Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lake Port Square Health Center during CMS and state inspections, most recent first.
A facility failed to ensure accurate MDS assessments for a resident with a feeding tube. An LPN administered medications via a gastric tube, but the resident's MDS inaccurately indicated no feeding tube. Physician orders confirmed the presence of a gastric tube and enteral feeding instructions. The MDS Coordinator admitted the error, acknowledging the resident did have a feeding tube.
A facility failed to develop comprehensive care plans for a resident with atrial fibrillation and two residents requiring respiratory services. The first resident, on anticoagulant medication, lacked a care plan for monitoring complications. The second resident, using CPAP for sleep apnea, and the third resident, receiving inhalation treatments and oxygen therapy, both lacked care plans for respiratory services. The DON confirmed these omissions, which should have been addressed shortly after admission.
A facility failed to provide appropriate CPAP therapy for a resident with sleep apnea. Observations showed the CPAP nose piece was not in use, and there was no physician's order for the CPAP documented. The resident had multiple diagnoses, including sleep apnea, requiring CPAP use, but the facility did not have the necessary order in place.
The facility failed to properly store medications, as observed with a resident's menthol gel and antifungal powder left unsecured on bedside tables. Another resident had Latanoprost eye drops left unattended. Staff confirmed that medications should be secured unless a physician orders self-administration, in which case they must be locked in the bedside table.
The facility failed to ensure proper food storage, labeling, and cleanliness in the kitchen. Observations revealed unlabeled open food condiments, debris on the freezer floor, and a dietary aide without hair covering. Breakfast items were placed on the tray line too early, and there was excessive buildup on kitchen equipment. The CDM and FSD confirmed these issues, which violated facility policies on equipment cleanliness, food storage, and personal cleanliness.
The facility failed to accurately document medication administration for three residents, leading to discrepancies in the Medication Administration Record (MAR). A resident's hypertension medications were held without proper documentation of vital signs or physician notification. Another resident's insulin was held without documenting communication with the provider. Additionally, a resident's refusal of insulin was incorrectly documented as held due to low blood sugar. Staff interviews revealed inconsistencies in following documentation policies, highlighting the need for accurate record-keeping and communication with physicians.
The facility failed to adhere to infection control protocols, with staff not donning required PPE during high-contact care and improper storage of respiratory equipment. A CNA entered a resident's room without a gown despite contact precautions, and an LPN forgot to wear a gown while administering medication via a gastric tube. Additionally, respiratory equipment was not stored in bags as per policy, and a CNA assisted a resident on contact isolation without PPE. These lapses indicate non-compliance with infection control standards.
The facility failed to change central venous catheter dressings according to professional standards for two residents. One resident had an outdated dressing with gauze underneath, and the other had a dressing with gauze that should have been changed earlier. Staff did not notice or address these issues during their assessments and medication administrations.
Inaccurate MDS Assessment for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for a resident reviewed for nutrition. During an observation, a Licensed Practical Nurse (LPN) administered medications to a resident via a gastric tube. However, the resident's quarterly MDS inaccurately indicated that the resident did not have a feeding tube under Section K - Swallowing/Nutritional Status. A review of the resident's physician orders dated December 6, 2024, confirmed the presence of a gastric tube and specified enteral feeding instructions. During an interview, the MDS Coordinator acknowledged that the section was coded in error, confirming the resident did have a feeding tube. The facility's policy on resident assessments assigns responsibility to the resident assessment coordinator to ensure timely and appropriate assessments by the interdisciplinary team.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident #26, who was admitted with diagnoses including atherosclerotic heart disease, cardiac pacemaker, prosthetic heart valve, and atrial fibrillation. Despite having a physician's order for Eliquis, an anticoagulant medication, there was no focus area or interventions for anticoagulant medication or atrial fibrillation in the resident's care plan. The Director of Nursing and the MDS Coordinator both acknowledged the absence of a care plan for monitoring anticoagulant complications, which should have been initiated upon admission. Resident #265, who was admitted with multiple diagnoses including sleep apnea, did not have a care plan for respiratory services. During an observation, the resident was seen with a CPAP nose piece on the bedside table, indicating the use of CPAP for breathing at night. The Director of Nursing confirmed the lack of a care plan for respiratory services, which should have been developed within 72 hours of admission. Similarly, Resident #266, admitted with conditions such as sepsis, pneumonitis, acute respiratory failure, and obstructive sleep apnea, did not have a care plan for respiratory services. The resident was observed with an inhalation mask and had physician orders for inhalation treatments and oxygen therapy. The Director of Nursing acknowledged the absence of a care plan for respiratory services, which was required to be developed promptly after admission.
Failure to Provide Appropriate CPAP Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #265, who required the use of a CPAP machine for sleep apnea. Observations on multiple occasions revealed that the CPAP nose piece was consistently left on the bedside table, indicating it was not in use. Despite the resident's acknowledgment of using the CPAP to breathe better at night, there was no physician's order for the CPAP documented in the resident's records. The resident was admitted with several diagnoses, including sleep apnea, which necessitates the use of a CPAP machine. The Director of Nursing confirmed that there should have been an order in place for the resident to receive CPAP therapy at the facility. The facility's policy on CPAP/BiPAP support requires a physician's order to determine the necessary settings for the machine, which was not adhered to in this case.
Improper Storage of Medications in Resident Rooms
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly stored, as evidenced by several observations. In one instance, a tube of menthol pain-relieving gel was found on the bedside table of a resident's room on two separate occasions. The resident confirmed using the gel for shoulder pain a couple of times a week. In another case, a bottle of antifungal powder was observed on the bedside table of a different resident, who stated they used it under their breast. Interviews with staff, including an LPN and the Director of Nursing, confirmed that medications should not be left unsecured at the bedside unless there is a physician's order for self-administration, in which case the medication must be locked in the bedside table. Additionally, a bottle of Latanoprost eye drops was found on the bedside table of another resident who was not able to self-administer medications. The resident mentioned that the eye drops were left behind by someone and needed to be discarded. The Director of Nursing confirmed that medications should not be left unattended in residents' rooms. The facility's policy on medication labeling and storage requires that all medications and biologicals be stored in locked compartments and that only authorized personnel have access to the keys. The policy also states that compartments containing medications should be locked when not in use, and transport trays or carts should not be left unattended if open.
Deficiencies in Food Storage and Kitchen Cleanliness
Penalty
Summary
The facility failed to ensure proper food storage, labeling, and cleanliness in the kitchen, leading to several deficiencies. During a walk-through tour, it was observed that several containers of open food condiments in the reach-in cooler were not labeled with an open date. Additionally, the freezer floor was littered with trash and debris, and open box flaps were exposing food items. A dietary aide was observed working without a hair covering or beard guard, which was confirmed during an interview. The Certified Dietary Manager (CDM) acknowledged the issues, stating that he was unaware of the need for open dates on condiment containers and agreed that the freezer floor should be cleaned and lids should be closed. The CDM also confirmed that all staff should use hair restraints in the kitchen. Further observations revealed that breakfast food items were placed on the tray line earlier than the facility policy allowed. There was a large buildup of food bits and dried debris on the floor mixer, and the convection ovens had excessive dirt and debris buildup. The food/grease trap drawer on the regular stove was also found to have excessive food particles and burnt debris. The Food Service Director (FSD) confirmed these observations, noting that the cook had placed food on the tray line too early and that the covered mixer was not cleaned as required. The facility's policies and procedures, which were reviewed, outlined the expectations for equipment cleanliness, food storage, and personal cleanliness, all of which were not adhered to, leading to these deficiencies.
Documentation Errors in Medication Administration
Penalty
Summary
The facility failed to accurately document notifications of medication parameters for three residents reviewed for medication administration. For Resident #27, there were discrepancies in the documentation of blood pressure and pulse readings in the Medication Administration Record (MAR) for medications prescribed for hypertension. The MAR indicated that medications were held due to vital signs being outside of parameters, but there was no documentation of blood pressure or pulse readings on specific dates. Interviews with staff revealed that while they used their nursing judgment to hold medications when blood pressure was low, they did not consistently document communication with the physician in the resident's medical record. For Resident #163, the MAR showed that insulin was held due to vital signs being outside of parameters, but there was no documentation of physician notification. Staff interviews indicated that the nurse did not document the communication with the provider when insulin was held, citing a busy admission process as the reason for the oversight. The facility's policy requires that all services provided to the resident, including changes in medical condition, be documented in the medical record to facilitate communication among the interdisciplinary team. Resident #26's case involved a documentation error where insulin was coded as held due to low blood sugar, but the resident had actually refused the medication. The nurse did not notify the physician of the refusal, and the documentation did not accurately reflect the resident's refusal. The facility's policy on medication administration requires that reasons for withholding, not administering, or refusing medication be documented accurately. The Director of Nursing acknowledged the documentation errors and emphasized the importance of proper documentation and physician notification.
Infection Control Deficiencies in PPE Usage and Equipment Storage
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple instances of non-compliance with infection control standards. During a medication administration observation, a CNA entered a resident's room without donning the required personal protective equipment (PPE) such as a gown, despite the resident being on contact precautions due to an ESBL infection. The CNA mistakenly believed that a gown was only necessary if the resident had a contagious illness. The Director of Nursing (DON) later clarified that staff should wear gloves and a gown when providing high-contact care for residents on enhanced barrier precautions. In another instance, an LPN failed to wear a gown while administering medication via a gastric tube to a resident on enhanced barrier precautions. The LPN acknowledged forgetting to don the gown, which was required by the facility's policy for high-contact resident care activities. Additionally, the facility's policy on storing respiratory care equipment was not followed, as observed with two residents. One resident's CPAP nose piece was repeatedly left unbagged on the bedside table, and another resident's inhalation mask was not stored in a bag after use, contrary to the facility's infection prevention policy. Furthermore, a CNA assisted a resident on contact isolation for C. diff without wearing a gown or gloves, despite clear signage indicating the need for such precautions. The CNA admitted to not paying attention to the signage and failing to don the appropriate PPE. The DON confirmed that staff are expected to wear a gown and gloves before entering rooms with contact precautions. These observations highlight lapses in adherence to infection control protocols, potentially compromising resident safety.
Failure to Change Central Venous Catheter Dressings as Per Standards
Penalty
Summary
The facility failed to ensure central venous catheter dressings were changed in accordance with professional standards of practice for two residents. Resident #3 had a PICC line with a transparent dressing dated 4/1/2024, which was observed curling at the edges and had gauze underneath. The resident's physician order required weekly dressing changes, but the dressing had not been changed for 10 days. Staff A, an RN, and Staff B, an LPN, both failed to notice and address the outdated dressing and the presence of gauze during their assessments and medication administrations. Resident #4 had a PICC line with a transparent dressing dated 4/6/2024, which also had gauze underneath. The resident's physician order required dressing changes every seven days and PRN, but the gauze should have prompted a change after two days. Staff A and Staff B admitted to not realizing the presence of gauze and the need for a dressing change. The Director of Nursing confirmed that the facility's policy required dressings with gauze to be changed every two days, which was not followed in these cases.
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 87 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 Leesburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Campus Care Center And Rehab | 0.4 mi | — | 11 | 0 |
| North Campus Rehabilitation And Nursing Center | 1.2 mi | — | 0 | 0 |
| Avante At Leesburg, Inc | 2.1 mi | — | 0 | 0 |
| Chatham Glen Healthcare And Rehabilitation Center | 8.5 mi | — | 5 | 0 |
| Villages Healthcare And Rehabilitation Center, The | 8.6 mi | — | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lake Port Square Health Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.