Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lakeland Community Care Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with heart failure, chronic kidney disease, hypertension, moderate cognitive impairment, and total dependence on staff for personal and toilet hygiene reported difficulty obtaining assistance with ADLs. Observation revealed the resident had ten long, dirty fingernails extending several millimeters beyond the fingertips with black material underneath, and the resident stated they needed cleaning and cutting. An LPN confirmed the nails were too long and dirty, acknowledged that nursing staff were responsible for daily and weekly fingernail checks and for providing fingernail care as part of ADLs, and noted that such nails could cause skin damage or scratches. The DON and Administrator both confirmed that personal hygiene and grooming are part of ADLs and are expected to be provided for all residents dependent on staff.
Surveyors found that two residents’ rooms were not maintained in a clean, orderly, and homelike condition as required by facility policy. Observations included a urine collection device on a bathroom floor, cracked linoleum tiles, holes and missing sections of drywall and door frame, discolored and dusty baseboards, dark buildup on floors and exposed plumbing, and a dust-covered hand sanitizer dispenser with brown spots and streaks on nearby walls. Both residents, admitted with conditions including DM, HTN, and acute kidney failure and assessed as cognitively intact, reported dissatisfaction with the thoroughness of housekeeping and noted cluttered personal belongings and poor attention by staff to putting items away. The housekeeping supervisor confirmed that many of the observed residues should have been cleaned by housekeeping and that damaged surfaces required maintenance.
The facility failed to ensure that in-room meals were served hot and palatable for two residents who reported that their meals were usually cold or not hot enough to be enjoyable, despite a policy requiring staff to check that hot foods are hot. Both residents, who were cognitively intact and had diagnoses including DM and HTN (with one also having acute kidney failure), received meals on trays where insulated dome covers were used without the corresponding heat-keeper bases, and some dome covers did not fully cover the plates. Kitchen observation showed inconsistent and incomplete use of insulated components due to an insufficient supply, and dietary staff and the Administrator were unable to explain the improper use and lack of insulated bases for all in-room meal trays.
A resident who had recently undergone hip replacement surgery and required opioid pain management was discharged home without her prescribed as-needed Hydrocodone-Acetaminophen, despite facility policy and physician orders requiring all current medications to be sent with her. Staff interviews confirmed that the medication was not provided due to unclear instructions and lack of consultation with the physician, and the remaining medication was destroyed after discharge. The resident later reported not receiving her pain medication.
The facility failed to provide sufficient nursing staff on four days in January 2025, as revealed by observations, interviews, and record reviews. The absence of a staffing policy and frequent call-ins led to inadequate CNA coverage, particularly on weekends. An LPN confirmed that a resident's medication was left unattended due to insufficient staff, highlighting the impact on resident care.
A resident's room had torn and buckling linoleum flooring, creating a potential fall hazard. The resident, who was moderately cognitively impaired and at high risk for falls, had been living with this issue for several months. Despite complaints from the resident's sister and reports from staff, the Maintenance Director had not repaired the floor due to being the only maintenance staff. The Administrator was aware of the problem and had plans for repair but had not yet acted.
A dietary staff member failed to sanitize a thermometer properly between food temperature checks, using a paper towel instead of an alcohol pad, leading to cross-contamination. The Dietary Manager confirmed that this practice was against training protocols and could cause gastrointestinal issues for residents.
A facility failed to follow Enhanced Barrier Precautions for a resident with a PEG tube, as observed during two care instances where LPNs did not wear gowns. Despite facility policy and signage indicating the need for gowns during high-contact activities, the LPNs did not comply, putting the resident at risk. The resident had a diagnosis of Metabolic Encephalopathy and was moderately cognitively impaired.
A facility inaccurately coded an MDS assessment for a resident discharged to home instead of a hospital. The resident, admitted for muscle weakness, was intended to return home after skilled care. Despite physician orders for home discharge, the MDS indicated a hospital discharge. Interviews confirmed the error, highlighting the importance of accurate MDS coding.
A facility failed to develop a person-centered care plan for a resident with impaired vision. The resident had diagnoses including Paralytic Ptosis and was seen by an optometrist who ordered glasses. However, the care plan did not address these needs due to a lack of awareness and documentation among staff, including LPNs and the Administrator. The Nursing Supervisors were responsible for updating the care plan, but the necessary information was not included, resulting in a deficiency.
The facility failed to secure medications, leaving them accessible to unauthorized individuals. An LPN left a medicine cup with various medications unattended on a cognitively impaired resident's bedside table. Another resident, cognitively intact, was found with medication cups containing Nystatin Cream on the bedside table, provided by a weekend nurse for self-application. Both instances violated the facility's medication storage policy.
The facility failed to document that residents were informed of their rights regarding Advance Directives. Three residents with various diagnoses, including dementia and heart disease, had incomplete Advance Directive forms that were not initialed to confirm receipt of information. The Social Services Director and Administrator acknowledged the oversight, confirming the forms did not reflect the residents' receipt of information.
Two residents reported disrespectful and demanding behavior by an LPN during procedures and medication administration, causing them anxiety. Despite complaints, the facility's response was inadequate, as the LPN continued to work in the same area. Both residents were cognitively intact, and the facility's investigation attributed the issue to personality conflicts.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Provide Adequate ADL Assistance for Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) to maintain personal hygiene for one resident who was dependent on staff for care. Facility policy on ADLs, revised March 2018, stated that residents unable to carry out ADLs independently would receive services necessary to maintain good grooming and personal and oral hygiene. Record review showed the resident was admitted with heart failure, chronic kidney disease, and hypertension, had a BIMS score of 12 indicating moderate cognitive impairment, was always incontinent of bowel and bladder, and required substantial/maximal assistance for personal hygiene and was dependent for toilet hygiene. A complainant reported that the resident had expressed difficulty getting staff to provide assistance with ADLs. During an observation and interview with the resident, accompanied by an LPN, the resident reported ongoing difficulty obtaining assistance with ADLs. The surveyor observed that the resident had ten long, dirty fingernails protruding 3.0 to 3.5 millimeters past the fingertips, with a black substance beneath all fingernails; the resident stated they needed cleaning and cutting and were too long. The LPN described the fingernails as too long and dirty, confirmed that nursing staff were responsible for checking fingernails daily during care and weekly during body audits, and acknowledged that staff were responsible for providing fingernail care as part of ADLs. The LPN also confirmed that long, dirty, unkempt fingernails had the potential to cause damage or scratches to the resident’s skin. The DON stated she was not aware of any complaints from the resident but confirmed her expectation that ADLs for residents dependent on staff for personal hygiene would be maintained and provided as needed, and that licensed nurses trimmed fingernails for some residents while any nursing staff could clean under fingernails. The Administrator confirmed that personal hygiene and grooming were part of resident ADLs and were expected to be provided for all dependent residents.
Failure to Maintain Clean, Orderly, and Homelike Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment as required by its own “Homelike Environment” policy, which states that residents are to be provided with a clean, sanitary, and orderly environment. During surveyor observations and interviews, one resident’s room contained a urine collection device on the bathroom floor, a hole in the drywall above the light, and six cracked linoleum tiles near the entrance. The resident reported being at the facility for therapy and expressed dissatisfaction with housekeeping services. The Housekeeping Supervisor acknowledged that blackish-brown discolored areas on the floor required stripping and scraping, confirmed that baseboards in both affected residents’ rooms were dust-covered, and stated that easily removable substances should have been cleaned by housekeeping, while missing plaster and broken tiles required maintenance. In another resident’s room, surveyors observed a three-inch piece of the bathroom door frame and the threshold between the room and bathroom missing, a dust-covered wall-mounted hand sanitizer dispenser, multiple brown pinpoint spots and streaks on the wall below the dispenser, discolored and dusty baseboards with residue that wiped off easily, and a floor area behind the door with brown to black discoloration in the corner. The exposed plumbing pipes under the bathroom sink were only partially covered with polyfoam and had a dark brown substance on them, and there was a six-inch by one-inch area of missing drywall in the bathroom. This resident, who was cognitively intact and admitted with diabetes and hypertension, stated that housekeepers came daily but did not do a thorough job, that she had limited ability to put belongings away, and that staff were not conscientious about putting her items away, resulting in clothing and other items scattered on all surfaces. Both residents involved were cognitively intact per their MDS BIMS scores, and the Administrator acknowledged awareness of housekeeping and maintenance needs in resident rooms.
Failure to Maintain Hot, Palatable Temperatures for In-Room Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to provide palatable food at an appetizing and safe temperature to residents receiving in-room meal service. Facility policy titled “Assisting the Resident with In-Room Meals” (revised 2013) directed staff to check that hot foods are hot. Two cognitively intact residents, both with diabetes and hypertension and one with additional acute kidney failure, reported that meals served in their rooms were usually cold or not hot enough to be enjoyable. One resident stated staff told her that her meals were not hot because she was the last served due to her room location, and the other resident reported that her meals were never served hot but that she continued to eat them without replacement or reheating. On a kitchen observation, the cook prepared meals while a dietary aide placed plates on trays and covered them with insulated dome covers but did not use the insulated heat-keeper bases/underliners. Nine of 25 meals had dome covers that did not fully cover the plates, leaving food not completely covered to conserve heat, including the meal for one of the affected residents. Six of 25 plates were covered only by heat-keeper bases instead of dome covers, again including a meal for one of the affected residents. During interviews, the dietary aide and dietary supervisor could not explain why heat-keeper bases were used instead of dome covers for some meals and acknowledged there were not enough heat-keeper bases for all residents receiving in-room meals. The Administrator stated she did not know why insulated bases were not being used and had not been informed of any shortage of insulated components.
Failure to Provide Discharge Medications to Resident
Penalty
Summary
The facility failed to ensure that a resident was discharged with all prescribed medications, specifically an as-needed opioid pain medication, as required by facility policy and physician orders. The resident, who had recently undergone hip replacement surgery and had diagnoses including end stage renal disease and acute postprocedural pain, was discharged home with home health care. Despite having a current physician order for Hydrocodone-Acetaminophen 5-325 mg to be taken as needed for pain, the medication was not sent home with the resident at discharge. Interviews with facility staff, including an LPN, the MDS nurse, the DON, and the Administrator, confirmed that the standard procedure was to send all current medications with the resident unless otherwise directed by the physician. The LPN responsible for the discharge did not send the pain medication, citing unclear instructions and without consulting the prescribing physician or the resident's primary healthcare provider. The MDS nurse and DON both confirmed that there were no orders to discontinue the medication and that the resident was expected to continue all current medications at home. Documentation reviewed included the resident's admission record, MDS, history and physical, physician orders, and discharge instructions, all of which indicated the ongoing need for pain management and continuation of prescribed medications. The controlled drug record showed that the remaining Hydrocodone-Acetaminophen tablets were destroyed after the resident's discharge, rather than being provided to the resident as required. The resident later contacted the facility to report that the pain medication had not been sent home.
Inadequate Staffing Leads to Deficiency
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents on four specific days in January 2025. The deficiency was identified through observations, staff interviews, and record reviews. The facility did not have a staffing policy in place, and anonymous complaints indicated that the 3-11 and 11-7 shifts were consistently short of Certified Nursing Assistants (CNAs). On one occasion, a single CNA was left to manage the Central Unit during the 3-11 shift. The Payroll Based Journal (PBJ) data for the 4th quarter showed a One Star Staffing Rating and excessively low weekend staffing, which corroborated the staffing issues. The Facility Assessment Tool indicated that the resident acuity and population required nine CNAs for the 3-11 shift and seven to eight CNAs for the 11-7 shift. However, the staffing grid revealed that on the days in question, the facility operated with fewer CNAs than required. Interviews with the LPN/Staffing Coordinator and the Administrator highlighted challenges in maintaining adequate staffing levels due to frequent call-ins and illnesses related to COVID-19. An LPN confirmed that a resident's medication was left unattended because there was insufficient staff to provide necessary care and encouragement, further illustrating the impact of inadequate staffing on resident care.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment for a resident, identified as Resident #5, due to the poor condition of the linoleum flooring in the resident's room. The flooring was torn and folded back under the resident's wheelchair and was also buckling under the bed. This condition was observed during a survey, and it was reported that the flooring had been in disrepair for several months. The resident's sister had complained to the nursing staff and the Administrator, expressing concerns about the flooring being a fall risk. The resident, who was moderately cognitively impaired with a BIMS score of eight, was at high risk for falls and transferred herself from bed to wheelchair without assistance. Interviews with facility staff, including a CNA, an LPN, and the Maintenance Director, confirmed that the flooring issue had been known for at least a month. The Maintenance Director acknowledged the potential fall hazard but had not repaired the floor due to being the sole maintenance staff. The Administrator was aware of the issue and had plans to install new tile but had not yet completed the repair. The Administrator expected CNAs to elevate the bed to prevent further damage to the flooring, but the bed required manual adjustment, complicating the process.
Improper Food Handling and Sanitation Practices
Penalty
Summary
The facility failed to ensure proper food handling and sanitation practices to prevent cross-contamination during a kitchen observation. Dietary staff member #2 was observed using a brown paper towel to clean a thermometer between checking food temperatures on the tray line, instead of using an alcohol pad as required. This improper practice was confirmed during an interview with the Dietary Manager, who stated that using a paper towel instead of an alcohol pad constitutes cross-contamination. Dietary staff had been trained to use alcohol swabs for this purpose. During a phone interview, the dietary staff member admitted to using a paper towel due to nervousness and acknowledged that this action could lead to cross-contamination and potential gastrointestinal issues for residents.
Failure to Follow Enhanced Barrier Precautions for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that Enhanced Barrier Precautions (EBP) were followed during care for a resident requiring high-contact precautions. Specifically, during two separate observations, Licensed Practical Nurses (LPNs) did not wear gowns while providing care to a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The facility's policy, dated April 2024, mandates the use of gowns for residents with indwelling medical devices during high-contact care activities to prevent infection, especially for those at risk of being infected with multidrug-resistant organisms (MDROs). The resident involved, admitted in June 2024, had a diagnosis of Metabolic Encephalopathy and a moderately impaired cognitive status. Despite the presence of signage on the resident's door indicating the need for gloves and gowns during high-contact activities, such as PEG tube care, the LPNs failed to comply. Interviews with the LPNs and the Infection Preventionist confirmed the oversight and acknowledged the risk posed to the resident due to the lack of proper personal protective equipment (PPE) usage.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code a Minimum Data Set (MDS) assessment for a resident who was discharged to home, not to a hospital as recorded. The resident, admitted with a diagnosis of muscle weakness, was intended to return home after a brief stay for skilled care. A review of the Discharge MDS with an Assessment Reference Date (ARD) indicated the resident was discharged to a short-term general hospital, contrary to the physician's telephone orders which specified discharge to home. Interviews with the Social Services Director and the MDS nurse confirmed the error, acknowledging that the MDS was incorrectly coded. The MDS nurse and the Administrator both recognized the importance of accurate MDS coding to reflect the care provided accurately.
Failure to Develop Person-Centered Care Plan for Impaired Vision
Penalty
Summary
The facility failed to develop a person-centered care plan for a resident with impaired vision. The resident, admitted on 6/23/23, had diagnoses including Paralytic Ptosis of the left eyelid and was seen by an optometrist on 09/19/2024, who diagnosed him with Dry Eye Syndrome and ordered glasses. Despite these diagnoses and orders, the resident's care plan did not address his impaired vision. Interviews with various Licensed Practical Nurses (LPNs) revealed a lack of awareness regarding the resident's optometrist visit, diagnosis, and the need for glasses. The care plan remained generic due to the absence of documented information about the resident's vision impairment. The Administrator and LPNs were unaware of the resident's impaired vision and the optometrist's orders, as the eye examination documentation was not included in the medical records. The Nursing Supervisors were responsible for ensuring that such orders were incorporated into the care plan, with the Care Plan Nurse serving as a backup. However, the optometrist's report and the admission diagnosis were not addressed, leading to the deficiency in the resident's care plan.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to ensure medications were secured and inaccessible to unauthorized residents and staff during the survey. On one occasion, an LPN left a medicine cup containing Vitamin C, Multivitamin, Levothyroxine, Metoprolol, and Pravastatin unattended on a resident's bedside table. The resident, who had a moderately impaired cognition with a BIMS score of eight, was lying flat in bed without staff supervision. The LPN admitted to leaving the medication because the resident was slow to take her medication and acknowledged the risk of choking or another resident taking the medication. In another instance, a resident with a BIMS score of 15, indicating cognitive intactness, was found with two medication dispensing cups containing an unidentified cream on the bedside table. The resident stated that the weekend nurse provided the cream for self-application as needed for itching. Upon review, the cream was identified as Nystatin External Cream. An LPN confirmed that medications should not be left at the bedside, indicating a lapse in following the facility's medication storage policy.
Failure to Document Resident Rights on Advance Directives
Penalty
Summary
The facility failed to maintain complete and accurate medical records by not documenting that residents were informed of their rights regarding Advance Directives. This deficiency was identified in the records of three residents who were admitted with various diagnoses, including Unspecified Dementia, Atherosclerotic Heart Disease, and Vascular Dementia. The review of the Resident Rights/Advance Directive forms revealed that these forms were not initialed by the residents or their representatives, indicating that they had not been informed about formulating an Advance Directive. During interviews, the Social Services Director (SSD) confirmed her responsibility for completing the Advance Directive forms and acknowledged that they were incomplete. The Administrator also confirmed that the forms failed to reflect the residents' receipt of information related to Advance Directives. The responsibility for ensuring that all information related to the residents' choices was documented was attributed to the SSD.
Failure to Ensure Respectful Treatment of Residents
Penalty
Summary
The facility failed to ensure that nursing staff treated residents with respect and dignity during procedures and medication administration, affecting two residents. Resident #5 reported that an LPN was disrespectful and demanding when collecting a urine sample, a behavior she had experienced frequently. Despite her repeated complaints, the facility only transferred her medications to another nurse after the incident. The resident expressed anxiety about seeing the LPN, who continued to work in her hall. The facility's investigation concluded that the allegations of abuse were not valid, attributing the issue to a personality conflict. Resident #6 also reported similar issues with the same LPN, describing her as rude and demanding during medication administration and medical procedures. The resident had previously complained to the Administrator, which led to temporary improvement in the LPN's behavior. However, the LPN resumed her previous conduct, causing the resident anxiety. The resident's representative noted that the facility should have taken more decisive action, such as moving the LPN to another hall. Both residents were cognitively intact, as indicated by their BIMS scores. The facility's response to the complaints was inadequate, as the LPN continued to work in the same area despite the residents' discomfort and anxiety. The Administrator acknowledged the complaints but did not initially reassign the LPN or the residents' medications, which contributed to the ongoing issues.
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Illustrative
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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 Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alyce G Clarke Center For Medically Fragile Childr | 0.5 mi | — | 0 | 0 |
| Manhattan Community Care Center | 1.3 mi | ★★★★★ | 7 | 1 |
| Compere Nh Inc | 2.4 mi | ★★★★★ | 0 | 0 |
| Pine Forest Health And Rehabilitation | 3.6 mi | ★★★★★ | 6 | 0 |
| Methodist Sepcialty Care Center | 3.6 mi | ★★★★★ | 1 | 0 |
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