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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake City Center For Nursing And Healing Llc during CMS and state inspections, most recent first.
Insufficient nursing staffing led to delayed ADL care, late medication administration, and missed ordered enteral feeding. Residents and CNAs reported long waits for incontinence care, help with meals, and response to call lights, especially on the overnight shift. MARs showed repeated late doses for multiple residents, including meds given hours late or after midnight, and an LPN confirmed she forgot to connect a resident’s PEG tube feeding because she had too many tasks and about 30 residents assigned.
A resident with dysphagia, PEG tube status, and multiple neurologic diagnoses did not receive enteral feeding as ordered. The resident was observed disconnected from Jevity 1.5 with the pump turned off and about 1,300 mL remaining when the feeding should have been running, and was later still disconnected when a new feeding cycle should have started. An LPN confirmed she forgot to connect the feeding as ordered, and the DON later confirmed the error.
Failure to Provide Bathing Care During Hot Water Outage: A resident who required partial to moderate assistance with bathing reported going weeks without hot showers while hot water was unavailable. CNAs confirmed that most residents on the unit received bed baths with lukewarm water during the outage, with only two residents able to shower elsewhere. The DON stated residents were told they could go to another hall for showers, but the resident said he felt dirty, neglected, and had reported his concerns to staff.
A resident with dysphagia, PEG status, and tube feeding as the sole source of nutrition experienced a 35-pound weight loss while the RD documented the regimen met estimated needs and the loss was beneficial due to obesity. During two observations, the resident was not connected to the ordered Jevity 1.5 infusion, the pump was off, and about 1,300 mL remained in the bottle; the DON later confirmed the feeding was not connected and that it was an error.
A resident who depended on PEG tube feeding was ordered Jevity 1.5 at 60 mL/hr for 22 hours daily with free-water flushes, but was observed disconnected from the feeding with the pump turned off and about 1,300 mL of formula still hanging at the bedside. An LPN confirmed she had not connected the feeding and said she forgot to do so, and the DON later confirmed the enteral feeding had not been connected as ordered.
An LPN left a medication cart unlocked and unattended during medication administration while entering a resident’s room and again while leaving to replace an oxygen cylinder. The cart was outside the LPN’s line of sight on both occasions. The DON stated medication carts were expected to be locked whenever unattended or out of view, and the LPN acknowledged the cart should have been secured.
Surveyors found that staff failed to follow facility policy for safe food storage and labeling in dry storage and in resident refrigerators on two halls. In the kitchen’s dry storage, multiple cereal bins were past their expiration dates and dozens of pre-packaged cereal bowls were kept without labels or dates. On two halls, refrigerators contained unlabeled, undated leftovers, including visibly moldy veggie trays, chicken plates, sandwiches, and other food items wrapped or covered but not dated. Dietary staff, CNAs, and unit managers confirmed these foods should have been labeled, dated, and discarded within the facility’s stated time frames, and leadership acknowledged the refrigerators were unsanitary and that no performance improvement plan was in place to address these issues.
Failure to provide nail care for a resident with DM and CKD was identified when the resident reported staff were not cutting toenails and observed toenails were excessively long, jagged, and curling over the toes. Staff stated nurses were responsible for nail care, but podiatry typically cut toenails and residents had to be added to the podiatry list through SSA; the DON noted the resident was not yet on the list and podiatry scheduling had changed.
Medication Error Rate Exceeded 5 Percent: Surveyors found 3 medication errors in 38 opportunities, resulting in a 7.89% error rate. An LPN gave a resident citalopram 20 mg instead of the ordered 10 mg and administered hydralazine after it had already been given earlier that morning. In a separate observation, another LPN gave a resident Mucinex 400 mg instead of the ordered 600 mg ER dose.
Unlocked medication carts and an unsecured pill were observed on two hallways. An LPN left the 500 Hall cart unlocked while documenting, and a round pink pill was left on top of the cart after being found on the floor. Another LPN left the 200 Hall cart unlocked and unattended while in a resident’s room and stated she was unsure of the protocol for unlocked medication carts.
Meal Preferences Not Followed for A Resident: A resident with cerebral infarction, CKD stage 5, and DM2 with little to no cognitive impairment repeatedly received grits for breakfast even though hot cereal was listed as a dislike on the meal ticket. The resident stated she was sent grits all the time and did not like hot cereal, and staff interviews showed the tray checker was responsible for verifying the tray while a CNA said she did not read the meal ticket.
Multiple residents who were dependent on staff for ADLs did not consistently receive scheduled showers, nail care, shaving, or skin moisturizing as outlined in their care plans and the facility’s ADL policy. One resident with muscle wasting and atrophy was repeatedly observed unkempt, unshaven, and with long, dirty fingernails despite being scheduled for regular showers and staff assistance with all ADLs, and reported not having had a bath in over two weeks. Another resident with hemiplegia, totally dependent for personal hygiene, was observed unshaven with long nails containing debris, even though the unit manager stated that shaving and nail care should occur on shower days. A third resident with gout and nutritional deficiency had documented frequent showers but was found with dry, flaky feet that had not been moisturized, contrary to expectations for skin care on bath days. A fourth resident with a collapsed vertebra, cognitively intact and requiring assistance with all ADLs, reported not having had a shower in weeks and was observed with matted, greasy hair, while a CNA attributed missed showers to short staffing and leadership confirmed expectations that scheduled showers and related grooming be provided and documented.
The facility failed to maintain adequate nursing staff to meet resident needs, as indicated by the Facility Assessment Tool and PBJ Staffing Data Report for Q2 2024. The facility, with a census of 212 residents, required 84 hours for licensed nurses and 233 hours for aides daily. However, it triggered low weekend staffing and received a one-star rating due to issues like missed PBJ data deadlines and RN staffing gaps. The Administrator and President of Operation acknowledged these deficiencies.
The facility failed to maintain food safety and sanitation standards, with issues such as improper hair restraint use, unlabeled food items, missing temperature logs, and unsanitary kitchen conditions. Structural problems, including a malfunctioning drainage system and gaps in the kitchen door, contributed to the deficiencies.
The facility failed to assess residents for self-administration of medications and did not ensure safe storage, leading to incidents where medications were found in residents' rooms without authorization. One resident with severe cognitive impairment experienced a medical emergency after accessing unknown medications, while others were found with expired or unauthorized medications. Staff interviews confirmed that no residents were assessed for self-administration, and medications should not have been left at the bedside.
The facility failed to properly store personal care items in five bathrooms, leading to potential cross-contamination. Observations showed that bedpans and urinals were not bagged or labeled and were improperly stored. The DON confirmed these findings and stated that CNAs were expected to rinse, bag, and label these items, which was not done.
A resident with intact cognition and multiple medical conditions was served a meal that did not align with her stated preferences, despite the facility's policy to support resident choice. The resident, who does not eat potatoes, was served sweet potatoes, which was incorrectly labeled on her meal card. The dietary manager acknowledged the error, and the resident expressed dissatisfaction with meal options, particularly on weekends.
The facility failed to maintain a safe, clean, and comfortable environment, with deficiencies noted in four rooms across two halls. Issues included missing paint, holes, crumbling walls, dirty floors, and broken air conditioning vents. The Administrator and Maintenance Director confirmed these concerns and were aware of the need for repairs.
The facility failed to complete PASRR Level II assessments for two residents with bipolar disorder, as required. Staff interviews revealed a lack of coordination and responsibility in verifying PASRR Level I accuracy, with the Admissions Director not checking for accuracy and the Social Service Department responsible for follow-up. The facility lacked a PASRR policy, contributing to the deficiency.
The facility failed to provide proper care for PICC lines for two residents. One resident's PICC line dressing was not changed according to physician's orders, and the IV tubing was not labeled. Another resident had no physician's orders for PICC line care, and the dressing was not changed weekly. Staff interviews revealed confusion about responsibilities and documentation for PICC line care.
The facility failed to adhere to physician orders for oxygen therapy for two residents, leading to incorrect oxygen delivery rates. One resident received less oxygen than prescribed, while another received more. These discrepancies were confirmed and corrected by an LPN, highlighting a lapse in following established protocols.
Insufficient Nursing Staffing Caused Delays in Care and Medication Administration
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs and did not have an established planned staffing level for determining the number and type of nursing staff needed. The census was 208 residents, and the DON stated the facility had many open RN, LPN, CNA, and ADON positions and could not state the number of vacant nursing positions. The DON also stated the facility did not have a specific number of nursing staff established for each shift. Staff interviews described ongoing short staffing, especially on the 7:00 PM to 7:00 AM shift, with residents reporting long waits for care and treatment, limited staff availability in the dining room, and difficulty reaching staff by telephone. Resident interviews described delays in ADL care and response to needs. One resident stated that on an evening shift he lay in his own feces for over two hours waiting for care, that staff cut off the call light and said they would return, and that his buttocks became irritated while he waited. Another resident stated that at night residents would spend hours itching and waiting to be changed and reported a recent urinary tract infection. A CNA stated there was insufficient staff to provide care for residents who required two or more staff for ADLs and transfers, and that the facility often relied on overtime because staff called out during the evening shift. Medication administration records showed repeated delays across multiple residents and shifts. For one resident with paraplegia, multiple scheduled morning medications were given several hours late on multiple days, evening medications were often administered after midnight, and one antibiotic dose scheduled for 6:00 AM was not given until more than 27 hours later. For another resident with multiple chronic conditions and dependence for ADLs, numerous scheduled medications were administered several hours late, including one dose of adalimumab given more than eight hours late and one antibiotic dose not administered until the following day. For a third resident, multiple evening medications were administered many hours late, including doses given the next morning after being scheduled for the prior evening. The DON stated the acceptable medication administration window was one hour before to one hour after the scheduled time, but said she did not know about the repeated delays and that nurses either forgot to document or were running late. The report also documented missed ordered enteral nutrition. A resident with a PEG tube and an order for Jevity 1.5 at 60 mL per hour for 22 hours daily was observed disconnected from the feeding at a time when the feeding should have been infusing, and later remained disconnected even after a new feeding cycle should have started. An LPN assigned to the resident confirmed she had not connected the feeding and said she forgot because there were a lot of things going on. The DON stated the LPN’s assignment was typically about 30 residents and acknowledged the facility had received complaints and grievances regarding insufficient staffing and delays in resident care.
Enteral Feeding Not Implemented as Ordered
Penalty
Summary
The facility failed to implement the comprehensive care plan for one resident receiving enteral nutrition. The resident had diagnoses including anoxic brain damage, cerebral infarction, oropharyngeal dysphagia, gastrostomy status, tracheostomy status, myoclonus, epilepsy, and morbid obesity due to excess calories. The resident’s MDS indicated that 51% or more of total calories were received through enteral tube feeding and that 501 mL or more of fluid per day were received by IV or tube feeding during the assessment period. The care plan addressed the resident’s need for enteral nutrition related to dysphagia and included interventions to maintain nutritional and hydration status and provide enteral nutrition as ordered. The physician ordered Jevity 1.5 via PEG tube at 60 mL per hour for 22 hours daily, starting at 2:00 p.m. and stopping at 12:00 p.m. the next day, for a target volume of 1,320 mL daily. During observation, the resident was found disconnected from the enteral feeding, with the pump turned off and approximately 1,300 mL of Jevity 1.5 remaining in the bottle when the feeding should have been infusing. Later the same day, the resident was again observed disconnected, with the pump still turned off and approximately 1,300 mL remaining, even though a new feeding cycle should have started at 2:00 p.m. The assigned LPN confirmed she had not connected the feeding as ordered and stated she forgot because there were a lot of things going on. The DON was informed and later confirmed the feeding had not been connected as ordered.
Failure to Provide Bathing Care During Hot Water Outage
Penalty
Summary
The facility failed to provide necessary ADL bathing care for one of three residents reviewed. A review of the facility policy titled Activities of Daily Living noted that residents who are unable to carry out ADLs are to receive the necessary services to maintain good nutrition, grooming, and personal oral hygiene, and that bathing care is to be provided based on the resident’s comprehensive assessment and needs. R2’s quarterly MDS, with an ARD of 05/01/2026, showed a BIMS score of 14, indicating intact cognition, and that R2 required partial to moderate assistance with bathing. During interviews, R2 stated that hot water was not working for about three to four weeks during June 2026 into July 2026, and that he only received bed baths with tepid water during that period. R2 reported that he went without hot showers for at least three weeks, felt dirty, nasty, and neglected, and had reported his concerns to staff. CNAs confirmed there were hot water issues affecting the unit, and stated that most residents received bed baths with lukewarm water during that time, with only two residents able to go upstairs for showers. The DON stated that residents on the affected units should have received hot water for baths, but individual care plans were not updated, and residents were told they could go to the 200 hall for showers. CNA GG also confirmed that R2 did not receive any showers during the several weeks the hot water was out.
Tube Feeding Not Connected as Ordered With Significant Weight Loss
Penalty
Summary
The facility failed to ensure that one of 16 residents receiving tube feeding maintained acceptable parameters related to body weight. The resident was admitted with diagnoses including morbid obesity, anoxic brain damage, cerebral infarction, oropharyngeal dysphagia, gastrostomy status, tracheostomy status, myoclonus, and epilepsy. The resident’s MDS indicated that 51% or more of total calories were received through enteral feeding and that 501 mL or more of fluid per day were received by IV or tube feeding. The care plan identified the resident’s need for enteral nutrition related to dysphagia and included interventions for nutritional and hydration status monitoring. Weight records showed a decline from 243 pounds to 208 pounds over the documented period, a loss of 35 pounds or 14.4%. Physician orders directed Jevity 1.5 via PEG at 60 mL per hour for 22 hours daily, with free-water flushes at 50 mL per hour for 22 hours. RD notes documented that the resident was NPO and that the prescribed tube feeding was the sole source of nutrition, while also stating that the regimen met estimated nutritional needs and that the resident’s weight loss was considered beneficial due to obesity. During two observations, the resident was not connected to the enteral feeding, the pump was turned off, and approximately 1,300 mL of Jevity 1.5 remained in the bottle even though the feeding should have been infusing. The DON was informed and later confirmed that the feeding was not connected and that this was an error.
Enteral Feeding Not Administered as Ordered
Penalty
Summary
R6, a resident with anoxic brain damage, cerebral infarction, oropharyngeal dysphagia, tracheostomy status, epilepsy, myoclonus, and morbid obesity, was admitted with enteral nutrition as the sole source of nutrition through a PEG tube. The resident’s physician ordered Jevity 1.5 at 60 mL per hour for 22 hours daily, starting at 2:00 PM and stopping at 12:00 PM the following day, with free-water flushes at 50 mL per hour for 22 hours. The care plan addressed enteral feeding, hydration, aspiration precautions, tube dysfunction monitoring, and gastrostomy site care, and the RD documented continuation of the prescribed regimen. During observation, R6 was found disconnected from the enteral feeding with the pump turned off, and a bottle of Jevity 1.5 remained hanging at the bedside with approximately 1,300 mL still in it. The feeding was observed again later the same day still not connected, with the pump off and the same amount of formula remaining, even though a new 22-hour feeding cycle should have been underway. An LPN assigned to R6 confirmed she had not connected the feeding, was unsure who had disconnected it, and stated she forgot to connect it because there were a lot of things going on. The DON was notified and later confirmed the enteral feeding had not been connected and that this was an error.
Unsecured Medication Cart During Medication Administration
Penalty
Summary
The facility failed to ensure that medications were secured and inaccessible to unauthorized individuals during one of three medication administration observations. During medication pass observations on 07/29/2026 at 8:35 AM, an LPN prepared medications for a resident and then left the medication cart unlocked and unattended in the hallway while entering the resident’s room to administer the medications. The cart was outside of the LPN’s line of sight while she was in the room. At 8:45 AM, the LPN again left the medication cart unlocked and unattended when she exited the resident’s room and stated she would be right back, then took an oxygen cylinder down the hallway to replace it. The medication cart remained outside of her line of sight while she was away. During interview, the LPN stated the cart should be locked when left unattended and acknowledged she did not lock it that time. The DON stated medication carts were expected to be locked whenever left unattended or outside the nurse’s line of sight and confirmed the cart should have been locked on both occasions. The DON was asked for the facility policy on medication storage and security, but it was not provided before the survey exit.
Failure to Safely Store, Label, and Discard Food in Dry Storage and Resident Refrigerators
Penalty
Summary
The deficiency involves the facility’s failure to follow its “Food Receiving and Storage” policy and safe food handling practices for dry storage and resident refrigerators on Hall 100 and Hall 800. During an initial kitchen tour, surveyors observed five plastic bins of cereal in the dry storage area with expired dates and 73 bowls of pre-packaged cereal stored without labels or dates, despite policy requirements that dry foods removed from original packaging be labeled, dated, and rotated using a first-in, first-out system. The Certified Dietary Manager (CDM) confirmed the cereal was expired and should have been discarded. On Hall 800, the refrigerator contained unlabeled and undated food items, including a 2 lb 6 oz veggie tray and a leftover cooked chicken plate with unidentifiable food items due to a fuzzy green substance, as well as three unlabeled and undated peanut butter and jelly sandwiches. The Dietary Aide stated nursing was responsible for the hall refrigerators, and the CNA and Unit Manager on Hall 800 confirmed the items were undated, moldy, and should have been thrown away, noting nursing staff were expected to discard food after three days. On Hall 100, the Unit Manager confirmed the presence of unlabeled, undated leftover chicken, rice, an egg roll, a small plastic container of greens, and a plate of unidentifiable food with a fuzzy green substance covered with a paper towel and wrapped in a brown plastic bag, and stated these items should have been labeled, dated, and discarded within three to five days. The CDM, Dietitian Manager, and Administrator later acknowledged that the refrigerators on both halls were in an unsanitary condition and that there was no Performance Improvement Plan in place to address food storage, labeling, and sanitation of the resident refrigerators.
Failure to Provide Nail Care
Penalty
Summary
Provide appropriate foot care was not ensured for R92, a resident admitted with diagnoses including spinal stenosis, cervical region and type 2 diabetes mellitus with diabetic chronic kidney disease. The EMR showed an order for Podiatry/Oral/Dental Care as needed starting 01/21/2025. During an interview and observation on 04/17/2026, R92 reported that staff were not cutting toenails. During a later interview and observation, R92 stated that his toenails and fingernails were as long as they would get, and he would allow someone to cut his toenails if offered. The left great toenail was observed to be jagged, and the other toenails were curling over the toes due to their length. Staff interviews showed that nurses were responsible for nail care, but podiatry typically cut toenails, and residents had to be added to the podiatry list through Social Services. The SSA reported podiatry was last scheduled in the facility on 04/07/2026 and was scheduled again for 04/30/2026. The DON stated that SSA would add R92 to the podiatry list and that the next appointment was scheduled for 04/30/2026, while also noting that prior podiatry services were no longer being used and a new podiatrist had just started in April 2026.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent during a medication administration review. Surveyors identified 3 errors out of 38 opportunities, resulting in a 7.89 percent medication error rate. The deficient practice involved medication administration observations, record review, and staff interviews that showed errors in dose and timing during administration to residents. On 04/18/2026, an LPN administered citalopram 20 mg and hydralazine 50 mg to a resident when the physician order was for citalopram 10 mg daily and hydralazine 50 mg every 8 hours. The MAR showed hydralazine had already been given earlier that morning, and an RN supervisor later confirmed the 20 mg citalopram blister pack remained in the cart above the 10 mg pack. On 04/19/2026, another LPN administered Mucinex 400 mg to a resident when the order was for Mucinex ER 600 mg every 12 hours. An RN supervisor and the LPN confirmed the resident received the wrong dose.
Unlocked Medication Carts and Unsecured Medication
Penalty
Summary
Drugs and biologicals were not properly locked, secured, and discarded on two of seven medication carts, including the 500 Hall and 200 Hall carts. The facility policy titled Medication Storage stated that all drugs and biologicals are to be stored in locked compartments such as medication carts, cabinets, drawers, refrigerators, and medication rooms under proper temperature controls. During an observation on 04/18/2026 at 3:09 AM, an LPN was observed sitting behind the nurse’s station while the 500 Hall medication cart was unlocked and unattended, and an unsecured round pink pill was sitting on top of the cart. The LPN confirmed the cart was unlocked while she was putting in notes and stated the pill had been found on the floor and she forgot to discard it. During another observation on 04/18/2026 at 11:40 AM, an LPN was observed in a resident’s room while the 200 Hall medication cart was unlocked and unattended. The LPN confirmed she had left the cart unlocked while retrieving a glucose check and stated she was not sure what the protocol was related to unlocked medication carts.
Meal Preferences Not Followed for Resident
Penalty
Summary
The facility failed to ensure that meal preferences were followed for one resident, R165, who had diagnoses including cerebral infarction, chronic kidney disease stage 5, and type 2 diabetes mellitus with proliferative diabetic retinopathy with macular edema of the left eye. A quarterly MDS assessment documented a Brief Interview of Mental Status score of 15, indicating little to no cognitive impairment. During an interview and observation on 04/17/2026, R165 stated she was sent grits all the time and did not like hot cereal, yet her breakfast tray contained a bowl of grits and the meal ticket listed hot cereal as a dislike. On 04/18/2026, R165 again reported receiving grits for breakfast. On 04/19/2026, R165's breakfast tray was observed at the bedside while paramedics were preparing her for transfer to the hospital, and she was observed with food in her mouth and a bowl of grits on her tray; the meal ticket on the tray again documented hot cereal as a dislike. The Food Service Director stated the checker was responsible for ensuring the tray was correct, and the Registered Dietician and Food Service Director reported dietary staff were educated to ensure meal tickets were followed correctly. A CNA stated she did not read the meal ticket and would rely on the resident to say what she liked or take the tray back if she did not like something.
Failure to Provide Scheduled ADL Care Including Showers, Nail Care, and Shaving
Penalty
Summary
The deficiency involves the facility’s failure to provide activities of daily living (ADL) care, including scheduled showers, nail care, and shaving, to multiple residents who were dependent on staff assistance. The facility’s ADL policy required that, based on comprehensive assessment and resident needs and choices, residents’ abilities in ADLs should not deteriorate and that care and services would be provided for bathing, dressing, grooming, and oral care. A review of the grievance log over several months showed multiple complaints from residents and families about missed baths/showers, shaves, nail care, and lack of skin moisturizing. Despite this, several residents with documented self-care deficits and staff-dependent status for personal hygiene did not receive consistent ADL care as scheduled. One resident with muscle wasting and atrophy, cognitively intact and care planned to receive staff assistance with all ADLs, was scheduled for showers three times weekly on the day shift. Documentation showed only four showers in December, and repeated observations on different days showed the resident unkempt, with disheveled hair, unshaven face, and long fingernails with dirt and brown debris. The resident reported that his bath days were different from what was in the POC, stated he preferred bed baths, and reported not having had one in over two weeks, also expressing a desire for nail clipping and shaving. A nurse supervisor confirmed the resident’s long, dirty nails and unshaven condition. Another resident with hemiplegia and total dependence on staff for personal hygiene, care planned for staff assistance of two, had scheduled shower days twice weekly but was documented as receiving only a limited number of showers in December. Observations on consecutive days showed this resident unshaven with long fingernails containing brown debris, and the unit manager confirmed the lack of shaving and nail care despite the expectation that these tasks be completed on shower days. A third resident with gout and nutritional deficiency, assessed as needing staff assistance with personal hygiene and care planned for a self-care performance deficit, had scheduled showers three times weekly on the night shift. CNA documentation indicated frequent showers throughout December, yet observation of the resident’s feet revealed white, dry, flaky skin, and the unit manager acknowledged that the resident’s skin had not been moisturized and that it would not appear that way if scheduled showers and associated skin care were being provided. A fourth resident with a collapsed vertebra, cognitively intact and requiring staff assistance with personal hygiene, was care planned for staff assistance with all ADLs and scheduled for showers three times weekly on the day shift. Documentation showed only four showers in December, and observation revealed matted, greasy, disheveled hair. This resident reported that her shower days were different from those in the POC and stated she had not had a shower in three weeks, also noting she had not attended activities because of this. A CNA reported that this resident had not received showers due to CNA short staffing. The DON stated her expectation that residents receive scheduled showers three times weekly and as needed, with nails clipped and faces shaved on shower days and as needed, and that CNAs and unit managers were responsible for following POC shower schedules and documentation.
Inadequate Staffing Leads to Deficiency
Penalty
Summary
The facility failed to ensure adequate nursing staff to meet the needs of its residents, as revealed by staff interviews and a review of the Facility Assessment Tool (FAT) and Payroll-Based Journal (PBJ) Staffing Data Report for Quarter 2, 2024. The facility, licensed for 242 beds, had a current census of 212 residents. The FAT indicated that the average daily staffing needs were 84 hours for licensed nurses providing direct care and 233 hours for nurses' aides. However, the PBJ Staffing Data Report showed that the facility triggered excessively low weekend staffing and received a one-star staffing rating due to several issues, including failure to submit PBJ data by the deadline, more than four days in the quarter without RN staffing hours, and failure to respond to or pass a CMS audit designed to discover discrepancies in PBJ data. Interviews with the Administrator and the President of Operation confirmed their awareness of these staffing deficiencies.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to several food safety and sanitation protocols, as observed during a kitchen tour. Dietary staff did not consistently wear hair restraints, leading to instances where hair was not fully covered while plating food. Additionally, the facility did not maintain proper labeling and storage of food items, with several unlabeled bags of fish, beef, chicken, biscuits, and turkey bacon found in the walk-in cooler and freezer. The temperature logs for refrigeration units were missing for several days, indicating a lack of monitoring to ensure food preservation. The kitchen environment was found to be unsanitary, with a buildup of grease and dirt on various surfaces, including the oven, hood vent, ceiling vents, and floor tiles. The reach-in refrigerator had a thick, dark liquid on its floor panel, and the kitchen floor was covered with water puddles and sticky substances. The facility also had structural issues, such as gaps in the kitchen door that allowed pests to enter, missing floor tiles, and a malfunctioning drainage system that caused water to seep onto the floor. The facility's maintenance and cleaning practices were inadequate, as evidenced by the presence of flies in the kitchen and personal items stored on kitchen counters. The Dietary Manager confirmed the lack of daily temperature logging and acknowledged the need for improved cleaning practices. The facility's leadership was aware of the plumbing issues and had begun seeking solutions, but the unsanitary conditions persisted, affecting the overall food safety and hygiene standards.
Failure to Assess and Safely Store Medications
Penalty
Summary
The facility failed to assess seven residents for their ability to self-administer medications and did not ensure safe storage of medications at the bedside. This oversight led to several incidents where medications were found in residents' rooms without proper authorization or assessment. For instance, one resident with severe cognitive impairment was found with a cup of unknown medications, leading to a medical emergency where the resident became lethargic and had unstable vital signs. Despite the severity of the incident, it was not reported to the State agency, and no preventative measures were implemented to prevent recurrence. Another resident, who was cognitively intact, was found with an expired inhaler at the bedside, which was not prescribed by the facility's physician. The medication was removed by a nurse, who confirmed it should not have been in the room. Similarly, a resident with a history of drug-induced disorders was observed with medications left at the bedside by a nurse who was called away to attend to another task. The nurse admitted to leaving the medications unattended, which was against the facility's policy. Additional observations revealed that residents with varying degrees of cognitive impairment had medications or medical supplies, such as isopropyl alcohol and hydrogen peroxide, left in their rooms without proper assessment or authorization for self-administration. Interviews with staff, including the DON and LPNs, confirmed that no residents had been assessed for self-administration, and medications should not have been left at the bedside. Despite these findings, the facility did not have a system in place to monitor or track such incidents, indicating a systemic failure in medication management and resident safety protocols.
Improper Storage of Personal Care Items
Penalty
Summary
The facility failed to ensure that resident personal care items were stored in a manner to prevent cross-contamination in five of 11 bathrooms on the 400 Hall. Observations revealed that items such as bedpans and urinals were not bagged or labeled, and were improperly stored on shelves above toilets, on the floor, or attached to rolling walkers. This practice was contrary to the facility's policy, which required personal items to be clean, stored appropriately, and not placed on floors. During observational rounds, the Director of Nursing confirmed the improper storage of these items and stated that the expectation was for Certified Nursing Assistants to rinse, bag, and label the urinals and bedpans with the room number. The lack of adherence to these procedures had the potential to expose residents to infections due to cross-contamination.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, as required by their policy on resident rights. The resident, who has intact cognition and multiple medical diagnoses including paranoid schizophrenia, type 2 diabetes, congestive heart failure, obesity, and renal failure, was served a meal that did not align with her stated preferences. Despite the facility's policy to support resident choice and provide food substitutes as needed, the resident was served sweet potatoes, which she does not eat, as indicated on her meal card. The dietary manager and registered dietitians acknowledged that the meal card should have specified the type of potatoes, and the dietary manager admitted that the resident should not have been served sweet potatoes. The resident expressed dissatisfaction with the meal options, particularly on weekends, and chose not to eat breakfast on the day of the observation. She also mentioned reluctance to request alternate meals, as they typically did not meet her preferences. The dietary staff had previously documented residents' food preferences, diets, restrictions, and allergies, and these were supposed to be reflected on the meal tray tickets. However, the oversight in accurately labeling the meal card led to the resident receiving food she did not want, highlighting a failure in the facility's process to ensure resident preferences are respected and accommodated.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by observations in two of the seven halls. Specific deficiencies were noted in four rooms across the 300 and 400 Halls. These rooms exhibited various issues, including missing paint on doors and walls, holes, punctures, and dents in the walls, crumbling walls with exposed rocks, dirty floors, and broken or soiled air conditioning vents. Additionally, one room's bathroom floor was found with dirt, debris, and a dead cockroach, while another room had food and debris in a broken air conditioning vent, loose light covers, and a missing floor tile at the entryway. During a follow-up round with the Maintenance Director, Administrator, and Housekeeping Supervisor, all the concerns in the identified rooms were confirmed. The Administrator, who had been at the facility for three weeks, acknowledged these issues during her initial walk-through and stated that facility improvements were actively being made. The Maintenance Director was aware of the structural damages and was working on repairs. The Administrator expressed her expectation for the facility to provide a clean, safe, and homelike environment for its residents.
Failure to Complete PASRR Level II Assessments
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) Level II was completed for two residents, R73 and R47, who were reviewed for PASRR Level II. Both residents were admitted with diagnoses that included bipolar disorder, which should have triggered a PASRR Level II assessment. However, the PASRR Level I assessments for both residents did not include the diagnosis of bipolar disorder, and there was no evidence that a PASRR Level II assessment was completed. This oversight was identified through staff interviews and record reviews, revealing a lack of coordination and verification of the PASRR process. Interviews with facility staff, including the Admissions Director, Licensed Practical Nurse/MDS Coordinator, Social Service Assistant, and Social Service Director, highlighted a breakdown in communication and responsibility regarding the PASRR process. The Admissions Director admitted to not checking the PASRR Level I for accuracy, while the Social Service Department was identified as responsible for following up on PASRR submissions. The Social Service Director confirmed that the residents did not have PASRR Level II assessments and acknowledged the need for a review of the process to ensure accuracy. The facility did not have a policy in place for PASRR, contributing to the deficiency.
Deficient PICC Line Care in LTC Facility
Penalty
Summary
The facility failed to provide care according to professional standards for two residents, R11 and R261, who were reviewed for intravenous catheter care. For R11, the facility did not follow the physician's orders for dressing changes for a PICC line and failed to ensure the IV infusion tubing was labeled and dated. R11 was readmitted to the facility with diagnoses including sepsis and chronic osteomyelitis and was on IV antibiotics. Observations revealed that the PICC line dressing was soiled and had not been changed since 6/27/2024, despite an order to change it every Monday. Additionally, the IV tubing was not labeled with a date or infusion time. Interviews with staff, including LPN FF and the Director of Nursing Services (DNS), revealed a lack of clarity and responsibility regarding the monitoring and documentation of the PICC line care. LPN FF was unsure who was responsible for changing the dressing and admitted that the order for dressing changes had not appeared on her eMAR. The DNS confirmed that there was no documentation of the PICC line dressing being changed or the site being monitored for infection, and acknowledged that the nurse administering medications was responsible for these tasks. For R261, the facility failed to obtain physician orders and provide care for a PICC line. R261 was admitted with diagnoses including major respiratory failure and COPD, but there were no physician's orders for the care of the PICC line. Observations confirmed that the PICC line dressing was dated 7/3/2024, and interviews with LPN II and the Assistant Director of Nursing (ADON) confirmed the absence of physician orders for the PICC line care. The ADON stated that physician's orders should have been obtained and the dressing should be changed weekly.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to follow physician orders for oxygen therapy for two residents, R65 and R187, which could potentially place them at risk for medical complications. For R65, the electronic medical record indicated a physician's order for oxygen at three liters per minute (LPM) via nasal cannula, starting from December 22, 2023. However, observations on July 14 and 15, 2024, revealed that R65 was receiving oxygen at two LPM instead of the prescribed three LPM. This discrepancy was confirmed by LPN HH, who adjusted the oxygen rate to the correct level. Similarly, for R187, the physician's order specified oxygen at two LPM via nasal cannula, starting from June 3, 2024. Observations on July 14 and 15, 2024, showed that R187 was receiving oxygen at three LPM instead of the ordered two LPM. LPN HH confirmed the error and adjusted the oxygen rate accordingly. The Assistant Director of Nursing expressed that it was expected for nursing staff to check oxygen concentrators every shift to ensure they are set at the prescribed rate.
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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 Lake City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arrowhead Post Acute Llc | 3.8 mi | ★★★★★ | 0 | 0 |
| Jonesboro Center For Nursing And Healing Llc | 4.4 mi | ★★★★★ | 16 | 0 |
| Riverdale Center For Nursing And Healing | 4.9 mi | ★★★★★ | 8 | 0 |
| Pruitthealth - Decatur | 7.2 mi | ★★★★★ | 11 | 0 |
| Georgia Regional Atlanta Ltc | 7.6 mi | ★★★★★ | 1 | 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.