmed these errors, and the facility's policy lacked specific standards for medication verification.
A resident with multiple health conditions was observed unresponsive and had medications withheld due to lethargy without notifying the physician, Hospice, or family. The facility's policy required prompt notification of changes in condition, but this was not followed, leading to a deficiency. Interviews with staff confirmed the lack of adherence to protocol, and the Director of Nursing acknowledged the failure to document and communicate these changes.
Improper Medication Storage and Expired Medications
Penalty
Summary
Medication storage was not maintained in accordance with accepted professional standards across multiple medication carts, medication rooms, and central supply. On the 100 Hall Top Medication Cart, surveyors found a loose ciprofloxacin pill with no resident name, cholestyramine powder that expired on 3/30/2026, and 11 safety syringes that expired on 2/3/2026. Staff M, RN verified the expired medications and stated they should have been removed, and said nurses were responsible for removing expired medications and cleaning the carts. On the 100 Hall Back Medication Cart, surveyors found an olanzapine medication card that expired on 11/29/2025, a Hydrocodone (Norco) medication card in the narcotic drawer that expired on 4/18/2026, and micro kill bleach wipes stored next to cholestyramine packets without a divider. Staff N, LPN verified the expired narcotic medications and, after the interview, placed the expired medication cards back into the cart. On the 200 Hall Front Half Medication Cart, bleach wipes were stored touching drinking straws and spoons without a divider, and Staff O, LPN stated the wipes should not have been in the cart and verified they were touching the straws. Additional observations showed expired or improperly labeled items in other storage areas. The 400 Hall Medication Cart contained blood glucose test strips with no opened date, opened inhalers and a nasal spray without opened or expiration dates, bleach wipes stored next to oral liquid medications, an opened Ellipta inhaler without an opened or expiration date, opened artificial tears without an opened date, and two opened Symbicort inhalers without opened or expiration dates. The 300 Hall Medication Cart contained an opened and used inhalation solution with an opened date of 4/24/2026 and no expiration date, and a worn Tylenol Three bottle that could not identify the resident or expiration date. The 200 Hall Back Half Medication Cart contained expired AZO, four loose capsules, and bleach wipes and hand sanitizer wipes stored with transdermal nicotine patches without a divider. The 100 Hall Medication Room contained expired Arformoterol Tartrate and expired Pilot Covid-19 at Home Tests, the 300 Hall Medication Room contained expired opened boxes of NovoLog and insulin Lispro prefilled pens, and central supply contained expired Pink-Bismuth and acetaminophen suppositories. The DON and Staff P confirmed several of these items were expired and stated they should have been discarded.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for multiple residents during observations and interviews. Resident #63 was observed in bed with the call light on the floor under the head of the bed on two separate observations, despite having diagnoses including lack of coordination, difficulty walking, dizziness, and muscle weakness and a care plan intervention to use visual aids to remind him to use the call light. Resident #115 was observed in bed with the call light tangled in the bed rail and dangling out of reach while he tried for over two minutes to reach it and then gave up. Resident #7 stated she had a stroke and needed assistance with movement, and her call light was wrapped around the bed rail and hanging out of reach. Resident #124 was observed with the call light stuck under the bed frame with the button facing down, and on a later observation it remained in the same position; the resident stated she yelled out for help until staff arrived. Resident #82’s call light was wrapped around the handrail and hanging low, and the resident stated they did not know what it was or what it was used for. Resident #95 stated the call light was always wrapped around the handrails and she did not know what it was used for. Resident #61 was observed reaching for a call light tangled on the bed rail and unable to extend from the railing, and the resident stated it was out of reach. Record review showed these residents had diagnoses and care needs including weakness, difficulty walking, lack of coordination, cognitive impairment, dementia, Alzheimer’s disease, and dependence or substantial assistance with toileting, bathing, dressing, or mobility. Staff interviews confirmed call lights should be within reach and not wrapped around bed rails, under beds, or under mattresses. The facility policy stated the call light should be positioned within easy reach of the resident.
Inaccurate PASRR Screening for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASRR) was accurate for one resident. The resident’s record showed diagnoses including schizoaffective disorder, depressive type, generalized anxiety disorder, major depressive disorder, recurrent, moderate, and insomnia. The Minimum Data Set indicated the resident was taking an antidepressant and an antipsychotic regularly, and psychiatric notes documented schizoaffective disorder, depression, anxiety, and insomnia. Additional documentation stated the resident had a history of chronic and consistent psychosis with emotional and behavioral disturbance for six months or more. The Level I PASRR dated 9/6/2024 showed anxiety disorder, depressive disorder, and schizoaffective disorder were marked under mental illness, but Section II questions 1 through 7 were marked no, Section III indicated no provisional admission, and Section IV stated no diagnosis or suspicion of serious mental illness or intellectual disability was indicated. Based on this screening, a Level II PASRR was not submitted. During interview, the DON stated she and the ADON share responsibility for completing PASRRs, that she reviews diagnoses and speaks with the physician, psychiatrist, and family to identify MI information, and that the listed diagnoses could potentially be considered serious MI. She also stated she was not aware whether the resident had a history of functional limitations as a result of the MI when she marked no in Section II.
Malfunctioning Resident Call Light
Penalty
Summary
The facility failed to maintain an effective resident call system in room 113, one of four rooms sampled for call light functioning. On 4/20/2026 at 9:55 a.m., room 113 was observed with a malfunctioning call light. During an interview at 9:58 a.m., the resident stated that the call light system had been broken 2-3 times in the past few days. The resident then activated the call light, and it did not function. During interviews, the Nursing Home Administrator stated she had been notified of the broken call lights in the identified room and expected the maintenance director to test all call lights and repair them immediately, with staff trained on call light responses. The Director of Maintenance stated he performed a monthly audit of call lights and repaired the system as needed, but no other routine testing was done unless a malfunction was reported. Staff CNAs stated they were trained to keep call lights within reach, answer them immediately, and report broken call lights verbally or through the electronic reporting system. Review of facility documents showed a weekly task schedule to test the nurse call system and a call light answering policy directing staff to explain and demonstrate call light use and promptly report defective call lights.
Failure to Individualize and Update Transfer Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents, resulting in unclear instructions for staff regarding the required level of assistance for transfers. For one resident with severe cognitive impairment, muscle weakness, and contractures, the care plan was not updated in a timely manner to specify the use of a mechanical lift with two staff members. Staff interviews revealed confusion and lack of clarity about whether one or two staff were needed for transfers, and an incident was observed where a CNA used a Hoyer lift alone, contrary to best practices and the resident's needs. The care plan was only revised after the incident to specify two-person assistance with a mechanical lift. For another resident with hemiplegia, muscle weakness, and a history of falls, the care plan and Kardex documentation were inconsistent regarding the number of staff required for transfers. The care plan included vague instructions such as "1-2 assist as needed" and did not clearly communicate the resident's current needs. Staff interviews indicated that CNAs were left to decide whether one or two staff should assist, based on their judgment rather than clear care plan directives. The resident reported using a sit-to-stand mechanical lift and being informed of a recent fall, but documentation did not specify the required assistance level. The facility's policy required care plans to be individualized, updated with changes in resident condition, and clearly communicated to all staff. However, the interdisciplinary team did not ensure that care plans were consistently revised or that staff were provided with clear, measurable actions for resident transfers. This lack of specificity and timely updating in care plans led to staff uncertainty and inconsistent care practices for residents requiring assistance with transfers.
Failure to Reconcile and Administer Critical Medications on Admission
Penalty
Summary
A resident with a history of type 2 diabetes, hypertension, and cognitive impairment was admitted to the facility with a detailed hospital discharge medication list, including multiple critical medications such as insulin. Upon admission, the facility failed to accurately reconcile and transcribe the resident's medications. Several essential medications from the hospital discharge list, including insulin, were not entered into the facility's physician orders or administered. Instead, the resident received medications not listed on the hospital discharge summary, and some medications were given at incorrect dosages. The admitting nurse and another LPN were involved in entering the orders, but there was confusion and lack of clarity regarding the process, and the provider was not properly consulted to verify the medication reconciliation. Throughout the resident's stay, there was a lack of monitoring and response to abnormal clinical findings. The resident experienced multiple episodes of significantly elevated blood pressure and abnormal laboratory results, including extremely high blood glucose levels. Despite these findings, there was no documentation that the provider was notified of the abnormal results on several occasions, and the resident did not receive insulin or other diabetes medications as ordered by the hospital. Blood glucose checks were not performed until the resident's condition deteriorated significantly, at which point a critically high blood sugar was detected, and the resident was transferred to the hospital. Interviews with staff revealed that the medication reconciliation process was not properly followed, and there was no documentation that the provider reviewed or clarified the orders before they were entered. The facility's admission checklist lacked a mechanism for verification or sign-off, and staff could not produce completed checklists for the resident. The resident's representative and staff confirmed that the resident was unable to advocate for herself due to confusion, and her condition worsened during her stay, culminating in a hospital transfer for severe hyperglycemia and other complications.
Failure to Reconcile Medications and Monitor Diabetic Resident Leads to Immediate Jeopardy
Penalty
Summary
Nursing staff failed to demonstrate competency in reconciling hospital discharge medication orders, monitoring blood glucose levels for a diabetic resident, and recognizing or responding to elevated blood pressures and abnormal laboratory results. Upon admission, the resident, who had a history of type 2 diabetes mellitus, hypertension, and nontraumatic intracerebral hemorrhage, was confused and unable to communicate her medication needs. Despite clear documentation in the hospital discharge instructions indicating the need for daily insulin and other specific medications, these orders were not properly entered into the facility's medical record. Instead, the resident received medications not listed on her hospital discharge summary, and some required medications, including insulin, were omitted entirely. Throughout the resident's stay, there was a lack of appropriate monitoring and response to critical health indicators. Blood glucose checks were not performed from admission until the day the resident was transferred to the hospital, despite the resident being diabetic and having abnormal lab results indicating hyperglycemia. The resident also experienced multiple episodes of significantly elevated blood pressure, with inconsistent or delayed provider notification and intervention. Laboratory results showing dangerously high blood glucose and other abnormal values were reviewed by nursing staff but not communicated to the provider in a timely manner, and there was no documentation of follow-up or corrective action. Interviews with staff revealed confusion and lack of clarity regarding the medication reconciliation process, with nurses relying on incomplete or incorrect documentation and failing to ensure provider review and verification of orders. Admission checklists and protocols were inconsistently used or not documented, and there was no reliable system to confirm that chart checks and medication reconciliations were completed accurately. The resident's condition deteriorated during her stay, culminating in a critical hyperglycemic episode that required emergency transfer to the hospital.
Failure to Ensure Accurate Medication Reconciliation and Administration on Admission
Penalty
Summary
A resident with a history of type 2 diabetes mellitus, hypertension, and other significant medical conditions was admitted to the facility with clear hospital discharge instructions that included multiple medications, notably sliding scale insulin and long-acting insulin glargine. Upon admission, the resident was confused and unable to communicate her medication needs. Despite the hospital records and the resident representative informing staff about the insulin requirement, the facility failed to enter the correct medication orders into the resident's medical record. Instead, several medications not listed on the hospital discharge summary were ordered and administered, while critical medications, including insulin, were omitted. The medication reconciliation process was not properly completed or documented. The admitting LPN and another assisting LPN did not ensure that the hospital discharge medication list was accurately transcribed or reconciled with a provider before entering orders into the system. There was no evidence that the provider reviewed or clarified the orders, and the required chart checks by night shift staff were not documented. As a result, the resident did not receive insulin or have blood glucose monitoring performed for several days, despite having abnormal lab results and elevated blood glucose levels documented in the record. Providers were not consistently notified of these abnormal findings, and the resident's condition deteriorated, leading to hospitalization for severe hyperglycemia. Interviews with facility staff, including nurses, the DON, ADON, and the medical director, confirmed that the medication lists did not match and that the expected process for medication reconciliation and provider review was not followed. The consultant pharmacist also confirmed that the facility is responsible for entering medication orders correctly and that she was not aware of the full extent of the medication errors. The resident's health declined during her stay, with documented confusion, lethargy, and ultimately a critical episode of hyperglycemia requiring emergency intervention.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 27.27% error rate during the observation of medication administration for two residents. Staff A, an LPN, administered medications to Resident #2, including incorrect dosages of Fish Oil and a probiotic. Specifically, Resident #2 received 500 mg of Fish Oil instead of the ordered 2000 mg and was given lactobacillus acidophilus instead of the prescribed Saccharomyces boulardii. These errors were confirmed by Staff A upon review of the medication profile. In another instance, Staff B, an RN, administered medications to Resident #3, which included several discrepancies. Resident #3 was given Magnesium Oxide instead of the ordered Magnesium Gluconate and received Vitamin D in a different form and dosage than prescribed. Additionally, an expired Ipratropium nasal spray was nearly administered, but the error was caught by a state surveyor. Furthermore, Metoprolol was withheld based on incorrect parameters, as the resident's heart rate did not meet the criteria for withholding the medication. The Director of Nursing acknowledged these errors as legitimate upon being informed. The facility's policy on medication administration lacked specific standards for ensuring the correct medication and dosage were administered, contributing to these errors. The policy did not include verification procedures for medication administration, which may have prevented these discrepancies.
Failure to Notify Physician and Hospice of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the attending physician or Hospice of a change in condition for a resident, leading to a deficiency. The resident was observed in a low bed with fall mats, wearing an oxygen cannula, and was unresponsive. The resident's medical history included chronic obstructive pulmonary disease, schizoaffective disorder, major depression, anxiety disorder, and dementia. The care plan indicated the resident was incapable of making healthcare decisions and had an activated medical decision maker. The facility was required to work with Hospice to meet the resident's needs and monitor for complications related to hypertension and sedative/hypnotic therapy. The facility's records showed several instances where medications were withheld due to the resident's lethargy, but the attending physician, Hospice, and family were not notified. Specifically, the resident's blood pressure was recorded at 157/114, and Klonopin and Haloperidol were not administered on multiple occasions without proper notification. The facility's policy required prompt notification of changes in the resident's condition, but this was not followed, as evidenced by the lack of documentation and communication with the necessary parties. Interviews with staff, including RNs and the Director of Nursing, confirmed that the facility's protocol for notifying physicians and families was not adhered to. The Hospice RN also noted complaints about the facility holding medications without notifying the ordering physician. The Director of Nursing acknowledged the failure to document and communicate these changes, emphasizing that if it wasn't documented, it wasn't done. The facility's policy on changes in a resident's condition or status was not followed, leading to the deficiency identified in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakeland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Highlands Lake Center | 2.9 mi | ★★★★★ | 2 | 0 |
| Bridgewalk On Harden Health And Rehabilitation, Ll | 3.9 mi | ★★★★★ | 0 | 0 |
| Florida Presbyterian Homes Inc | 5.5 mi | ★★★★★ | 0 | 0 |
| Lakeland Hills Center | 8.1 mi | ★★★★★ | 17 | 0 |
| Charming Lakes Rehab | 8.1 mi | ★★★★★ | 11 | 0 |
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