Lake City Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review the dietary department failed to store, prepare, and serve food in a sanitary manner for the resident for 1 of 2 observations of the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify residents' physicians and/or Resident Representatives for three (Resident #2, Resident #37 and Resident #28) of ten residents reviewed for skin issues, one (Resident #11) of three reviewed for ADL (Activities of Daily Living) care, and one (Resident #30) of three reviewed for accidents.

Inspectors wroteBased on interview and record review the facility failed to encode and transmit the resident discharge assessment for 1 of 4 residents, Resident #9, reviewed for minimum data set [MDS] completion.

Inspectors wroteBased on observation, interview, record review the facility failed to develop and implement a comprehensive care plan for 1 (Resident #6) of 2 residents reviewed for dialysis and 1 (Resident #18) of 3 residents reviewed for urinary catheter devices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that met professional standards for two (Resident #37 and Resident #2) of ten reviewed for skin issues and one (Resident #43) of three reviewed for feeding tube management.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure assistance with activities of daily living (ADLs) for haircuts for 1 of 3 residents, Resident #7 reviewed for ADL care.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure physician orders and facility policy were followed for wound care for 3 of 10 residents reviewed for wounds (Resident #113, Resident #21 and Resident #28). Findings Include: 1)During an observation on 08/09/2026 at 11:05 AM, Resident #28 was lying in bed. There was a gauze dressing to Resident's right wrist, which was dated 08/06/2026. Review of Resident #28's nursing note, authored by Staff F, LPN (Licensed Practical Nurse) dated 08/06/2026 read, [Certified Nursing Assistant's name] noticed resident had a new skin tear to right wrist (top) and was bleeding this am. Nurse notified assessed area. Bleeding stopped area cleaned and dressed. Review of Resident #28's physician orders revealed there were no orders for wound care to the right wrist. [...]

Inspectors wroteBased on interview, observation and record review the facility failed to provide treatment and services for the care of one out of five residents reviewed for indwelling urinary catheter. Findings Include:During observation of Resident #60 on 08/09/2026 at 9:15 AM Foley tubing had cream colored sediment residing along length of the tubing. During observation of Resident #60 on 08/11/2026 at 10:21AM Foley line sediment was observed to be unchanged in appearance with cream colored sediment along the length of the tubing. During an interview with Staff N, CNA on 08/11/2026 10:31 AM she stated Hospice comes on Fridays. If I noticed something wrong with his foley when I was emptying it I would let the nurse know. During interview via phone with Haven Hospice Director of Clinical Operation, on 08/11/2026 at 11:53AM stated, Our last visit was 08/07/2026. [...]

Inspectors wroteBased on interview and record review the facility failed to complete dialysis communication sheet for 1 (Resident #6) of 2 residents reviewed for dialysis.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the exterior waste properly.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure complete and accurate documentation in the medical record for activities of daily living care for 1 of 3 residents reviewed (Resident #11), and documentation on the treatment administration record for 3 of 10 residents reviewed for skin conditions (Resident #113, Resident #21, Resident #3). Findings Include: 1) Review of Resident #3's physician order dated 06/20/2026 read, Wound Care: RLE [right lower extremity]- cleanse with wound cleanser. Apply A&D ointment to peri wound. ABD [abdominal] pad to wound bed. Wrap with Ace bandage. Daily and as needed. every day shift for Weeping. Review of Resident #3's TAR (Treatment Administration Record) for July 2026 showed wound care for right lower extremity was not documented on July 10, 2026, July 12, 2026, July 21, 2026 and July 30, 2026. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to perform hand hygiene for 1 (Resident #115) of 10 residents reviewed for skin conditions, failed to perform hand hygiene for 1 (Resident #35) of 9 medication observations, failed to donned appropriate personal protective equipment for 2 (Resident #35 and Resident #92) of 4 residents review for enhanced barrier precautions, and failed to clean medical equipment and perform hand hygiene during dining.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate wound care for 2 of 4 residents reviewed for skin and wound care, Residents #23 and #49, and 1 of 8 residents reviewed for medication management, Resident #65.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection control standards for storing respiratory therapy equipment for 3 of 4 residents reviewed for respiratory services (Residents #45, #51, and #87), for 3 of 6 residents reviewed for enhanced barrier precautions (Residents #6, #93, #114), for 1 of 4 residents reviewed for skin conditions (Resident #2), for 4 of 5 residents reviewed for medication administration (Residents #61, #116, #321 and #324) to help prevent the possible spread of infection and communicable diseases.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure accuracy of Minimum Data Set (MDS) assessments for 3 of 8 residents reviewed, Residents #2, #18, and #49.

Inspectors wroteBased on record review and interview, the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed for 1 of 5 residents reviewed for unnecessary medications, Resident #61.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 2 of 9 residents reviewed, Residents #3 and #114.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medication regimen recommendations agreed by the physician were followed for 1 of 5 residents reviewed for unnecessary medications, Resident #8.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' medication regimen was free from unnecessary drugs, for 1 of 5 residents reviewed for unnecessary medications, Resident #8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored in accordance with currently accepted professional principle in 1 of 4 hallways.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received dental services for 1 of 2 residents reviewed for dental services, Resident #18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was safely stored in the areas of the nutrition room and kitchen walk-in freezer.

Inspectors wroteBased on interview and record review, the facility failed to provide therapy evaluation and services for 1 of 3 residents reviewed for rehabilitation, Resident #27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for 1 of 2 residents reviewed for behaviors (Resident #3), for 2 of 8 residents reviewed for medication management (Residents #54 and #72), and for 1 of 3 residents reviewed for skin and wound care (Resident #49).

Inspectors wroteBased on record review and interview, the facility failed to maintain an effective, data driven Quality Assurance and Performance Improvement (QAPI) program related to weight loss and obtaining weights for 1 of 3 current performance improvement plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish antibiotic stewardship program to monitor antibiotic use for 2 of 5 residents reviewed, Residents #30 and #39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired or outdated food was properly discarded in the areas of the kitchen coolers or refrigerators and that all kitchen equipment were cleaned and maintained in proper working order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) services received nail care for 1 of 3 residents reviewed, Resident #81.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the insulin pens used in the facility were stored in accordance with currently accepted professional principles in 2 of 4 medication carts observed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene during medication administration to prevent the possible spread of infection and communicable diseases.