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 Lodge Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with a known peanut allergy was given a snack containing peanuts by a CNA who did not check the resident's meal ticket or electronic medical record for allergy information. The resident consumed part of the snack and experienced an allergic reaction, requiring medical intervention. Interviews revealed a lack of consistent procedures for verifying resident allergies before distributing snacks.
A resident with a PICC line refused its removal, but the facility failed to notify the provider and family of this change in condition. The LPN mistakenly documented the line as discontinued, and the DON confirmed the lack of communication and documentation. The resident's daughter and APRN were not informed, contrary to facility policy.
The facility failed to implement comprehensive care plans for two residents requiring respiratory services. One resident's oxygen was set higher than the physician's order, and another resident's care plan for oxygen use was canceled without reinstatement. The DON acknowledged the expectation for staff to follow care plans, but discrepancies were noted in adherence to physician orders and facility policies.
A facility failed to provide appropriate care for three residents, leading to deficiencies in IV line management and medication administration. A resident's PICC line was not properly maintained, resulting in missed saline flushes and dressing changes. Another resident did not receive necessary saline flushes or insulin coverage for high blood glucose levels, and a third resident received medication outside prescribed parameters. Staff interviews revealed communication and documentation lapses, impacting resident care and safety.
The facility failed to provide correct oxygen flow rates for three residents, as prescribed by their physicians. One resident's concentrator was set at 3 liters instead of the ordered 2 liters, another was at 1 liter instead of 2 liters, and a third was at 4 liters instead of 3 liters. Additionally, oxygen tubing was not changed weekly as required. These discrepancies were confirmed by staff and indicate a failure to follow physician orders and facility policies.
The facility's medication error rate was 6.98%, exceeding the acceptable threshold. An RN failed to ensure a resident followed the correct nasal spray dosage, and an LPN administered an incorrect nicotine patch dosage without proper hand hygiene. The DON confirmed expectations for adherence to physician orders and infection control procedures.
The facility failed to properly store and label medications, with observations of unsecured and unlabeled drugs in resident rooms and medication carts. A resident had an unidentified tablet, another had a pain cream, and a third had an unlabeled cream. Medication carts contained opened drugs without proper labeling. Staff acknowledged the need for proper labeling and storage.
The facility failed to ensure proper food storage and cleanliness in the kitchen. Observations included a hand washing sink without paper towels, a live roach on an overflowing trash can, unlabeled raw meat in the cooler, and boxes on the freezer floor. The Certified Dietary Manager confirmed pest presence and equipment issues, noting that policies were not followed. The facility's policies require food to be stored off the floor, labeled, and dated, which was not adhered to.
The facility failed to maintain accurate medical records for residents, leading to deficiencies in care. A resident's PICC line dressing change was inaccurately documented, and another resident's blood pressure readings were missing from the MAR, affecting medication administration. Additionally, behavior monitoring for a resident on Alprazolam was incorrectly documented. Staff acknowledged these errors, highlighting issues in documentation practices.
The facility failed to follow infection control standards during medication administration and enhanced barrier precautions. An RN did not perform hand hygiene between residents, and an LPN did not sanitize equipment or don a gown for a resident requiring enhanced precautions. The DON confirmed the expectations for hand hygiene and PPE use.
Failure to Prevent Allergen Exposure in Resident with Peanut Allergy
Penalty
Summary
The facility failed to ensure that a resident with a known peanut allergy was provided with food free from allergens. A resident with a documented peanut allergy was given a snack containing peanuts by a Certified Nursing Assistant (CNA) who did not check the resident's meal ticket or electronic medical record for allergy information. The resident consumed part of the snack and experienced an allergic reaction, which required medical intervention. The resident, who had a history of severe allergic reactions to peanuts, including facial and tongue swelling, was given a snack that contained peanuts. The CNA responsible for distributing the snack did not verify the resident's allergies, as indicated on the meal ticket and electronic medical record. The resident, who has visual impairments, was unable to identify the snack as containing peanuts and consumed it, leading to a burning and itching sensation in her throat. Interviews with facility staff revealed a lack of consistent procedures for verifying resident allergies before distributing snacks. The CNA admitted to not checking the computer for allergy information due to time constraints. The facility's policy required all staff to verify resident diets and allergies, but this was not consistently followed, leading to the resident's exposure to a known allergen.
Removal Plan
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting and completed a root cause analysis (RCA) related to the provision of the snacks for Resident #297.
- The Director of Nursing, Assistant Director of Nursing and Nurse Consultant completed an audit of 97 of 97 residents for accuracy of prescribed diet and allergies.
- The Director of Nursing and Dietary Consultant completed an audit of resident allergies listed in the electronic medical record with resident and resident representative interviews to confirm accuracy of allergies listed for 97 of 97 residents.
- The facility initiated the use of a Diet Type Report from the Electronic Health Record during the provision of snacks and meals to ensure the accuracy of diet order, texture and allergies.
- The facility initiated the use of an Alternative Diet Tool in the dietary department to ensure residents received diets as ordered by the physician or snacks in the correct form and ensuring resident are not allergic to food items when requesting food items from the kitchen.
- The facility initiated the use of a Supervisory Monitoring Tool for facility leadership to validate staff are providing appropriate meals and snacks per physician orders and validation of allergies using the Diet Type Report.
- The facility initiated printing meal tickets in color to highlight the red allergies noted on the tickets.
- Residents with food allergies have snacks labeled by the dietary department for them specifically to ensure allergy requirements are maintained.
- Director of Nursing and Assistant Director of Nursing/designee educated staff on: Provide Diet to Meet Needs of Each Resident - Policy and Procedure; Allergies-types of allergies, how they affect individuals, emergency response, the medications commonly used to manage allergic reactions and protecting residents from allergic reactions and accuracy of Diet/Snack education.
- A review of the facility audits documented the DON/designee and dietary consultant conducted a full house audit of 97 residents to determine accuracy of diets and allergies.
- Review of the facility audit tool titled Diet Type Report documented audits were completed.
- Review of the resident meal tickets for 12 of 12 residents with allergies were reviewed and allergies were printed in red.
- A review of the training and education documented 53 of 53 Certified Nursing Assistants, 23 of 23 Licensed Practical Nurses, 5 of 5 Registered Nurses, 23 of 23 rehabilitation therapy staff, 2 of 2 social services staff, 3 of 3 activities staff, 13 of 13 dietary staff, 11 of 11 housekeeping staff and 10 of 10 administrative staff received education on mechanically altered diets/ allergies, emergency response for allergic reactions, medications for allergies, common allergy symptoms in Long Term-Care Residents, and verifying the correct diets/snacks for patients.
Failure to Notify Provider and Family of Change in Condition
Penalty
Summary
The facility failed to notify the provider and resident representative of a change in condition for a resident receiving intravenous therapy. During an observation, the resident was found with a peripherally inserted central catheter (PICC) line in her right upper arm, with a dressing that was partially lifted and stained. Despite a physician's order to discontinue the PICC line, the resident refused its removal. The Licensed Practical Nurse (LPN) mistakenly documented the PICC line as discontinued, although it was not removed. The Director of Nursing (DON) confirmed that the resident's refusal should have been communicated to the doctor and documented accurately, but no such notification was found in the resident's records. Interviews with the resident's daughter and the Advanced Practice Registered Nurse (APRN) revealed that neither was informed about the resident's refusal to have the PICC line removed. The facility's policy requires notifying the physician and family of significant changes in condition, but this protocol was not followed. The resident's daughter stated she was only contacted by the facility for hospital transfers or billing issues, and the APRN expected to be informed of any refusals of care to ensure appropriate orders for maintenance. The lack of communication and documentation led to the deficiency identified by the surveyors.
Failure to Implement Comprehensive Respiratory Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for two residents requiring respiratory services. Resident #71 was observed with an oxygen concentrator set at 3 liters, contrary to the physician's order of 2 liters per minute via nasal cannula with humidification. The care plan for Resident #71 included goals and interventions related to maintaining a patent airway and administering oxygen as ordered, but these were not followed as per the physician's directive. The Director of Nursing (DON) acknowledged the expectation for nursing staff to adhere to the care plan and respiratory care protocols. For Resident #63, the care plan initially documented the potential for respiratory distress related to COPD, but the oxygen focus was canceled and not reinstated. Observations showed oxygen being administered at 1 liter per minute, which did not align with the physician's order of 2 liters per minute. The DON was unaware of the cancellation and received information from the Regional MDS Consultant that the oxygen focus was removed during a modification. The facility's policy requires that respiratory conditions and oxygen use be reflected in the resident's care plan, which was not adhered to in these cases.
Deficiencies in IV Line Management and Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and care according to professional standards for three residents, leading to deficiencies in intravenous line management, medication administration, and monitoring. Resident #397 had a PICC line with a dressing that was not changed as required, increasing the risk of infection. The PICC line was mistakenly documented as discontinued, leading to a lack of necessary saline flushes and monitoring. Staff interviews revealed a lack of communication and adherence to protocols, with the Director of Nursing acknowledging the oversight in maintaining orders for the PICC line care. Resident #301 did not receive necessary saline flushes for their intravenous line, as there were no orders in the system, and the nursing staff failed to notify the physician of blood glucose levels exceeding 400. This oversight in communication and documentation resulted in the resident not receiving appropriate insulin coverage, despite the resident's awareness and communication of their condition. The Director of Nursing and staff acknowledged the failure to notify the provider and document the elevated blood glucose levels. Resident #2 received Midodrine medication outside of the prescribed parameters, with the medication being administered despite systolic blood pressure readings above the threshold. The Director of Nursing and the APRN were unaware of the medication being given out of parameters, indicating a lack of adherence to physician orders and communication among the staff. These deficiencies highlight significant lapses in the facility's medication administration and monitoring processes, impacting resident care and safety.
Failure to Adhere to Prescribed Oxygen Flow Rates
Penalty
Summary
The facility failed to ensure that residents received the correct oxygen flow rate as prescribed by their physicians, affecting three residents. Resident #71 was observed with an oxygen concentrator set at 3 liters per minute, contrary to the physician's order of 2 liters per minute. The resident was unaware of how to adjust the concentrator, and a Licensed Practical Nurse (LPN) confirmed the discrepancy. Similarly, Resident #63 was found with oxygen running at 1 liter per minute, while the physician's order specified 2 liters per minute. Additionally, the oxygen tubing for Resident #63 was not changed weekly as required, with tubing dated from earlier in the month still in use. Resident #65, diagnosed with chronic obstructive pulmonary disease and chronic respiratory failure, was observed with an oxygen flow rate of 4 liters per minute, despite a physician's order for 3 liters per minute. The oxygen concentrator was placed out of the resident's reach, preventing self-adjustment. The LPN acknowledged the incorrect setting. These observations indicate a failure to adhere to physician orders and facility policies regarding respiratory care, potentially compromising resident safety and care quality.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, with an observed rate of 6.98 percent. During an observation, a Registered Nurse (RN) administered medication to a resident without performing hand hygiene and allowed the resident to self-administer two nasal sprays per nostril, contrary to the physician's order of one spray per nostril. The RN acknowledged the error, stating that the resident should have been reminded of the correct dosage. In another instance, a Licensed Practical Nurse (LPN) failed to perform hand hygiene multiple times while administering medications and handling equipment. The LPN also administered an incorrect dosage of a nicotine patch to a resident, applying a 7 mg patch instead of the prescribed 14 mg. The LPN admitted to not paying attention to the dosage and failing to contact the provider when the correct dose was unavailable. The Director of Nursing (DON) confirmed the expectation for staff to follow physician orders and maintain proper infection control procedures.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional principles, as evidenced by several observations. In one instance, a resident was found with an unidentified white oval tablet on their nightstand, and the resident was unaware of what the medication was. Another resident had a bottle of Aspercreme Lidocaine Cream on their nightstand, which they used for pain. Additionally, a third resident had an unlabeled medication cup with white cream on their bedside table, which was intended for application by a nurse. The Director of Nursing acknowledged that medications should not be left unattended in resident rooms. Further observations revealed issues with medication carts in two hallways. The 100 Hall medication cart contained several opened medications, including an inhaler, a vial of Humalog, and eye drops, all lacking open or expiration dates. Similarly, the 500 Hall medication cart had an opened inhaler and insulin pen without open or expiration dates. Staff members confirmed that medications should be labeled with open and expiration dates once opened. The facility's policy on medication storage emphasized the importance of locking compartments and not using outdated or deteriorated medications.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper food storage and cleanliness in the kitchen, as observed during a tour on February 23, 2025. A hand washing sink lacked paper towels, and a live roach was seen on an overflowing trash can nearby. In the walk-in cooler, a large pan of raw meat was found without a label or date, and two large boxes were on the floor in the walk-in freezer. Staff M, the morning cook, acknowledged the labeling oversight and the improper placement of boxes. A follow-up tour on February 24, 2025, revealed further issues, including a reach-in cooler with an out-of-order sign dated August 29, 2023, and visible food splashes, dirt, and spills on various kitchen surfaces and equipment. The Certified Dietary Manager (CDM) confirmed the presence of pests, spills, and splashes, and noted that the out-of-order signs were placed on unusable equipment. The CDM, who had been in the position for approximately three weeks, stated that she expected all policies to be followed regardless of her presence. The facility's policies on food delivery, storage, and refrigerated storage, last reviewed on January 28, 2025, require that food be stored off the floor, labeled, and dated, which was not adhered to in this instance.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for several residents, leading to deficiencies in care. For Resident #397, there was a discrepancy in the documentation of a PICC line dressing change. The Medication Administration Record (MAR) indicated a dressing change on a date that did not align with the observed date on the dressing itself. Additionally, a Licensed Practical Nurse (LPN) mistakenly documented the discontinuation of the PICC line, which was not actually performed. These inaccuracies in documentation were acknowledged by the staff involved, who admitted to errors in their charting practices. Resident #2's medical records also contained deficiencies related to the administration of medications for blood pressure management. The MAR lacked necessary blood pressure readings on multiple occasions, which were required to determine whether medications should be administered. The nursing staff admitted to not documenting the blood pressure readings, which should have been included in the MAR as per the facility's policy. For Resident #15, the facility failed to accurately document behavior monitoring related to the administration of Alprazolam for anxiety. The MAR incorrectly used 'n/a' instead of the appropriate behavior code, which should have been '0' to indicate no behaviors. Staff members acknowledged the mistake and recognized that the documentation was incorrect. The Director of Nursing emphasized the importance of accurate documentation, which was not adhered to in these instances.
Infection Control and Barrier Precaution Deficiencies
Penalty
Summary
The facility failed to adhere to infection control standards during medication administration and enhanced barrier precautions. Observations revealed that a Registered Nurse (RN) did not perform hand hygiene between residents while administering medications to four out of seven residents. The RN was observed exiting a resident's room and immediately preparing medications for another resident without washing hands. Similarly, a Licensed Practical Nurse (LPN) was seen not performing hand hygiene after exiting a resident's room and before handling a blood pressure machine, which was not sanitized between uses. The LPN continued to administer medications and handle equipment without proper hand hygiene, despite acknowledging the oversight during an interview. Additionally, the facility did not follow enhanced barrier precautions for a resident requiring such measures due to dialysis and gastric tube care. An LPN entered the resident's room, which had an enhanced barrier sign, and administered medications via a gastric tube without donning a gown, as required by the facility's policy. The LPN admitted to forgetting this step due to nervousness. The Director of Nursing confirmed the expectations for hand hygiene and the use of personal protective equipment, as outlined in the facility's policies.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 135 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Ocala
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avante At Ocala, Inc | 0.5 mi | ★★★★★ | 27 | 0 |
| Ocala Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 10 | 0 |
| Aviata At Arbor Springs | 0.9 mi | ★★★★★ | 15 | 0 |
| Palm Garden Of Ocala | 2.7 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Ocala | 3 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Lodge Healthcare And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.