Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Lakeland Rehab & Healthcare Center during CMS and state inspections, most recent first.
A resident with ESRD and multiple comorbidities repeatedly refused scheduled dialysis treatments, and staff documented refusals on more than one occasion. Despite a care plan emphasizing adherence to dialysis and a facility policy requiring notification of the resident’s representative and physician for significant condition changes, nursing staff did not notify the family or physician at the time of the refusals or when a dialysis session was cut short. Family members reported they were not informed of these events, even when present in the facility, and staff interviews revealed confusion and inconsistency about who was responsible for making required notifications and how to follow the notification policy.
A resident with multiple comorbidities, moderate cognitive deficit, bowel and bladder incontinence, and existing MASD on the coccyx required two-person assistance for bed mobility and transfers and used pressure-reducing devices. The care plan did not specify repositioning frequency, and incontinence care was ordered only as every shift and as required. Observations and interviews showed the resident was kept in a wheelchair for many consecutive hours, often from early morning until mid-afternoon, without being repositioned or routinely checked for incontinence, despite reporting pain at the coccyx area. When finally transferred to bed, the resident’s brief was wet, a small open area was present on the coccyx, and red creases were noted on the buttocks and upper legs. CNAs acknowledged residents should be repositioned every two hours and that this had not occurred, and the DON stated that alert residents should use the call light to request checks; no facility policy addressing this practice was provided.
A resident with severe cognitive impairment, CKD, diabetes, and urinary incontinence had a physician-ordered UA with C&S that confirmed a UTI and documented thick yellow/green penile drainage, with a query for antibiotics, urology referral, and topical bacitracin. Facility notes showed ongoing abnormal penile discharge and monitoring, but the October order summary and medical record contained no antibiotic or bacitracin orders and no evidence of a urology referral, and the infection control log did not include the UA/C&S results or related treatment. The resident was later sent to the hospital, where records noted purulent penile drainage and antibiotic treatment, and the DON and LPN/IP acknowledged that treatment orders and follow-up were not implemented or documented in accordance with facility policy.
The facility failed to follow its standardized recipe and cooking procedures for potato au gratin, resulting in potatoes that were hard and not tender, as reported by multiple cognitively intact residents. A resident with a history of CVA and dysphagia, on a regular diet under AMA, choked in the dining room on a large, hard piece of potato that could not be cut with a fork and required multiple Heimlich maneuvers by an LPN to expel. Documentation showed no recorded food temperatures for the meal, and the Dietary Manager stated the potatoes should have been soft enough to break apart with a fork, indicating the menu and recipe requirements for proper preparation and consistency were not met.
Failure to Follow Pureed Diet Menus: Four residents with physician-ordered pureed diets and nectar thick liquids were observed receiving pureed fish, rice, vegetables, and pudding, but no pureed roll even though the master menu listed one. The Dietary Manager said the rolls were probably missed, and the Administrator stated residents on a pureed diet should receive all menu items as ordered.
Improper IV Medication Administration and Breaks in Infection Control: An RN failed to follow standard infection control practices while giving IV antibiotics to two residents with PICC lines and intact cognition. She handled supplies, the IV pole, and medication prep with the same gloves used to access the PICC, and in one case did not wear a gown despite enhanced barrier precautions. The DON stated gloves should be changed and hand hygiene performed before accessing the line if anything else was touched, and the facility had no IV therapy policy or procedure.
Staff failed to follow infection prevention practices during IV and catheter care for two residents with PICC lines, urinary catheters, wounds, and enhanced barrier precautions. An RN handled IV supplies, medication prep, and PICC access with the same gloves without changing them or consistently performing hand hygiene, and CNAs changed gloves during catheter care without hand hygiene between glove changes. The DON stated hand hygiene is expected between glove changes and that a gown should be worn for care under contact isolation and enhanced barrier precautions.
A cognitively impaired resident was subjected to inappropriate sexual touching and comments by another resident in an LTC facility. Despite staff awareness of the situation and the perpetrator's history of inappropriate behavior, the facility failed to implement adequate measures to prevent further incidents. The deficiency highlights a lack of effective enforcement of abuse prevention policies and insufficient intervention to protect vulnerable residents.
A facility failed to report a peer-to-peer sexual abuse incident involving two residents. One resident, with severe cognitive impairment, was inappropriately touched by another resident with a history of inappropriate behavior. Despite observations by an LPN, the incident was not reported to the facility's Abuse Coordinator, and no investigation was initiated, violating the facility's abuse prevention policy.
A facility failed to report and investigate peer-to-peer sexual abuse involving two residents. One resident with severe cognitive impairment was inappropriately touched by another resident with a history of inappropriate behavior. Staff observed and documented the interactions but did not report them as abuse, leading to a lack of immediate investigation and intervention.
A resident under hospice care in an LTC facility did not receive a scheduled dose of morphine due to the medication going missing. The nurse responsible claimed to have locked the medication in the cart after administering the previous dose, but no narcotic count was conducted between shifts. Despite an investigation and interviews with staff, the facility could not determine what happened to the morphine, and the incident remains unresolved.
A resident with diabetes experienced a hypoglycemic event, and an LPN attempted to start an IV without a physician's order. The facility lacked specific protocols for managing low blood sugar, and there was no documentation of further action or glucagon administration.
A facility failed to provide adequate supervision for two residents with dementia, resulting in an inappropriate sexual interaction. Both residents, diagnosed with Alzheimer's and severe cognitive impairment, were found in a compromising situation. The facility lacked specific supervision plans and did not follow its policy on consent, as there was no documentation of discussions or education regarding consent in the residents' records.
A facility failed to reconcile narcotic medication counts, leading to a missing morphine dose for a resident. An LPN did not perform a narcotic count when transferring the medication cart to another nurse. Interviews confirmed that narcotic counts should occur during such transitions, as per facility policy.
A resident with severe cognitive impairment was verbally abused by an RN, who threatened to kick him in the forehead. The incident was witnessed by a CNA and reported to the Director of Nursing, leading to an investigation. The facility substantiated the allegation of verbal abuse based on the CNA's account.
A resident with severe cognitive deficits and multiple diagnoses experienced an infection due to the facility's failure to remove surgical staples and obtain an x-ray as ordered after hip fracture surgery. The discharge instructions were not followed, leading to a delay in care and subsequent infection at the surgical site. The facility lacked policies for surgical wound care and did not communicate effectively with the orthopedic surgeon's office.
The facility failed to provide adequate daily denture and oral hygiene care for four residents, leading to grievances and reports of unclean dentures. Residents with cognitive and physical impairments were not consistently assisted with oral care, and the facility lacked a formal policy and documentation system for tracking care. Interviews with CNAs revealed inconsistencies in care routines, contributing to the deficiency.
A resident experienced frustration, embarrassment, and neck pain due to prolonged wait times for toileting assistance, with staff confirming delays were due to high demand from heavy care residents.
The facility failed to respond to resident call lights in a timely manner, with residents reporting wait times ranging from 15 minutes to 2 hours. Staff attributed the delays to the high care needs of residents, particularly on the 200 hall. Despite attempts to address the issue, the problem persisted, leading to significant delays in care.
The facility failed to notify resident representatives in writing of hospital transfers for two residents with cognitive impairments. The administrator confirmed that while phone calls are made to the family or POA, written documentation regarding the transport, reasons, and bed hold policy is not provided.
The facility failed to notify resident representatives in writing of the bed hold policy during resident transfer for two residents with cognitive impairments. The administrator confirmed that only phone calls were made to the family or POA, without providing written documentation regarding the reasons for transport and the bed hold policy.
The facility failed to revise a care plan to include antibiotics ordered for a UTI for a resident with multiple diagnoses. Despite a urine culture indicating a bacterial infection and a subsequent prescription for Bactrim, the care plan did not document the antibiotic treatment. The Regional Nurse confirmed the expectation to include all medications in care plans, and it was noted that the facility lacks a specific care plan policy.
The facility failed to ensure that as-needed psychotropic medications were ordered for a specific duration for two residents. Both residents had orders for Lorazepam without a specified duration, contrary to the facility's policy requiring PRN psychotropic medications to be limited to 14 days unless otherwise specified by a physician.
The facility failed to protect two residents from abuse. One resident with severe cognitive impairment had clothing placed over his mouth by a CNA to quiet him, while another resident was pushed by a fellow resident, causing her to fall. Both incidents were reported and investigated, leading to the termination of the abusive staff member and the removal of the aggressive resident.
The facility failed to provide a resident with written notification of discharge, including the reason and appeal rights, after the resident exhibited aggressive behavior. The family was only verbally informed, and no emergency discharge paperwork was completed, violating the facility's policy and regulatory requirements.
Failure to Notify Family and Physician of Resident’s Repeated Dialysis Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family and physician of significant changes in condition related to missed dialysis treatments, as required by facility policy. The resident had multiple serious diagnoses, including acute osteomyelitis of the right ankle and foot, COPD, type 2 diabetes, generalized anxiety, end-stage renal disease, chronic diastolic heart failure, anemia in chronic kidney disease, and dependence on renal dialysis. The care plan identified a focus on dialysis related to renal failure, with interventions to encourage attendance at scheduled Monday, Wednesday, and Friday dialysis sessions and to monitor labs and report to the physician as needed. Progress notes show that on one date at 4:58 A.M., an LPN documented that the resident refused to get up for dialysis, and on another date at 5:24 A.M., another LPN documented that the resident refused multiple attempts by four staff members to take him to dialysis. A subsequent note by the DON documented that the family POA was notified that the resident had refused dialysis and that they were awaiting a return call. Family interviews revealed that family members and the POA were not notified of the resident’s dialysis refusals on the days they occurred, nor were they informed that a dialysis treatment had been cut short on a prior date. One family member stated that the facility usually called for any change in the resident, but no calls were made regarding the refusals or the shortened treatment, and that family members were present in the facility on two separate days without being told the resident had missed dialysis. The administrator stated she was not aware the resident did not complete the full treatment on the earlier date and agreed that family and physician should be notified when a resident refuses dialysis or other treatment. The DON stated she called the family only after discovering there was no documentation of family or physician notification and was unsure if the physician had been notified. Nursing staff interviews showed inconsistent understanding and implementation of the notification policy: one LPN admitted she did not notify the family or physician and assumed the oncoming nurse would do so, another LPN did not notify the family because the resident was alert and oriented and was unsure of the policy, and another LPN stated she would have notified the family and physician if she had been made aware. The facility’s written policy on significant condition change and notification requires that the resident’s representative and medical practitioner be notified of changes and that calls be made until the representative is reached, with documentation of the resident’s status and ongoing charting for 72 hours after a change, which was not followed in this case.
Failure to Reposition and Provide Timely Incontinence Care for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate turning, repositioning, and incontinence care to prevent skin breakdown for one resident with known risk factors and existing moisture-associated skin damage (MASD). The resident was admitted with multiple diagnoses including heart disease, diabetes, kidney disease, hypertension, osteoarthritis, and dementia, and was documented as always incontinent of bowel and bladder with MASD on the coccyx requiring pressure-reducing devices and skin treatments. The MDS showed a moderate cognitive deficit, and the care plan identified ADL self-care deficits, impaired mobility, and bladder incontinence, requiring two staff for bed mobility and transfers with a Hoyer lift. However, the care plan did not specify how often the resident should be turned and repositioned, and incontinence interventions only directed staff to check the resident every shift and as required, without defined frequency for repositioning or incontinence checks. Surveyor observations and interviews showed that the resident remained in a wheelchair for extended periods without being repositioned or checked for incontinence, despite reporting pain at the coccyx “gash” when sitting too long. On one day, the resident reported being up in the wheelchair for 2–3 hours and later stated she did not like staying up that long because it hurt. On another day, the resident and a family member reported she was typically up in her chair from early morning until mid-afternoon, and that this was too long. That same day, staff confirmed the resident had been in her wheelchair since about 7 a.m. and was not transferred back to bed until 1:42 p.m., at which time her brief was wet with urine, a small open area was observed on the coccyx, and red creases were noted on the buttocks and upper legs. The CNAs acknowledged the resident should have been repositioned every two hours and that there was no real reason she had not been, while the DON stated that an alert and oriented resident should use the call light so staff can check and change them. The facility was unable to provide a policy addressing this practice.
Failure to Implement UTI Treatment Orders and Specialist Referral
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and obtain specialist referrals for the treatment of a urinary tract infection (UTI) in a resident with multiple comorbidities, including diabetes, Stage 5 chronic kidney disease, hypertension, morbid obesity, muscle weakness, hydrocele, and vertebral compression fracture. The resident’s MDS documented severe cognitive impairment and occasional urinary incontinence, and the care plan included monitoring and documenting signs and symptoms of UTI. On 10/01, the facility received an order from the physician’s office to obtain a urinalysis with culture and sensitivity via straight cath. On 10/02, staff were informed by the physician’s office that the resident had a UTI and that they were waiting for culture and sensitivity results before giving orders due to the resident’s CKD diagnosis. A progress note on 10/06 documented ongoing thick pale green penile discharge and that peri-care was being provided, while the resident remained alert and able to verbalize needs. The urine culture dated 10/04 showed greater than 100,000 colonies/mL of streptococcus viridans, and under the culture’s document history it was noted that the resident had pus and thick yellow/green drainage from the penis, with a question to the provider about starting antibiotics, a urology referral, and topical bacitracin. However, the resident’s October order summary contained no orders for antibiotics or bacitracin, and the medical record did not show a referral to urology. The infection control log for October did not include the urinalysis or culture results or any treatment related to the penile drainage. On 10/10, CNAs reported the resident could not move his right leg, and he was transferred to a local hospital, where records documented a small amount of purulent penile drainage and treatment with antibiotics during his stay. During interviews, the DON and the LPN/Infection Preventionist acknowledged that the urinalysis and culture results were not on the infection control log, that no treatment was documented in the facility record, and that they could not locate evidence that the bacitracin order or urology follow-up had been implemented, despite the facility’s policy requiring documentation of significant condition changes and practitioner notification.
Improper Preparation of Potato Au Gratin Leading to Choking Incident
Penalty
Summary
The deficiency involves the facility’s failure to prepare potato au gratin according to the standardized recipe and to ensure the potatoes were cooked to a tender consistency before service. The facility’s Fall/Winter menu listed potato au gratin for the dinner meal, and the kitchen production report for that meal contained no documented temperatures to verify that the food items were cooked thoroughly. The facility’s standardized recipe for potato au gratin required potatoes to be peeled, sliced, boiled or steamed until softened, then baked until tender and soft enough to break apart with a fork. The Dietary Manager stated that the potatoes should be soft after baking and easily broken with a fork, but acknowledged that the cook responsible for the meal left the facility and did not participate in an interview. One resident with cerebrovascular disease, aphasia, dysphagia, and hemiplegia had a care plan identifying swallowing problems and interventions such as staff education on special dietary and safety needs, upright positioning, slow eating, and thorough chewing. This resident had a physician order for a regular diet under an AMA agreement despite the dysphagia. On the evening in question, the resident choked while eating potato au gratin in the main dining room. Nursing documentation described the resident turning blue, having difficulty breathing with no notable breaths, and requiring multiple abdominal thrusts (Heimlich maneuver) before expelling a large, hard piece of potato that could not be cut with a fork. A subsequent health status note recorded that the resident declined hospital transfer and that a STAT chest X-ray was ordered. Two other cognitively intact residents reported that the potatoes served at that meal were hard and not tender. One resident stated the potatoes were “hard like they were still raw” and reported this to staff but said nothing was done to correct the issue. Another resident, who had a care plan for nutritional risk and monitoring for dysphagia signs, stated she was present when the choking incident occurred and observed the affected resident place a large piece of potato in his mouth. She reported that the potatoes were “not so good” and “not tender,” and commented that sometimes the food is cooked well and sometimes it is not. These resident interviews, combined with the lack of documented cooking temperatures and the description of the expelled potato piece as hard and not cuttable with a fork, demonstrate that the potatoes were not prepared and cooked according to the facility’s standardized recipe and menu requirements.
Failure to Follow Pureed Diet Menus
Penalty
Summary
The facility failed to ensure menus were followed for 4 of 6 residents reviewed for nutrition. R57, R24, R13, and R119 each had physician-ordered pureed diets with nectar thick liquids, and their care plans identified nutritional problems or potential nutritional problems with interventions to provide and serve the ordered diet. During the noon meal observation, R57 was served pureed catfish, rice, vegetables, and pudding, but no pureed bread; R24 was served pureed fish, rice, vegetables, and pudding, but no pureed dinner roll; R13 was served four bowls of pureed food including fish, rice, vegetables, and pudding; and R119 was served pureed fish, wild rice, mixed vegetables, and banana pudding, but no pureed roll. The facility Master Menu for the meal listed a wheat roll with the pureed diet meal. When asked why the four residents were not served a pureed dinner roll, the Dietary Manager stated they were probably just missed. The Administrator stated she would expect residents on a pureed diet to receive all menu items as they should. The facility Therapeutic Diets policy stated therapeutic diets shall be prescribed by the attending physician and that the physician's diet order should match the terminology used by Food Services.
Improper IV Medication Administration and Breaks in Infection Control
Penalty
Summary
The facility failed to administer IV medications according to professional standards of practice for 2 residents who had PICC lines and orders for IV antibiotics. One resident had diagnoses including sepsis, infection related to an indwelling urethral catheter, stage 3 pressure ulcers of both heels, and osteomyelitis of the ankle and foot, and had intact cognition. During IV medication administration, the RN applied gloves at the doorway without first performing hand hygiene, then moved the IV pole, handled supplies from her pocket, organized items on the bedside table, prepared the IV medication, and accessed the PICC line without changing gloves or wearing a gown throughout the procedure. The resident was also on enhanced barrier precautions related to wounds, a urinary catheter, and the PICC line. A second resident with diagnoses including sepsis, urinary tract infection, infection related to an indwelling urethral catheter, and pneumonia also had intact cognition and orders for PICC flushing and IV ertapenem. During IV administration, the RN donned a gown and gloves, but then entered the bathroom, handled the IV pole, removed supplies from her shirt pocket, prepared the medication and tubing, and accessed the PICC line without changing gloves. The DON stated the nurse should wear clean gloves when accessing the IV and should change gloves and perform hand hygiene if touching anything else before accessing the line, and also stated the facility did not have a policy or procedure for IV therapy preparation, administration, or maintenance. The RN stated she did not know the policy for glove changes and had not received special training on IV access procedures at the facility.
Infection Control Practices Not Followed During IV and Catheter Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were used during resident care for two residents who had PICC lines, urinary catheters, wounds, and enhanced barrier precaution orders. One resident had diagnoses including sepsis, infection related to an indwelling urethral catheter, stage 3 pressure ulcers of both heels, and osteomyelitis of the ankle and foot, and had orders for daily IV daptomycin and PICC line flushing. Another resident had diagnoses including sepsis, UTI, infection related to an indwelling urethral catheter, and pneumonia, with orders for IV ertapenem, PICC line flushing, and enhanced barrier precautions related to the urinary catheter and IV site. During IV medication administration to the first resident, the RN applied gloves at the doorway without performing hand hygiene first, then handled the IV pole, supplies, bedside table, medication preparation, and PICC access with the same gloves throughout the entire procedure. The RN did not change gloves or wear a gown during the observation. During urinary catheter care for the same resident, CNAs changed gloves multiple times without performing hand hygiene between glove changes, then removed gloves and performed hand hygiene at the end of the task. During IV medication administration to the second resident, the RN applied a gown at the door and performed hand hygiene, but then entered the bathroom, moved the IV pole, retrieved supplies from a shirt pocket, prepared the IV medication and tubing, and accessed the PICC line with the same gloves on throughout the observation. The RN did not change gloves during the procedure. The DON stated that hand hygiene is expected between glove changes, that clean gloves should be worn when accessing the IV, and that a gown should be worn anytime care is being performed for a resident on contact isolation and enhanced barrier precautions. Facility policy stated gloves are to be removed before touching uncontaminated surfaces or other areas of the same resident's body, and enhanced barrier precautions require gown and glove use during high-contact resident care activities, including caring for or using an indwelling medical device.
Failure to Prevent Peer-to-Peer Sexual Abuse
Penalty
Summary
The facility failed to prevent peer-to-peer sexual abuse involving a cognitively impaired resident, R1, who was unable to give informed consent. R1, diagnosed with Alzheimer's Disease and severe cognitive impairment, was subjected to inappropriate sexual touching and unsolicited sexual comments by another resident, R2. R2, who is cognitively intact but exhibits variable cognitive function and confusion, was observed engaging in inappropriate behavior towards R1 on multiple occasions, including touching R1's leg and breast without consent. Staff members, including a Licensed Practical Nurse and Certified Nursing Assistants, witnessed and reported R2's inappropriate actions towards R1. Despite being aware of R2's history of sexually inappropriate behavior towards staff, the facility did not implement adequate measures to prevent R2 from seeking out and interacting with R1. The facility's response to the incidents was insufficient, as R2 continued to have access to R1 and other female residents, raising concerns about the safety and well-being of residents. The facility's policies on abuse prevention and resident consent were not effectively enforced, leading to a failure in protecting R1 from abuse. The staff's actions, such as separating the residents and monitoring R2, were reactive rather than proactive, allowing the inappropriate behavior to persist. The facility's lack of timely and effective intervention contributed to the deficiency, as R1 was repeatedly exposed to unwanted and inappropriate interactions with R2.
Failure to Report Peer-to-Peer Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of peer-to-peer sexual abuse involving two residents, R1 and R2, to the facility Administrator or designated representative. R1, who has severe cognitive impairment due to Alzheimer's Disease, was involved in an incident with R2, who is cognitively intact but has a history of inappropriate sexual behavior. On a specific date, R2 was observed by a Licensed Practical Nurse (LPN) engaging in inappropriate touching of R1 in a common area and later in a dining area. Despite these observations, the interactions were not reported to the facility's Abuse Coordinator, and no abuse investigation was initiated. R1's care plan documented a behavior problem related to a resident-to-resident touching incident, and interventions were put in place, such as changing R1's room and implementing 15-minute checks. R2's care plan also noted a problem area regarding inappropriate sexual behavior, with interventions to ensure the safety of others and to separate R2 from the environment when necessary. However, the LPN who observed the incidents did not perceive them as sexual abuse and only reported them to the Director of Nurses or Assistant Director of Nurses, who were the Weekend Managers on Duty, rather than directly to the Administrator. The facility's policy requires immediate reporting of any abuse or neglect to the Administrator, who is the designated Abuse Coordinator. The Administrator confirmed that she was not made aware of the interactions between R1 and R2, and no investigation was conducted. The Assistant Director of Nurses recalled being informed of R2's behavior but did not consider it to be progressing into sexual abuse, despite R2's history of inappropriate behavior with staff. This lack of reporting and investigation constitutes a deficiency in the facility's handling of abuse prevention and response.
Failure to Report and Investigate Peer-to-Peer Sexual Abuse
Penalty
Summary
The facility failed to report, investigate, and prevent further peer-to-peer sexual abuse involving two residents. One resident, with severe cognitive impairment due to Alzheimer's Disease, was involved in inappropriate interactions with another resident who was cognitively intact but had a history of inappropriate sexual behavior. The interactions included the cognitively intact resident touching the impaired resident's leg and arm, and later, more inappropriate touching occurred, which was not immediately reported to the facility's Abuse Coordinator. The nursing staff, including an LPN, observed and documented these interactions but did not classify them as sexual abuse, leading to a lack of immediate reporting and investigation. The facility's Assistant Director of Nurses was informed of the interactions but did not perceive them as potentially escalating to sexual abuse, given the history of the resident's behavior. The Director of Nurses was not informed of the ongoing interactions until a more severe incident occurred, and the facility's Abuse Coordinator was not notified at all until much later. The facility's policy required immediate reporting of abuse to the Administrator, who is also the Abuse Coordinator, but this protocol was not followed. The lack of immediate action and investigation allowed the inappropriate behavior to continue without adequate intervention, highlighting a significant deficiency in the facility's abuse prevention and reporting procedures.
Misappropriation of Morphine in LTC Facility
Penalty
Summary
The facility failed to protect a resident from the misappropriation of a controlled substance, specifically morphine, which was intended for pain management. The incident involved a resident who was under hospice care and had a prescription for Morphine Sulfate to be administered every two hours. On the day of the incident, the resident received the 8 am dose, but when the nurse attempted to administer the 10 am dose, the morphine bottle was missing from the medication cart. Despite a thorough search of the facility and grounds, the medication was not located. The investigation revealed that the nurse responsible for administering the medication, identified as V4, claimed to have followed standard procedures by placing the morphine back in the cart and locking it after the 8 am dose. However, there was no narcotic count conducted between shifts, which could have verified the presence of the medication. Interviews with staff, including the night shift nurse V11, indicated that the medication cart was in front of the nurse's station, but no one observed the morphine being misplaced or taken. V4 was the only staff member suspended and investigated, although he denied taking the medication and passed a drug test. The facility's policy on abuse prevention and prohibition was referenced, highlighting the prohibition of misappropriation of resident property. Despite the investigation, the facility was unable to determine the fate of the missing morphine, and the incident remains unresolved. The resident involved had multiple health conditions, including chronic pain, and was being assessed for pain management during the investigation.
Unauthorized Medical Treatment Without Physician's Order
Penalty
Summary
The facility failed to prevent a resident from receiving medical treatment without a doctor's order. A resident, who was admitted with diagnoses including type II diabetes mellitus with hypoglycemia, had an order for ACCUCHECK every two hours due to hypoglycemia. On a specific date, the resident's blood sugar was recorded at a hypoglycemic level of 46, but there was no documentation of further action or administration of glucagon, which was ordered for low blood sugar. Additionally, an LPN attempted to start an IV on the resident without a physician's order, which was not successful, and no medications were administered. The Director of Nursing (DON) confirmed that the LPN had spoken with a nurse at the doctor's office about the resident's condition, but no standing order for IV dextrose was given. The facility lacked a specific policy or protocol for managing low blood sugars, and the resident did not have standing orders for such situations. The incident was documented as a failure to follow departmental policies and procedures, with no order obtained from a physician prior to initiating a medical procedure or medication.
Inadequate Supervision Leads to Inappropriate Resident Interaction
Penalty
Summary
The facility failed to provide adequate supervision for residents with dementia, leading to an incident involving inappropriate sexual behavior between two residents, identified as R3 and R4. Both residents were found in a compromising situation, with R4 having his pants down and R3 providing oral sex. The incident was witnessed by a housekeeper, and both residents were immediately separated. R3 believed R4 was her husband, while R4 did not recognize R3, indicating a lack of cognitive ability to consent to the interaction. R4's medical records show a diagnosis of Alzheimer's disease and a severely impaired cognitive status, with a Brief Interview for Mental Status (BIMS) score of 3. His care plan included a focus on inappropriate sexual behavior, but there was no specific supervision plan in place. R4 had a history of wandering into female residents' rooms and displaying inappropriate sexual conduct, yet the facility did not have a clear protocol for monitoring his behavior or ensuring his safety and the safety of others. Similarly, R3 was diagnosed with Alzheimer's and dementia, with a BIMS score of 7, indicating severe cognitive impairment. Her care plan also addressed inappropriate sexual behavior, but like R4, there was no documentation of discussions or education regarding consent. The facility's policy on abuse prevention and resident capacity to consent was not followed, as there was no evidence of one-on-one discussions or consent documentation in the clinical records of R3 and R4.
Failure to Reconcile Narcotic Medication Counts
Penalty
Summary
The facility failed to consistently and accurately reconcile narcotic medication counts in accordance with professional standards of practice for a resident. The incident involved a resident who was supposed to receive a dose of morphine at 10 am, but the medication could not be located. An investigation was initiated following the discovery of the missing narcotic. Interviews with staff revealed that the narcotic count was not performed when the responsibility of the medication cart was transferred between nurses. Specifically, an LPN who stayed over from the midnight shift did not count the narcotics with the oncoming nurse, as she was still using the cart to pass medications. The keys for the cart were handed over without performing a count. Further interviews with other nursing staff, including another LPN and an RN, confirmed that narcotic counts should be conducted whenever a nurse assumes responsibility for a medication cart. The Director of Nursing also stated that narcotics should be counted any time a nurse takes over responsibility for the cart and before anyone leaves. The facility's controlled substance policy requires that all controlled substances be counted every shift, with the oncoming and off-going licensed nurses signing to verify the inventory. Employee corrective action forms for the involved LPNs documented their failure to follow departmental policies and procedures regarding narcotic counts.
Verbal Abuse Incident Involving RN and Resident
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving a registered nurse (RN) and a resident. The RN, identified as V21, verbally abused a resident, R3, by telling him to go away and threatening to kick him in the forehead. This incident was reported by a certified nursing assistant (CNA), V4, who witnessed the exchange at the nurse's station. The CNA described the RN's demeanor as aggressive and threatening, which she perceived as abusive. The incident occurred when R3, who has severe cognitive impairment and a history of heart disease, dementia, and anxiety disorder, approached the nurse's station and asked about small motors. The RN, V21, responded in a dismissive and threatening manner, which was reported to the Director of Nursing and led to an investigation. Despite R3 not recalling the incident due to his cognitive condition, the facility substantiated the allegation of verbal abuse based on the CNA's account. The facility's policy on abuse prevention and prohibition emphasizes the right of residents to be free from abuse, including verbal abuse. The RN involved in the incident was immediately suspended, and the facility notified relevant authorities and initiated an investigation. The facility's failure to protect R3 from verbal abuse by a staff member constitutes a deficiency in maintaining a safe and respectful environment for residents.
Failure to Follow Post-Surgical Care Orders
Penalty
Summary
The facility failed to remove surgical staples and obtain an x-ray as ordered for a resident who had been readmitted after a hip fracture surgery. The resident, who had severe cognitive deficits and multiple diagnoses including congestive heart failure and chronic kidney disease, was supposed to have the staples removed and an x-ray done on a specific date as per the discharge instructions from the hospital. However, the facility did not remove the staples on the scheduled date, and the x-ray was delayed due to issues with the portable x-ray provider. The nursing progress notes indicated that the resident experienced severe pain in the right hip and leg, which led to an emergency room visit where a hip fracture was diagnosed. After readmission to the facility, the discharge instructions were not followed correctly. The x-ray was delayed, and the staples were not removed until much later, which resulted in the surgical site becoming infected. The infection was identified when a wound care nurse assessed the incision, which was red, warm, swollen, and had purulent drainage. The Director of Nurses and other staff members were not familiar with the resident's care and did not clarify the discharge orders or report the delay in obtaining the x-ray to the orthopedic surgeon. The facility lacked policies for surgical wound care and following physician's orders, which contributed to the oversight. The orthopedic surgeon's office confirmed that the staples should have been removed and the x-ray obtained on the specified date, and the failure to do so led to the infection at the staple sites.
Inadequate Denture and Oral Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate daily denture and oral hygiene care for four residents, as evidenced by interviews and record reviews. Resident 1, who has severe cognitive deficits and requires moderate assistance, was reported by a family member to have dentures that were yellow, odorous, and covered with food particles. Resident 7, with minimal cognitive deficits and range of motion impairment, stated that staff do not offer or remind her to clean her dentures, and assistance is only provided upon request. Resident 5, who also has minimal cognitive deficits, reported losing her dentures two weeks prior and stated that staff only assist with oral care when CNA students are present. Resident 6, with severe cognitive deficits and restricted range of motion, had a grievance filed by her power of attorney due to inadequate denture care, as evidenced by a calendar in her room that was rarely initialed by staff. The facility lacks a formal policy for denture care and oral hygiene, and there is no documentation in the electronic medical records to track when care is provided. Interviews with CNAs revealed inconsistencies in the care routine, with some reporting that dentures are not always cleaned and soaked overnight as required. The administrator acknowledged the grievance filed regarding Resident 6's care but believed that staff were performing the care without documenting it. The absence of a structured policy and documentation system contributed to the deficiency in providing necessary oral hygiene care for the residents.
Failure to Provide Timely Assistance for Toileting Needs
Penalty
Summary
The facility failed to provide timely assistance for toileting needs for a resident, resulting in undue feelings of frustration, embarrassment, and neck pain. The resident, a cognitively intact [AGE] year old female with diagnoses including Secondary Parkinsonism and End Stage Renal Disease, reported that it often took staff between 30 minutes to 2 hours to respond to her call light, leading to incontinence episodes and neck pain from prolonged periods on the commode. The resident expressed that these delays were particularly problematic in the morning, after lunch, and around 2 PM, causing her significant discomfort and emotional distress. Certified Nurse Assistants (CNAs) working on the 200 hall confirmed that the resident frequently experienced incontinence by the time staff responded to her call light. They acknowledged that the 200 hall had heavy care residents requiring significant staff time, which contributed to the delays. Despite the facility having what some staff considered adequate staffing levels, the high demand for assistance from multiple heavy care residents often led to prolonged wait times for individual residents. The facility administrator acknowledged that there had been ongoing concerns about call light response times, which had been discussed in resident council meetings. The administrator stated that the facility had explored various options to improve response times, such as redistributing heavy care residents and evaluating staffing needs and productivity. However, the issue persisted, with the administrator and medical director both emphasizing the importance of timely responses to call lights to address residents' needs and discomfort promptly.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to respond to resident call lights in a timely manner for four residents, leading to significant delays in care. Resident R32, a [AGE] year-old male with chronic conditions including COPD and diabetes, reported an average wait time of 15 minutes, with instances extending up to 45 minutes. Similarly, Resident R92, a [AGE] year-old female with heart failure and hip pain, experienced an average wait time of 15 minutes, but reported a recent instance where she waited for 2 hours. Both residents confirmed these times by observing the clock in their rooms. Resident R103, an [AGE] year-old male with dementia and anxiety, had his family member report that call lights typically took 20 minutes to be answered. Resident R56, a [AGE] year-old female with Parkinsonism and end-stage renal disease, reported waiting up to 2 hours for assistance, particularly during peak times such as mornings and after lunch. This delay led to incontinence episodes and physical discomfort. Staff members acknowledged the delays, attributing them to the high care needs of residents on the 200 hall, which often required the assistance of two staff members. The facility's administrator admitted that there have been ongoing concerns about call light response times, as documented in resident council meeting minutes and grievance forms. Despite attempts to address the issue, such as redistributing heavy care residents and evaluating staffing needs, the problem persisted. The administrator stated that the expectation is for call lights to be acknowledged within 5 minutes, but this standard was not consistently met, as evidenced by the residents' complaints and staff testimonies.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to notify resident representatives in writing of hospital transfers for two residents who were reviewed for hospitalization. Resident 36, who had a cognitive impairment as indicated by a BIMS score of 7, was transported to the emergency room due to a change in condition. Similarly, Resident 71, with a BIMS score of 9 indicating cognitive impairment, was also transported to the emergency room for a change in condition. The facility's administrator confirmed that while they call the resident's family or POA via phone during transfers, they do not provide written documentation regarding the hospital transport, reasons for the transport, or the bed hold policy to the POA or family members.
Failure to Notify Resident Representatives of Bed Hold Policy
Penalty
Summary
The facility failed to notify resident representatives in writing of the bed hold policy during resident transfer for two residents reviewed for hospitalization. Resident 36, who had a cognitive impairment as indicated by a BIMS score of 7, was transported to the emergency room after a change in condition. Similarly, Resident 71, with a BIMS score of 9 indicating cognitive impairment, was also transported to the emergency room due to a change in condition. The facility's administrator confirmed that while they call the resident's family or POA via phone during transfers, they do not provide written documentation regarding the reasons for transport and the bed hold policy to the POA or family member.
Failure to Update Care Plan for UTI Medication
Penalty
Summary
The facility failed to revise a care plan to include medications ordered for a Urinary Tract Infection (UTI) for one resident. The resident, who has multiple diagnoses including Type 2 Diabetes Mellitus, Parkinsonism, and obstructive uropathy, was admitted to the facility on 03/29/2024. A urine culture from a local hospital dated 05/15/2024 showed a bacterial infection sensitive to Bactrim, and the resident was subsequently prescribed Bactrim 800-160 mg twice a day starting 05/20/2024. However, the resident's care plan, which included monitoring for UTI symptoms, did not document the antibiotic treatment for the UTI. On 05/24/2024, the Regional Nurse confirmed that it is her expectation that any medication should be included in the care plan. Additionally, it was noted that the facility does not have a specific policy on care plans and follows state guidelines. This oversight in updating the care plan to reflect the prescribed antibiotic treatment for the UTI constitutes a deficiency in the facility's care planning process.
Failure to Specify Duration for PRN Psychotropic Medications
Penalty
Summary
The facility failed to ensure that as-needed psychotropic medications were ordered for a specific duration for two residents. One resident, a male with diagnoses including Generalized Anxiety Disorder and Unspecified Dementia with Agitation, had an order for Lorazepam without a specified duration. Another resident, a female with Generalized Anxiety Disorder, also had an order for Lorazepam without a specified duration. Both orders were for as-needed use every 12 hours for anxiety or behaviors. The Regional Nurse stated that she believed no end date was necessary if there was clinical rationale for continued use. However, the facility's policy requires that PRN psychotropic medications be limited to 14 days unless a longer timeframe is deemed appropriate by the attending physician or prescribing practitioner. This discrepancy between practice and policy led to the deficiency noted in the report.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure residents are free from abuse, resulting in two incidents involving residents R2 and R6. R6, who has severe cognitive impairment and is dependent on assistance for daily activities, experienced abuse when a CNA placed clothing over his mouth twice to quiet him. This incident was reported by another CNA, leading to the immediate removal and termination of the abusive staff member. Despite R6's inability to recall the event due to his cognitive condition, the incident was substantiated by the facility's investigation and witness statements. In another incident, R2, who has cognitive impairment and multiple diagnoses including vascular dementia, was pushed by another resident, R5, causing her to fall and hit her back on the bed. This incident was witnessed by a CNA and documented in nursing progress notes. Although R2 did not sustain any physical injuries, the facility substantiated the abuse and took steps to prevent R5 from returning to the facility due to his behavioral issues. Both incidents highlight the facility's failure to protect residents from abuse, as required by their abuse prevention policy. The facility's policy mandates that residents must not be subjected to abuse by anyone, including staff and other residents. The incidents were reported and investigated, but the initial failure to prevent these abusive actions resulted in emotional and physical distress for the affected residents.
Failure to Provide Written Notification of Discharge
Penalty
Summary
The facility failed to notify a resident in writing of the reason for transfer/discharge. The resident, who had severe cognitive impairments and a history of behavioral issues, was involved in an incident where he shoved another resident, causing her to fall. Following this, the resident exhibited further aggressive behavior, including attempting to punch a door and rearing his fist at another resident. The facility decided to send the resident to the emergency room and informed the hospital that the resident would not be allowed to return. However, the facility did not provide the required written notice of discharge to the resident or his family at that time. The resident's family member was initially notified of a potential discharge in January, but no further written notice was given after the recent incidents. The facility's administrator believed that the initial notice from January was sufficient and did not complete any emergency discharge paperwork. The family member was only verbally informed that the resident would not be allowed to return after being sent to the hospital. The facility's policy requires written notice to be provided at least 30 days in advance or as soon as practicable in emergency situations, but this was not done. The facility's failure to provide timely written notification of the discharge, including the reason for the discharge and the resident's right to appeal, constitutes a deficiency. The facility's policy mandates that such notice must be given to the resident and their family or legal representative, but this procedure was not followed in this case. The lack of proper documentation and communication led to a violation of the resident's rights and regulatory requirements.
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 54 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 Effingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Effingham Healthcare & Senior Living | 0.7 mi | ★★★★★ | 6 | 0 |
| Evergreen Nursing & Rehab Center | 0.7 mi | ★★★★★ | 4 | 0 |
| Lutheran Care Center | 11.9 mi | ★★★★★ | 7 | 1 |
| Heartland Senior Living | 14.3 mi | ★★★★★ | 4 | 0 |
| The Haven Of St. Elmo | 17.2 mi | ★★★★★ | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.