Lake City Center for Nursing and Healing LLC

Inspectors wroteBased on observations, resident interviews, staff interviews, record review, and policy review, the facility failed to provide sufficient nursing staff to meet the needs of residents. Specifically, the facility had multiple vacant nursing positions and did not have an established, planned staffing level to determine the number and type of nursing staff needed to meet residents' needs. During the review period, residents experienced delays in activities of daily living (ADL) care, repeated delays in medication administration, and a failure to provide ordered nursing services, including enteral nutrition. The facility census was 208 residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement the comprehensive care plan for one of 16 residents (R) (R6) receiving enteral nutrition. This deficient practice had the potential for residents not to receive nutrition and hydration to meet their dietary needs.

Inspectors wroteBased on observations, record review, interviews, and review of facility policy, the facility failed to provide necessary activities of daily living (ADL) care for one of three residents (R)(R2) reviewed for ADL care. Specifically, the facility failed to ensure R2 received appropriate bathing services during an extended disruption in hot-water availability.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that one of 16 residents (R) (R6) receiving tube feeding maintained acceptable parameters related to body weight.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that one of 16 residents (R) (R6) who required enteral nutrition through a gastrostomy tube received the tube feeding in accordance with the physician's orders. Specifically, the facility failed to ensure R6's prescribed Jevity 1.5 was administered at 60 milliliters (mL) per hour for the ordered 22-hour duration when the feeding was disconnected and the feeding pump was turned off during the prescribed administration period. This deficient practice resulted in R6 not receiving the prescribed enteral feeding and required practitioner intervention, including orders for additional, immediate enteral nutrition.

Inspectors wroteBased on observations and interviews, the facility failed to ensure that medications were secured and inaccessible to unauthorized individuals during one of three medication administration observations. During the affected observation, Licensed Practical Nurse (LPN) EE left the medication cart unlocked and unattended at 8:35 AM and again at 8:45 AM.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled Food Receiving and Storage, the facility failed to ensure food safety protocols and maintain sanitary conditions for two of two resident refrigerators on Hall 100 and Hall 800 and failed to discard expired food in the dry storage area. The deficient practices had the potential to place 201 residents (R) who received an oral diet from the kitchen at risk of contracting a foodborne illness. Findings Include:Review of the facility's policy titled Food Receiving and Storage, issued April 2025, documented: POLICY: Foods shall be received and stored in a manner that complies with safe food handling practices. GUIDELINES: .6. Dry foods that are stored in bins will be removed from original packaging, labeled, and dated. Such foods will be rotated using a first in first out system. 7. [...]

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure that nail care was provided for one resident (R) (R92) of 35 sampled residents. This failure could lead to skin impairment resulting from toenail overgrowth.

Inspectors wroteBased on observations, record review and staff interview, the facility failed to ensure a medication error rate was less than five percent during medication administration review. Three errors were identified from 38 opportunities, resulting in a 7.89 percent (%) medication error rate. The deficient practice placed residents at risk for inaccurate dosing and adverse clinical outcomes.

Inspectors wroteBased on observations, staff interviews, and a review of the facility policy titled Medication Storage, the facility failed to properly lock, secure and discard medications on two of seven medication carts (500 Hall and 200 Hall.) The deficient practice increased the risk of unauthorized access and potential medication diversion.

Inspectors wroteBased on observations, interviews, record review, and review of facility policy titled Resident Nutrition Services, the facility failed to ensure that meal preferences were followed for one resident (R) (R165) of 35 sampled residents. The deficient practice had the potential to affect the quality of life for R165.

Inspectors wroteBased on observations, resident, staff, and family interviews, and a review of the facility's policy titled Activities of Daily Living (ADLs), the facility failed to provide ADLs for four of 16 sampled residents (R) (R1, R8, R7, and R6) dependent of staff for care related to: scheduled showers for R1, R8, R7, and R6; nail care for R1 and R8; and shaving facial hair for R1 and R8. This deficient practice had the potential to place R1, R8, R7, and R6 at increased risk of unmet needs.

Inspectors wroteBased on staff interviews and review of the Facility Assessment Tool and the Payroll-Based Journal (PBJ) Staffing Data Report Quarter (Q) 2 2024, the facility failed to ensure there were adequate nursing staff to serve their residents. The deficient practice had the potential to adversely affect the care and services provided to the facility residents. The facility census was 212 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Labeling and Dating Foods, Refrigerator and Freezer Temperatures, Cleaning Instructions: Conventional Oven (2020), Hair Restraints, and Cleaning Instructions: Floors, the facility failed to ensure dietary staff contained hair in hair nets, ensure that food was properly labeled, stored and prepared in a sanitary condition to prevent foodborne illness, and failed to monitor and log daily temperature of refrigerator and freezer temperatures to ensure food was preserved per recommended guidelines. In addition, the facility failed to ensure the cleaning of appliances (stove, refrigerator), countertops, floor tiles, and ceiling vents. [...]

Inspectors wrote3. Review of R73's EMR revealed she was admitted to the facility with diagnoses including but not limited to drug-induced subacute dyskinesia, extrapyramidal and movement disorder, poisoning by unspecified drug/meds biological substance/accidental, major depressive disorder, conversion disorder with seizures or convulsions, bipolar disorder with current hypomanic, anxiety disorder, other psychoactive substance abuse, intentional self-harm by other specific means, poisoning by unspecified drug/meds/biological substance, self-harm substance. Further record review revealed no evidence that an assessment for self-administration of medications was completed, there were no physician orders for the resident to have medications at the bedside for self-administration, and there was no care plan addressing R73's ability to self-administer medications. [...]

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Storage of Items in Resident Rooms, the facility failed to ensure resident personal care items were stored in a manner to prevent cross-contamination in five of 11 bathrooms on the 400 Hall. The deficient practice had the potential to expose residents to infections due to cross-contamination.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident [NAME] of Rights, the facility failed to provide a resident with food preferences for one of 55 sampled residents (R) (R58). Review of the facility policy titled Resident [NAME] of Rights reviewed January 2023 revealed under Facility residents shall have the right to: . 10. Reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.15. Self-determination, which the facility must promote and facilitate through support of resident choice, consistent with his or her interests, assessments and plan of care and make other choices about aspects of his or her life in the facility that are significant to the resident. [...]

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Resident [NAME] of Rights, the facility failed to ensure that it was maintained in a safe, clean, comfortable environment for two of seven halls, with one room (room [ROOM NUMBER]) on the 300 Hall and three rooms ( room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) on the 400 Hall. These rooms had missing paint on the doors and walls; holes, punctures, and dents in the walls; crumbling walls with rocks exposed, dirty floors, and broken and or soiled air conditioning vents.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Level II was completed for two of two residents (R) (R73 and R47) reviewed for PASRR Level II. This deficient practice had the potential to affect the level of care and services provided to R73 and R47.

Inspectors wrote2. Review of the EMR revealed R261 was admitted into the facility with diagnoses including but not limited to major respiratory failure, intracranial hemorrhage, and medical history of chronic obstructive pulmonary disease (COPD), anemia, and cervical disk myelopathy. A review of R261's admission Minimum Data Set (MDS) revealed the MDS was in process. A review of R261's active Physician Orders, dated July 2024, revealed no physician's orders for the care of the PICC line. Observation on 7/15/2024 at 1:17 pm of R261 revealed a PICC line was inserted in R261's left arm. During observation and interview on 7/15/2024 at 1:27 pm, LPN II confirmed the date on R261's PICC line dressing was 7/3/2024. She also confirmed there were no physician orders for the care of the PICC line or dressing changes. [...]

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled, Oxygen Therapy, the facility failed to follow Physician Orders for two of 12 residents (R) (R65 and R187) with orders for oxygen. The deficient practice had the potential to place the residents at risk for medical complications such as respiratory distress, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to label/date open food items in the walk-in freezer and dry storage, failed to discard expired food items in the cooler, and failed to ensure baking sheets and serving trays were stacked and stored dry.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain a clean environment in the laundry washer area related to two of two dirty sinks.

Inspectors wroteBased on resident and staff interviews, record review, and review of facility policies, the facility failed to follow physician's orders for two of 63 sampled residents (R) (R#55 and R#208).

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure appropriate services and assistance was provided to maintain or improve mobility for one of 63 sampled residents (R) (R#75).

Inspectors wroteBased on observations, interviews, medical record review, and review of the facility policy, titled Oxygen Therapy, the facility failed to obtain a physician's order for oxygen therapy and establish a process for cleaning filter of oxygen concentrator for one of 63 sampled residents (R#112).

Inspectors wroteBased on record review and staff interviews the facility failed to document the intended rationale and duration of therapy for two of five sampled residents (R) (R#75 and R#208), that had an as needed order (PRN) for antianxiety and hypnotic medication beyond 14 days.