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 Lakeland Hills Center during CMS and state inspections, most recent first.
A resident with severe hypoxic ischemic encephalopathy and Full Code status experienced cardiac arrest, and staff initiated CPR prior to EMS arrival, as confirmed by an EMS report and the RN assigned to the resident. However, review of the medical record showed no documentation of CPR in progress notes or assessments, and no code blue sheet could be located in the facility’s binder, despite policy requiring use of a Code Blue Worksheet and transcription of the event into the medical record. The ADON, DON, and RN all acknowledged that required CPR documentation was missing for this event.
The facility failed to accurately reconcile hospital discharge medications and follow physician orders for several residents, resulting in missed or incorrect medication administration, lack of follow-up on laboratory and outpatient orders, and failure to document or notify physicians as required. These failures led to serious harm, including seizures, falls, hospitalization, and death. Staff interviews confirmed lapses in medication reconciliation, order verification, and adherence to prescribed protocols.
Nursing staff failed to demonstrate competency in medication reconciliation, laboratory follow-up, and adherence to physician orders, affecting multiple residents. Deficiencies included lack of proper training, failure to document or report G-tube malfunctions, unauthorized medication administration, and inadequate follow-up on lab orders. These failures resulted in worsened resident conditions and led to an Immediate Jeopardy determination.
Three residents experienced significant medication errors due to failures in medication reconciliation and administration. One resident with a seizure disorder and G-tube did not receive the correct dose and form of anti-seizure medication, leading to multiple seizures, a fall, and death. Another resident with epilepsy and a feeding tube did not receive all prescribed seizure medications after readmission, resulting in seizure-like activity and hospital transfer. A third resident with diabetes received unauthorized insulin doses from an LPN, contrary to physician orders, and was hospitalized for hyperglycemia. These incidents were linked to failures in communication, documentation, and adherence to medication protocols.
The QAPI committee failed to ensure effective diabetes management for two residents, resulting in nursing staff not following physician orders for insulin administration, lack of required physician notifications for high blood sugar readings, and inadequate documentation of care. These deficiencies were not effectively identified or addressed through the facility's QAPI process.
The facility failed to maintain essential laundry equipment, resulting in a shortage of clean linen for resident care. One of two industrial dryers was non-functional due to a trunnion bearing assembly failure, leading to delays in repairs and communication issues with the vendor. CNAs reported linen shortages and resorted to using the remaining dryer after hours, which was against protocol.
Two residents experienced a deficiency in their shared bathroom, which had a strong odor and improperly sized toilet seat. A CNA used towels to soak up water, concerned for a resident with sight challenges and fall risk. The Maintenance Director was unaware of the issue due to a lack of communication and absence of an electronic work order system, leading to the deficiency.
A resident with hemiplegia and heart failure was unable to reach the call light due to improper implementation of the care plan. Despite being cognitively intact, the resident reported difficulty in accessing the call light, which was observed to be out of reach. The facility's policy mandates that care plans be followed to ensure residents' well-being, which was not done in this instance.
The facility failed to ensure proper food labeling, storage, and sanitation in the kitchen. Observations revealed unlabeled food items, dirty cookware, and improper glove use by staff. Additionally, the facility did not maintain accurate sanitizer logs or calibrate thermometers correctly, leading to multiple deficiencies in food safety and handling practices.
Failure to Document CPR Event in Resident Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to accurately document a CPR event in accordance with its own policy and accepted professional standards. Resident #2, who had severe hypoxic ischemic encephalopathy and an advanced directive of Full Code, experienced a cardiac arrest. An EMS county Fire Rescue report showed that staff initiated CPR at 00:55 and EMS arrived at 01:37:48, continued CPR, provided medication support, and transferred the resident to a local hospital. However, review of Resident #2’s clinical chart, including the face sheet, progress notes, and assessments, revealed no indication that CPR had been performed on the resident on the date of the event. During interviews, the ADON and Regional Nurse Consultant confirmed that staff were required to complete a code blue sheet when CPR was conducted and that these sheets were kept in a binder, but no code blue sheet for Resident #2 was found. The DON, after reviewing the paper medical file, also confirmed there was no documentation in the medical record related to CPR being performed. A phone interview with the RN assigned to the resident that night confirmed that CPR had been administered and that she had participated in the code. The RN stated she had filled out the code blue sheet but did not know what happened to it and acknowledged that documentation in the clinical record “would be on me,” explaining that there had been a lot going on that night. The facility’s CPR-Code Status Orders and Response policy requires use of a Code Blue Worksheet to notate the timeline and activity, with transcription of those notes into the medical record upon resolution of the event, and completion of a 24-hour and nurse’s note, which did not occur for this resident.
Failure to Reconcile Medications and Follow Physician Orders Resulting in Resident Harm
Penalty
Summary
The facility failed to protect residents from neglect by not accurately reconciling medications, failing to follow up on physician orders for laboratory testing, medical equipment, and outpatient services, and not administering medications as ordered. One resident was readmitted from the hospital with a history of seizures and a G-tube, requiring a specific dose and form of seizure medication. The facility did not accurately reconcile the hospital discharge medication orders, resulting in the resident receiving an incorrect dose and form of medication. Despite multiple notifications to the physician and pharmacy about the need to change the medication to a solution for G-tube administration, the correct order was not implemented in a timely manner. The resident subsequently experienced multiple seizures, a fall with head trauma, and ultimately died from his injuries. Laboratory orders for seizure medication levels were not completed as ordered, and follow-up on outpatient cardiology appointments and equipment was not performed. Another resident with epilepsy and a feeding tube was readmitted to the facility, but the hospital discharge medication list was not properly reconciled. Several medications, including a seizure medication, were omitted from the facility's orders, and the resident did not receive these medications. The resident experienced seizure-like activity and required transfer to a higher level of care. Staff interviews revealed that the admitting nurse did not verify the medication list with the physician, and the correct discharge medication list was not obtained until after the incident. The facility initiated an investigation after being notified by the resident's family that the resident had not received her seizure medications since her last hospitalization. A third resident with diabetes and epilepsy was not managed according to physician orders for blood sugar testing and insulin administration. An LPN administered large doses of insulin without a physician's order after observing high blood sugar readings, and failed to document the blood sugar readings or notify the physician as required. The resident was subsequently sent to the hospital for hyperglycemia and influenza A. Staff interviews confirmed that the nurse did not follow the prescribed sliding scale insulin orders and acted without proper authorization or documentation.
Failure to Ensure Nursing Staff Competency and Adherence to Physician Orders
Penalty
Summary
Licensed nursing staff failed to demonstrate knowledge and competency in several critical areas of resident care, affecting six out of ten sampled residents. Deficiencies included failure to accurately reconcile medications upon admission, failure to follow up on laboratory orders, administration of medication without a physician's order, failure to report and document gastrostomy tube (G-tube) malfunctions, practicing outside the nursing scope of responsibility, failure to follow physician orders for blood sugar testing, and failure to implement hospice consultation orders. These failures resulted in worsened conditions for residents and created the likelihood of serious injury or death, leading to a determination of Immediate Jeopardy. For one resident with a history of seizures and a G-tube, there were multiple failures in medication reconciliation and laboratory follow-up. Orders for seizure medication levels were entered as completed, but no lab results were found in the medical record. Interviews revealed that nurses lacked access to the lab portal, had not received formal training on the lab process or the admission process, and often relied on informal guidance from coworkers. The DON confirmed that the process for lab follow-up was not followed, and that staff were not supposed to reconcile medications or enter orders without physician communication. Additionally, the emergency drug kit did not contain necessary anti-seizure medications, and some nurses lacked access to the electronic medication dispensing system. In another case, staff failed to report and document a G-tube malfunction for a resident with multiple complex diagnoses. Nurses cut the G-tube without physician orders or documentation, and there was no facility policy on G-tube care. Staff interviews confirmed that cutting the tube was done without proper notification or documentation, and that education on this issue was lacking. In a separate incident, an LPN administered insulin to a resident with diabetes without a physician's order and failed to document blood sugar readings or the amount of insulin given. These actions were only discovered during shift handoff, and the resident required transfer to the emergency room for further care.
Failure to Prevent Significant Medication Errors and Ensure Accurate Medication Reconciliation
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the areas of medication reconciliation upon admission and the administration of physician-ordered medications. In one case, a resident with a history of seizures and a gastrostomy tube was readmitted from the hospital with orders for a specific dose and form of seizure medication (Levetiracetam/Keppra). The facility did not accurately reconcile the hospital discharge medication orders, resulting in the resident receiving an incorrect dose and form of the medication. Documentation showed confusion and delays in changing the medication from tablet to solution for G-tube administration, and there was a lack of clear communication and documentation regarding dose changes. The resident subsequently experienced multiple seizures, a fall with head trauma, and was transferred to a higher level of care, where he later died. Additionally, physician-ordered laboratory tests for seizure medication levels were not implemented as ordered, with no results found in the medical record. Another resident, also with a history of seizures and a feeding tube, was readmitted with hospital discharge orders for multiple medications, including two anti-seizure drugs and other critical medications. The facility failed to obtain and reconcile the correct hospital discharge medication list, resulting in the omission of key medications, including a prescribed seizure medication. The resident did not receive the ordered anti-seizure medication, and there were multiple missed doses of another seizure medication due to unavailability. The resident subsequently experienced seizure-like activity and required transfer to a higher level of care. Interviews revealed that the admitting nurse did not verify the medication list with the physician, and the correct discharge medication list was not obtained until after the incident. A third resident with diabetes and epilepsy was affected by improper medication administration when an LPN administered two large doses of insulin without a physician's order, contrary to the resident's sliding scale insulin protocol, which required physician notification for high blood sugar readings. The nurse did not document the blood sugar readings or the insulin administration and failed to notify the physician as required. The resident was later sent to the hospital for hyperglycemia and influenza A. Interviews confirmed that the nurse acted outside the scope of practice and did not follow established protocols for medication administration and physician notification.
Failure to Implement Effective QAPI Plan for Diabetes Management
Penalty
Summary
The facility's Quality Assurance and Performance Improvement Committee (QAPI) failed to implement an effective Performance Improvement Plan (PIP) for diabetes management, as evidenced by multiple incidents involving two residents with diabetes. In one case, a resident with Type 2 Diabetes Mellitus, legal blindness, epilepsy, and acute kidney failure was admitted and later discharged to an acute care hospital after experiencing uncontrolled hyperglycemia. Nursing staff failed to follow physician orders for insulin administration, with one LPN administering two separate 20-unit doses of insulin without a physician's order and without documenting the blood sugar readings or the insulin given. The nurse also failed to notify the physician as required when the blood sugar was above the specified threshold, and there was no documentation of these actions in the resident's medical record. Another resident with Type 2 Diabetes Mellitus and other complications had physician orders specifying that the physician should be notified if blood sugar exceeded a certain level. Despite multiple documented instances of blood sugar readings above this threshold, there was no evidence that the physician was notified as ordered. The medication administration records showed repeated high blood sugar readings and insulin administration, but the required notifications to the physician were not documented. The facility's QAPI policy outlines a process for tracking, measuring, and correcting performance issues, including the use of the Plan-Do-Study-Act (PDSA) cycle and regular reporting to the QA&A Compliance Committee. However, the events described demonstrate that the QAPI process was not effectively implemented or monitored in relation to diabetes management, as evidenced by the lack of adherence to physician orders, failure to document critical care actions, and absence of systematic follow-up on identified deficiencies.
Deficiency in Laundry Equipment Maintenance
Penalty
Summary
The facility failed to ensure that essential laundry equipment was in safe operating condition, specifically one of the two industrial dryers, which impacted the availability of clean linen for resident care. On the morning of January 14, 2025, a Certified Nursing Assistant (CNA) reported a shortage of linen, stating that she was unable to complete resident care due to the lack of towels, flat sheets, chuck pads, and washcloths. Another CNA confirmed that one of the dryers was not working, leading to competition among staff for available linens. The Laundry Aide confirmed that one of the dryers had been non-functional since the previous month, and the Housekeeping/Laundry Supervisor acknowledged that the dryer had been down for about three weeks, attributing the delay to the need for parts and technician availability. The Maintenance Director stated that the dryer had stopped working some time ago due to a failure in the trunnion bearing assembly, which caused the drum to lock up. Despite placing a service call to the vendor, there was a delay in diagnosing the problem and ordering the necessary parts. The Maintenance Director noted that two technicians visited the facility to diagnose the issue, confirming the initial diagnosis, but there was a lack of communication regarding the ordering of parts. A package containing the part arrived without paperwork, and the Maintenance Director was attempting to arrange for technicians to install the parts. This situation led to CNAs using the remaining functional dryer after hours to meet linen needs, which was against protocol and further slowed laundry production.
Failure to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to ensure a safe, clean, and comfortable environment for two residents, resulting in a deficiency. Observations revealed that the shared bathroom of two residents had a strong ammonia and urine odor, with wet towels placed around the base of the toilet. The toilet seat was improperly sized, being two inches shorter than the commode base. Staff A, a CNA, acknowledged the use of towels to soak up water, expressing concern for Resident #7, who has sight challenges and is at risk for falls. Resident #7, who has a history of hemiplegia, muscle weakness, and blindness, confirmed her ability to use the bathroom independently. Resident #8, who is cognitively intact, reported the persistent odor and expressed discomfort. Interviews with the Housekeeping/Laundry Supervisor and the Maintenance Director revealed lapses in communication and maintenance procedures. The Housekeeping/Laundry Supervisor stated that bathrooms should be cleaned daily and issues reported to the Maintenance Director, who was unaware of the bathroom's condition due to the absence of an electronic work order system. The Maintenance Director confirmed the toilet's instability and the incorrect toilet seat size, acknowledging that he had not been informed of the issue. The lack of communication and proper maintenance reporting contributed to the deficiency, as the Maintenance Director was not aware of the problem and therefore could not address it.
Failure to Implement Care Plan for Resident with Mobility Issues
Penalty
Summary
The facility failed to implement the care plan for a resident who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, weakness, and heart failure. The resident, who was cognitively intact, reported being unable to move her left arm and reach the call light, which was observed to be out of her reach. Despite the care plan specifying that the call bell should be within reach and that the resident required assistance for bed mobility, these interventions were not properly implemented. During an observation, the call light was found hanging on the left side of the bed, inaccessible to the resident. The Maintenance Director acknowledged the issue and suggested obtaining a clip to position the call light better. The facility's policy requires that each resident receives necessary care and services according to their comprehensive assessment and care plan, which was not adhered to in this case.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food and beverages were labeled and stored correctly, as observed during a kitchen tour. Three containers of red juice in the walk-in cooler were found without labels or dates, and two plates of food covered in plastic wrap were also unlabeled. Additionally, a box of frozen broccoli and a box of frozen pepperoni were found open to the air in the freezer. The Certified Dietary Manager (CDM) acknowledged these issues and stated that staff were expected to label and date all foods and beverages. The facility also did not maintain cleanliness and proper sanitation in the kitchen. A drying rack had an unknown black residue, and a pot and pan on the drying rack were found dirty with a greasy white substance and flaky reddish-brown spots. The three-compartment sink used for washing, rinsing, and sanitizing was not properly logged for sanitizer solution checks, with missing entries for multiple dates. The CDM and Senior Registered Dietitian (Sr RD) confirmed these observations and stated that logs should be filled out. Furthermore, staff did not adhere to proper glove use and thermometer calibration procedures. Staff A used the same gloves for multiple tasks, including handling food, writing in a logbook, and stirring food, without changing them. Additionally, Staff A's method of calibrating a digital thermometer was incorrect, as it involved running it under hot water instead of using an ice bath or boiling water method. Staff B was observed placing lids on bowls without wearing gloves initially. The Sr RD confirmed that gloves should be worn when handling ready-to-eat food and should be changed when soiled or ripped.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakeland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vivo Healthcare Lakeland | 0.1 mi | — | 2 | 0 |
| Charming Lakes Rehab | 0.5 mi | — | 0 | 0 |
| Valencia Hills Health And Rehabilitation Center | 2.2 mi | — | 16 | 0 |
| Manor At Carpenters, The | 2.3 mi | — | 0 | 0 |
| The Club At Lake Gibson | 2.3 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.