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 Scott Lake Health And Rehabilitation Center during CMS and state inspections, most recent first.
Two residents with significant mobility and cognitive impairments did not have individualized care plans specifying the required number of staff for transfer assistance. Care plans and documentation were unclear or outdated, leading to staff confusion and inconsistent transfer practices, including an incident where a CNA used a mechanical lift alone. The facility did not ensure care plans were promptly updated or clearly communicated to staff.
A resident with diabetes and cognitive impairment was admitted without proper reconciliation of her hospital discharge medications, resulting in critical medications like insulin not being ordered or administered. Facility staff failed to notify the provider of abnormal blood glucose and blood pressure readings, and did not perform necessary blood sugar checks until the resident's condition became critical, leading to a hospital transfer for severe hyperglycemia.
A resident with diabetes and hypertension was admitted in a confused state and did not receive required insulin or proper medication reconciliation due to nursing staff errors. Blood glucose monitoring was not performed, abnormal labs and high blood pressure readings were not consistently reported or addressed, and the resident's condition worsened, resulting in emergency hospitalization. Staff interviews revealed confusion about admission protocols and inconsistent use of checklists.
A resident with diabetes and cognitive impairment was admitted with clear hospital orders for insulin, but due to failures in medication reconciliation and provider review, the correct medications were not entered or administered. The resident did not receive insulin or blood glucose monitoring, resulting in severe hyperglycemia and hospitalization. Staff interviews and record reviews confirmed that the facility's medication entry and review processes were not followed, and critical provider notifications were missed.
A facility failed to maintain a medication error rate below 5%, resulting in a 27.27% error rate during observations. An LPN administered incorrect dosages of Fish Oil and probiotics to a resident, while an RN gave another resident incorrect forms and dosages of Magnesium and Vitamin D, nearly administered expired nasal spray, and withheld Metoprolol based on incorrect parameters. The DON confirmed these errors, and the facility's policy lacked specific standards for medication verification.
A resident with multiple health conditions was observed unresponsive and had medications withheld due to lethargy without notifying the physician, Hospice, or family. The facility's policy required prompt notification of changes in condition, but this was not followed, leading to a deficiency. Interviews with staff confirmed the lack of adherence to protocol, and the Director of Nursing acknowledged the failure to document and communicate these changes.
Failure to Individualize and Update Transfer Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement individualized care plans for two residents, resulting in unclear instructions for staff regarding the required level of assistance for transfers. For one resident with severe cognitive impairment, muscle weakness, and contractures, the care plan was not updated in a timely manner to specify the use of a mechanical lift with two staff members. Staff interviews revealed confusion and lack of clarity about whether one or two staff were needed for transfers, and an incident was observed where a CNA used a Hoyer lift alone, contrary to best practices and the resident's needs. The care plan was only revised after the incident to specify two-person assistance with a mechanical lift. For another resident with hemiplegia, muscle weakness, and a history of falls, the care plan and Kardex documentation were inconsistent regarding the number of staff required for transfers. The care plan included vague instructions such as "1-2 assist as needed" and did not clearly communicate the resident's current needs. Staff interviews indicated that CNAs were left to decide whether one or two staff should assist, based on their judgment rather than clear care plan directives. The resident reported using a sit-to-stand mechanical lift and being informed of a recent fall, but documentation did not specify the required assistance level. The facility's policy required care plans to be individualized, updated with changes in resident condition, and clearly communicated to all staff. However, the interdisciplinary team did not ensure that care plans were consistently revised or that staff were provided with clear, measurable actions for resident transfers. This lack of specificity and timely updating in care plans led to staff uncertainty and inconsistent care practices for residents requiring assistance with transfers.
Failure to Reconcile and Administer Critical Medications on Admission
Penalty
Summary
A resident with a history of type 2 diabetes, hypertension, and cognitive impairment was admitted to the facility with a detailed hospital discharge medication list, including multiple critical medications such as insulin. Upon admission, the facility failed to accurately reconcile and transcribe the resident's medications. Several essential medications from the hospital discharge list, including insulin, were not entered into the facility's physician orders or administered. Instead, the resident received medications not listed on the hospital discharge summary, and some medications were given at incorrect dosages. The admitting nurse and another LPN were involved in entering the orders, but there was confusion and lack of clarity regarding the process, and the provider was not properly consulted to verify the medication reconciliation. Throughout the resident's stay, there was a lack of monitoring and response to abnormal clinical findings. The resident experienced multiple episodes of significantly elevated blood pressure and abnormal laboratory results, including extremely high blood glucose levels. Despite these findings, there was no documentation that the provider was notified of the abnormal results on several occasions, and the resident did not receive insulin or other diabetes medications as ordered by the hospital. Blood glucose checks were not performed until the resident's condition deteriorated significantly, at which point a critically high blood sugar was detected, and the resident was transferred to the hospital. Interviews with staff revealed that the medication reconciliation process was not properly followed, and there was no documentation that the provider reviewed or clarified the orders before they were entered. The facility's admission checklist lacked a mechanism for verification or sign-off, and staff could not produce completed checklists for the resident. The resident's representative and staff confirmed that the resident was unable to advocate for herself due to confusion, and her condition worsened during her stay, culminating in a hospital transfer for severe hyperglycemia and other complications.
Failure to Reconcile Medications and Monitor Diabetic Resident Leads to Immediate Jeopardy
Penalty
Summary
Nursing staff failed to demonstrate competency in reconciling hospital discharge medication orders, monitoring blood glucose levels for a diabetic resident, and recognizing or responding to elevated blood pressures and abnormal laboratory results. Upon admission, the resident, who had a history of type 2 diabetes mellitus, hypertension, and nontraumatic intracerebral hemorrhage, was confused and unable to communicate her medication needs. Despite clear documentation in the hospital discharge instructions indicating the need for daily insulin and other specific medications, these orders were not properly entered into the facility's medical record. Instead, the resident received medications not listed on her hospital discharge summary, and some required medications, including insulin, were omitted entirely. Throughout the resident's stay, there was a lack of appropriate monitoring and response to critical health indicators. Blood glucose checks were not performed from admission until the day the resident was transferred to the hospital, despite the resident being diabetic and having abnormal lab results indicating hyperglycemia. The resident also experienced multiple episodes of significantly elevated blood pressure, with inconsistent or delayed provider notification and intervention. Laboratory results showing dangerously high blood glucose and other abnormal values were reviewed by nursing staff but not communicated to the provider in a timely manner, and there was no documentation of follow-up or corrective action. Interviews with staff revealed confusion and lack of clarity regarding the medication reconciliation process, with nurses relying on incomplete or incorrect documentation and failing to ensure provider review and verification of orders. Admission checklists and protocols were inconsistently used or not documented, and there was no reliable system to confirm that chart checks and medication reconciliations were completed accurately. The resident's condition deteriorated during her stay, culminating in a critical hyperglycemic episode that required emergency transfer to the hospital.
Failure to Ensure Accurate Medication Reconciliation and Administration on Admission
Penalty
Summary
A resident with a history of type 2 diabetes mellitus, hypertension, and other significant medical conditions was admitted to the facility with clear hospital discharge instructions that included multiple medications, notably sliding scale insulin and long-acting insulin glargine. Upon admission, the resident was confused and unable to communicate her medication needs. Despite the hospital records and the resident representative informing staff about the insulin requirement, the facility failed to enter the correct medication orders into the resident's medical record. Instead, several medications not listed on the hospital discharge summary were ordered and administered, while critical medications, including insulin, were omitted. The medication reconciliation process was not properly completed or documented. The admitting LPN and another assisting LPN did not ensure that the hospital discharge medication list was accurately transcribed or reconciled with a provider before entering orders into the system. There was no evidence that the provider reviewed or clarified the orders, and the required chart checks by night shift staff were not documented. As a result, the resident did not receive insulin or have blood glucose monitoring performed for several days, despite having abnormal lab results and elevated blood glucose levels documented in the record. Providers were not consistently notified of these abnormal findings, and the resident's condition deteriorated, leading to hospitalization for severe hyperglycemia. Interviews with facility staff, including nurses, the DON, ADON, and the medical director, confirmed that the medication lists did not match and that the expected process for medication reconciliation and provider review was not followed. The consultant pharmacist also confirmed that the facility is responsible for entering medication orders correctly and that she was not aware of the full extent of the medication errors. The resident's health declined during her stay, with documented confusion, lethargy, and ultimately a critical episode of hyperglycemia requiring emergency intervention.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 27.27% error rate during the observation of medication administration for two residents. Staff A, an LPN, administered medications to Resident #2, including incorrect dosages of Fish Oil and a probiotic. Specifically, Resident #2 received 500 mg of Fish Oil instead of the ordered 2000 mg and was given lactobacillus acidophilus instead of the prescribed Saccharomyces boulardii. These errors were confirmed by Staff A upon review of the medication profile. In another instance, Staff B, an RN, administered medications to Resident #3, which included several discrepancies. Resident #3 was given Magnesium Oxide instead of the ordered Magnesium Gluconate and received Vitamin D in a different form and dosage than prescribed. Additionally, an expired Ipratropium nasal spray was nearly administered, but the error was caught by a state surveyor. Furthermore, Metoprolol was withheld based on incorrect parameters, as the resident's heart rate did not meet the criteria for withholding the medication. The Director of Nursing acknowledged these errors as legitimate upon being informed. The facility's policy on medication administration lacked specific standards for ensuring the correct medication and dosage were administered, contributing to these errors. The policy did not include verification procedures for medication administration, which may have prevented these discrepancies.
Failure to Notify Physician and Hospice of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the attending physician or Hospice of a change in condition for a resident, leading to a deficiency. The resident was observed in a low bed with fall mats, wearing an oxygen cannula, and was unresponsive. The resident's medical history included chronic obstructive pulmonary disease, schizoaffective disorder, major depression, anxiety disorder, and dementia. The care plan indicated the resident was incapable of making healthcare decisions and had an activated medical decision maker. The facility was required to work with Hospice to meet the resident's needs and monitor for complications related to hypertension and sedative/hypnotic therapy. The facility's records showed several instances where medications were withheld due to the resident's lethargy, but the attending physician, Hospice, and family were not notified. Specifically, the resident's blood pressure was recorded at 157/114, and Klonopin and Haloperidol were not administered on multiple occasions without proper notification. The facility's policy required prompt notification of changes in the resident's condition, but this was not followed, as evidenced by the lack of documentation and communication with the necessary parties. Interviews with staff, including RNs and the Director of Nursing, confirmed that the facility's protocol for notifying physicians and families was not adhered to. The Hospice RN also noted complaints about the facility holding medications without notifying the ordering physician. The Director of Nursing acknowledged the failure to document and communicate these changes, emphasizing that if it wasn't documented, it wasn't done. The facility's policy on changes in a resident's condition or status was not followed, leading to the deficiency identified in the report.
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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) |
|---|---|---|---|---|
| Highlands Lake Center | 2.9 mi | — | 2 | 0 |
| Bridgewalk On Harden Health And Rehabilitation, Ll | 3.9 mi | — | 0 | 0 |
| Florida Presbyterian Homes Inc | 5.5 mi | — | 0 | 0 |
| Lakeland Hills Center | 8.1 mi | — | 1 | 0 |
| Charming Lakes Rehab | 8.1 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.