Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Sgmc Health Villa during CMS and state inspections, most recent first.
Surveyors found that three residents had unsecured and unauthorized medications accessible in their rooms, including topical creams, throat lozenges, and sore throat spray, without documented assessments or physician orders for self-administration. The DON confirmed that none of the residents were assessed or approved to self-administer medications, yet these items remained accessible at the bedside.
The facility did not transmit MDS assessments to CMS within the required timeframe for eight residents, with several quarterly and annual assessments submitted months late. The MDS Coordinator confirmed the late submissions and was unaware of the delays, as identified through staff interviews and record review.
Several residents with complex medical and psychological needs, including those requiring oxygen therapy, anticoagulant and psychotropic medications, ADL assistance, and PTSD management, did not have individualized care plans addressing these interventions. Staff and record reviews confirmed the absence of care plans despite physician orders and ongoing treatments.
A resident with severe cognitive impairment and a history of falls did not receive the required weekly post-fall assessments after a witnessed fall, as mandated by facility policy. Only one assessment was completed weeks after the incident, and staff confirmed that the necessary weekly evaluations were not performed.
Mail delivery was not provided to residents on Saturdays, as confirmed by resident council members, the Activities Director, and the Administrator. The Activities Director, responsible for mail delivery, did not work on Saturdays, resulting in mail being distributed on Mondays instead. This practice affected all residents in the facility.
A facility failed to report an allegation of abuse involving a CNA and a resident to the State Survey Agency within the required time frame. The incident involved the CNA spending excessive time in the resident's room and performing inappropriate tasks, such as shaving the resident's private area. Despite the resident having no concerns, the facility's staff did not report the situation as required by policy, and the Administrator acknowledged the policy's unclear wording contributed to the oversight.
A facility failed to implement protective measures during an abuse investigation involving a CNA and a resident. Despite allegations of inappropriate conduct, the CNA was not removed from the schedule or reassigned, allowing continued interaction with the resident. The facility's policy required suspension or reassignment of the suspected abuser, but this was not followed, leading to a deficiency.
Unsecured and Unauthorized Medications Found at Bedside
Penalty
Summary
The facility failed to ensure that residents did not have unsecured and unauthorized medications at their bedside, as evidenced by observations and record reviews for three residents. For one resident with dementia and moderate cognitive impairment, multiple medications including lidocaine cream, hydrocortisone otic solution, and ophthalmic drops were found on the overbed table. There was no care plan or physician order for self-administration of medications, and the DON confirmed the resident was not assessed or approved for self-administration. Similarly, another resident with a history of cataracts, glaucoma, and hemiplegia, but with little to no cognitive impairment, had throat lozenges, medicated ointment, and hydrogen peroxide accessible in the room. The resident reported occasional use of the lozenges, while the ointment and peroxide were applied by staff, yet no assessment or physician order for self-administration was present. A third resident with chronic obstructive pulmonary disease, tremor, and weakness, and also with little to no cognitive impairment, had a container of sore throat spray in the bathroom. The resident stated she used the medication occasionally, but again, there was no assessment or physician order for self-administration. The DON confirmed the presence of the medication and acknowledged that the resident was not assessed for self-administration. In all cases, the facility did not document assessments or obtain physician orders for self-administration, resulting in residents having unauthorized medications accessible in their rooms.
Failure to Timely Submit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required 14 days of completion for eight sampled residents. According to the Resident Assessment Instrument (RAI) Manual, all non-admission OBRA and PPS assessments must be completed and submitted no later than 14 days after the Assessment Reference Date (ARD). However, review of the records showed that multiple quarterly and annual MDS assessments for these residents were submitted significantly past the required timeframe, with some assessments being submitted several months after the ARD. During staff interviews, the MDS Coordinator confirmed that the identified assessments were submitted late and stated she was unaware of the delays. The deficiency was identified through staff interviews, record review, and examination of the RAI Manual, which established the timeliness criteria that were not met for the affected residents.
Failure to Develop Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for several residents with specific medical needs. For one resident with diagnoses including asthma and morbid obesity, the electronic medical record and physician orders indicated the use of oxygen therapy and anticoagulant medication, but there was no corresponding care plan addressing these interventions. Observations confirmed the resident was receiving oxygen, and the MDS Coordinator acknowledged the absence of care plan areas for both oxygen and anticoagulant use, despite documentation and physician orders supporting their necessity. Similarly, another resident with dementia, diabetes, COPD, and muscle weakness was receiving oxygen therapy and psychotropic medications, and required assistance with ADLs, but had no care plan addressing these needs. Multiple observations confirmed the use of oxygen and staff assistance with ADLs. The MDS Coordinator and Administrator both confirmed the lack of care plans for these areas. Additionally, a resident with PTSD had no care plan addressing this diagnosis, despite MDS documentation and staff interviews confirming the need. The failure to create care plans for these residents' specific needs was confirmed through record review, staff interviews, and direct observation.
Failure to Complete Timely Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that post-fall assessments were conducted according to its own Falls Assessments/ Falls Risk Policy for one resident. The policy required that any resident who experienced a fall receive weekly assessments for twelve weeks, with the assessment period resetting if another fall occurred. A review of the clinical record for a resident with diagnoses including muscle weakness, hypertension, osteoarthritis, and severe cognitive impairment revealed that the resident had a history of falls and experienced a witnessed fall from the side of the bed. Although an initial assessment and notifications were completed after the fall, the required weekly fall risk assessments were not performed as stipulated by facility policy. Documentation showed that after the resident's fall, only one fall assessment was completed several weeks later, with no assessments conducted in the immediate weeks following the incident. Interviews with the DON, MDS Coordinator, and Administrator confirmed that the required weekly assessments were not completed after the fall, and that the facility's policy was not followed. This lapse in conducting timely post-fall assessments constituted a deficiency in providing adequate supervision and accident hazard prevention.
Failure to Provide Timely Mail Delivery on Saturdays
Penalty
Summary
The facility failed to provide mail delivery service to residents on Saturdays, as required by its policy on Individual Rights and Responsibilities, which states that residents have the right to promptly receive unopened mail. Resident council members reported that mail was not delivered on Saturdays and had not been for some time. The Activities Director confirmed that she was responsible for delivering mail but did not work on Saturdays, resulting in mail being delivered on the following Monday. The Administrator also confirmed that mail was not delivered to the facility on Saturdays and described a plan to inform the mail delivery person to use a different entrance, but this did not address the lack of Saturday mail delivery. This practice had the potential to affect all 55 residents in the facility.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation and suspicion of abuse involving a resident and a Certified Nursing Assistant (CNA) to the State Survey Agency within the required time frame. The facility's policy mandates that any suspicion of abuse resulting in serious bodily injury must be reported within two hours, and those without serious injury within 24 hours. However, the allegation involving CNA BB and resident RA, which included inappropriate behavior and potential boundary violations, was not reported as required. The incident involved CNA BB spending excessive time in RA's room, shaving RA's private area, and lying on the bed with RA, which raised concerns among staff. Resident RA, who was cognitively intact and required assistance with Activities of Daily Living, had no concerns about CNA BB and described their relationship as friendly. Despite this, the facility's Assistant Director of Nursing (ADON) and Social Services Director (SSD) were aware of the situation but did not report it to the State Survey Agency. The Administrator acknowledged the failure to report and expressed concerns about the clarity of the facility's abuse policy, which was written by a previous Administrator. The policy's wording regarding the time frame for reporting abuse was considered awkward and unclear, contributing to the oversight.
Failure to Implement Protective Measures During Abuse Investigation
Penalty
Summary
The facility failed to implement protective measures following an allegation of staff-to-resident abuse. Specifically, a Certified Nursing Assistant (CNA) was not removed from the schedule or reassigned during the investigation of alleged inappropriate conduct with a resident. The facility's policy on abuse, neglect, exploitation, and mistreatment required steps such as suspension or reassignment of the suspected abuser to protect individuals from harm during an investigation. Despite being aware of the allegations, the facility allowed the CNA to continue working in the area where the resident resided. The resident involved was cognitively intact and required assistance with activities of daily living. The allegations included inappropriate comments and actions by the CNA, such as shaving the resident's private area and spending excessive time in the resident's room. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) was aware of the situation but did not ensure the CNA was reassigned or suspended during the investigation. The CNA continued to work on the resident's hall, contrary to the facility's policy, until receiving education on appropriate boundaries.
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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) |
|---|---|---|---|---|
| Berrien Oaks Nursing And Rehab Center | 14.4 mi | ★★★★★ | 4 | 0 |
| Pruitthealth - Lakehaven, Llc | 16.9 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Crestwood, Llc | 17 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Holly Hill, Llc | 17 mi | ★★★★★ | 10 | 2 |
| Pruitthealth - Valdosta, Llc | 17.1 mi | ★★★★★ | 0 | 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.