Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Club At Lake Gibson during CMS and state inspections, most recent first.
Unsafe sit-to-stand transfer with inadequate supervision. A resident who required 2-person assist and a mechanical lift was transferred by a CNA without another staff member present and without securing the lower leg straps on the lift. The resident slid from the sling during a long-distance move, reported severe shoulder pain, and was later hospitalized with a closed femur fracture and shoulder dislocation. Staff said the CNA had not been properly shown how to secure the straps and believed using the lift alone was standard practice.
Incompetent Use of Sit-to-Stand Lift During Resident Transfer: A CNA transferred a resident using a sit-to-stand lift without securing the lower leg straps and without another staff member assisting. The resident slid from the lift during transport and sustained a femur fracture and shoulder dislocation. Record review and staff interviews showed orientation and competency documentation did not specify training on the specific lift model or confirm return-demonstration competency, and staff reported differing familiarity with the facility's lift types.
The facility failed to implement effective infection control measures, as staff did not use appropriate PPE for residents on Enhanced Barrier Precautions and did not properly store respiratory equipment. Observations showed staff not wearing gowns during care activities for residents with catheters, wounds, and feeding tubes, despite clear signage. Additionally, a resident's nebulizer mask was left uncovered, contrary to infection control policies. Staff interviews confirmed awareness of protocols but admitted to not following them.
A resident's medications were found unsecured in their room, contrary to the facility's policy and care plan. The resident used a topical analgesic and an ointment, which were observed on the bedside table and nightstand. Staff confirmed that these should have been stored in a locked nightstand, as per the facility's guidelines.
A resident with COPD and a history of adverse reactions to Trelegy Ellipta was repeatedly administered this medication despite her preference for Breztri, which she used at home. The facility pharmacy's formulary interchange led to the replacement of Breztri with Trelegy Ellipta, and staff failed to adjust the medication orders despite being informed of the resident's adverse reactions and preferences.
A facility failed to properly assess and maintain a resident's PICC line, leading to a deficiency in care. The dressing was worn, undated, and not fully attached, with no cap on the catheter. Staff confirmed the lack of monitoring orders, and the resident's records showed no documentation for necessary care. The facility's policies for IV catheter care were not followed, resulting in inadequate care for the resident's IV site.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with IV sites. One resident with a PICC for a UTI lacked EBP signage and nearby PPE, while another receiving chemotherapy and antibiotics had EBP signage but no nearby PPE. Staff interviews revealed inconsistencies in EBP policy understanding and implementation, with the DON acknowledging PPE should be within 2-3 rooms of the resident's doorway.
The facility was found to have multiple deficiencies in medication storage, including unlocked and unattended medication carts, unsecured medications, and loose pills in cart drawers. Observations revealed intravenous and topical medications in an unlocked compartment, blister packs left on top of a cart, and a pill on the floor. Staff interviews confirmed these practices violated facility standards.
Unsafe Sit-to-Stand Transfer With Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and appropriate use of equipment during sit-to-stand transfers for one resident who required assistance from two staff members. The resident was dependent for transfers, did not walk, used a wheelchair for mobility, and had care plan interventions stating she needed assistance x2 and a mechanical lift for transfers. The report states that a CNA transferred the resident without asking for another staff member to assist and without securing the lower leg straps on the [vendor 3000] sit-to-stand lift. During the transfer, the CNA moved the resident from the toilet to the bed over approximately 28 feet. The resident slid to the floor while suspended in the transfer sling, with both arms elevated above her head. The resident reported that she told the CNA to call for assistance as she began sliding, but the CNA continued pushing the lift out of the bathroom and only went to the doorway to request help after the resident started yelling. The resident stated she landed on the floor and experienced severe pain in her left shoulder. The resident was transported to the hospital by EMS and was diagnosed with a closed right femur fracture and a left shoulder dislocation. Hospital records showed imaging confirming a displaced fracture of the distal right femur, and the left shoulder was reduced later that night. The resident’s record also showed chronic kidney disease, myocardial infarction, pacemaker, left artificial knee joint, generalized muscle weakness, and abnormal posture. Staff interviews indicated the CNA had not been shown how to use or secure the lower leg straps on the [vendor 3000] lift and believed it was standard practice to use the lift alone because she had observed other staff doing so. The manufacturer instructions reviewed in the report required securing all required buckles, applying the leg strap or calf support, and not transferring the resident over a long distance.
Incompetent Use of Sit-to-Stand Lift During Resident Transfer
Penalty
Summary
The facility failed to ensure nursing staff were competent in using the sit-to-stand mechanical lift for one resident. On 4/12/26, Staff A, a CNA, used the [vendor 3000] sit-to-stand lift to transfer Resident #1 from the toilet to the bed. Staff A did not ask another staff member for assistance, attached the transfer sling, and did not secure the standing sling clip attachment around the resident's lower legs before moving the resident approximately 28 feet. During the transport, the resident slid from the lift and was suspended in the sling with both arms elevated above the head before falling to the floor. Resident #1 stated during an interview that Staff A did not have assistance from another staff member when the injury occurred and had difficulty maneuvering the lift over a raised threshold in the bathroom doorway. The resident said that when she began sliding, she told Staff A to call for help, but Staff A continued pushing the lift out of the bathroom. The resident reported severe pain after landing on the floor. The admission record showed diagnoses including chronic kidney disease, myocardial infarction, presence of a pacemaker, left artificial knee joint, generalized muscle weakness, abnormal posture, and later documented injuries of a right femur fracture and left shoulder dislocation. Staff A stated she had observed another staff member using the sit-to-stand lift during orientation but realized she did not know how to operate it. She said she received verbal instruction and was not shown how to use or secure the lower leg straps on the [vendor 3000] lift. She also said she did not ask for help because she had seen other staff use the lift alone and believed that was standard practice. Facility interviews and record review showed the CNA onboarding and competency checklists did not identify whether training included the [vendor 3000] or [vendor flex] sit-to-stand lifts or whether competency was validated by return demonstration. Other staff interviewed stated the facility had different types of sit-to-stand lifts and that the [vendor 3000] lift was different from the one used in training, while an LPN said she had never seen that type of lift before.
Infection Control Deficiencies in PPE Use and Equipment Storage
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by staff not using appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). Observations revealed that staff members did not wear gowns while providing care to residents with urinary catheters, open wounds, and gastrostomy tubes, despite clear signage indicating the need for PPE. Interviews with staff confirmed their awareness of the requirement to wear gowns but admitted to not following the protocol during care activities. Additionally, the facility did not adhere to professional standards for storing respiratory equipment. A resident's nebulizer mask was observed uncovered and lying on a bedside table, contrary to the facility's infection control policy, which requires nebulizers to be stored in a bag to prevent contamination. Staff interviews corroborated the observation, acknowledging the need for proper storage of respiratory equipment. The deficiencies were identified across multiple residents and facility halls, indicating a systemic issue with adherence to infection control protocols. The Director of Nursing expressed expectations for staff to follow EBP guidelines and proper storage procedures, but the observations and staff admissions highlighted a gap between policy and practice.
Medication Storage Deficiency for a Resident
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored for a resident, leading to a deficiency. During observations on two consecutive days, a tube of topical menthol analgesic and a container of Dimethicone-Zinc Oxide-Vitamin A-Vitamin D ointment were found on the bedside table and nightstand of the resident's room. The resident confirmed using these medications for back pain and foot care, respectively. The care plan for the resident, revised a day after the initial observation, indicated that the resident should be observed taking medications to ensure proper storage and self-administration, and a lock box should be provided for medication storage as needed. Interviews with staff confirmed the deficiency in medication storage. A Licensed Practical Nurse/Unit Manager acknowledged that the medications should have been securely stored in the resident's nightstand, which was equipped with a lock. The Director of Nursing also stated that the expectation was for the resident to follow the rules and securely store the medications. The facility's policy on medication storage, last reviewed in January 2024, requires that medications and biologicals be stored safely and securely, following the manufacturer's or supplier's recommendations.
Failure to Honor Resident's Medication Preferences
Penalty
Summary
The facility failed to administer medications in accordance with a resident's preference, leading to a deficiency in medication administration. A resident with chronic obstructive pulmonary disease (COPD) and a history of adverse reactions to Trelegy Ellipta was administered this medication multiple times despite her preference and history of using Breztri instead. The resident had informed the facility staff of her adverse reactions to Trelegy Ellipta and her preference for Breztri, which she had been using at home. However, due to a formulary interchange, the facility pharmacy repeatedly replaced Breztri with Trelegy Ellipta, leading to its administration against the resident's wishes. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that the resident's adverse reactions and medication preferences were known, yet the medication orders were not appropriately adjusted. The resident's representative also confirmed that the resident had to repeatedly inform the facility of her inability to take Trelegy Ellipta. The Advanced Practice Registered Nurse (APRN) responsible for the resident's care had instructed the facility staff not to administer Trelegy Ellipta and to use Breztri instead, but this directive was not followed due to the pharmacy's formulary interchange. The facility's policy on resident rights emphasizes the importance of informing residents and involving them in their care planning, which was not adhered to in this case.
Failure to Maintain and Monitor IV Catheter
Penalty
Summary
The facility failed to properly assess and maintain a central intravenous (IV) catheter for a resident, leading to a deficiency in care. Observations revealed that the resident had a peripherally inserted central catheter (PICC) with a dressing that appeared worn and old, with a dried red/black substance around the insertion site. The dressing was not fully attached, lacked a date, and the catheter line was not properly closed. The resident reported having the IV site for at least a week, and photographic evidence was obtained to document the condition. Interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that the dressing was not dated, was coming off, and there was no cap on the catheter. The DON provided a list of residents with IV sites, which did not include the affected resident. A review of the resident's records showed no orders for monitoring the PICC line, flushing the line, or changing the dressing, despite the facility's policy requiring such actions every seven days or as needed. The facility's policies and procedures for IV catheter care, including flushing and dressing changes, were not followed. The resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation for necessary care and monitoring of the PICC line. The DON acknowledged the absence of orders for site monitoring and dressing changes, which are essential for maintaining catheter patency and preventing complications. The facility's failure to adhere to its own policies and procedures resulted in inadequate care for the resident's IV site.
Failure to Implement Enhanced Barrier Precautions for Residents with IV Sites
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were properly implemented for two residents with intravenous (IV) sites. Resident #5, who had a peripherally inserted central catheter (PICC) for antibiotic treatment due to a urinary tract infection, did not have EBP signage posted at the room entryway, and the nearest personal protective equipment (PPE) was located two rooms away. Similarly, Resident #7, who was receiving chemotherapy and antibiotics for a wound infection, had EBP signage posted, but PPE was not readily available near the room, being located around the corner and three rooms away. Interviews with staff revealed inconsistencies in the understanding and implementation of the facility's EBP policy. Staff A, an LPN, confirmed the medical conditions of the residents but did not address the lack of PPE availability. Staff C, another LPN, stated that EBP was used for residents with IVs, foleys, and colostomies, aligning with the facility's policy. The Director of Nursing (DON) acknowledged that PPE should be within 2-3 rooms of the resident's doorway and available in caddies at all times, which was not the case for the observed residents. The facility's policy, dated August 2022, mandates EBP to prevent the spread of multi-drug resistant organisms (MDROs) and requires PPE to be available near or outside resident rooms.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and security of medications, as observed during a survey. On multiple occasions, medication carts were found unlocked and unattended, with medications left unsecured. Specifically, a treatment cart was observed with intravenous and topical medications in an unlocked side compartment while the nurse was inside a resident's room. Additionally, a treatment cart near the nurses' station was left unlocked for an extended period, and a medication cart had blister packs of medication sitting on top without supervision. Furthermore, a yellow pill was found on the floor outside a resident's room, and loose pills were discovered in the drawers of medication carts on different units. The facility's policy requires medications to be stored securely and in an orderly manner, with compartments locked when not in use. However, audits revealed multiple instances of non-compliance, including loose pills, spilled liquid medication, and improperly labeled medications in the carts. Staff interviews confirmed that these practices were against the facility's standards, and management was aware of the issues. The Regional Director of Nursing acknowledged the problem after reviewing photographic evidence of the unsecured medications.
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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) |
|---|---|---|---|---|
| Manor At Carpenters, The | 0 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.