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🔎 Lake Mary Health And Rehabilitation Center

Inspection Results


Inspection Overview

Lake Mary Health And Rehabilitation Center has been cited for a total of 28 deficiencies since we began saving each survey.

In Florida, the average facility has **23.63 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: E

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2024-07-25
Correction Date: 2024-08-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Assure that each resident’s assessment is updated at least once every 3 months.

Survey Date: 2024-07-25
Correction Date: 2024-08-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2024-07-25
Correction Date: 2024-08-25
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2024-07-25
Correction Date: 2024-08-25
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2024-07-25
Correction Date: 2024-08-25
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2024-07-25
Correction Date: 2024-08-25
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2023-04-07
Correction Date: 2023-05-11
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: F

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2023-04-07
Correction Date: 2023-05-11
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Survey Date: 2023-04-07
Correction Date: 2023-05-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: H

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2023-04-07
Correction Date: 2023-05-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-04-07
Correction Date: 2023-05-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: F

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2023-04-07
Correction Date: 2023-05-11
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2023-04-07
Correction Date: 2023-05-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: E

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Survey Date: 2022-12-09
Correction Date: 2023-01-09
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2022-12-09
Correction Date: 2023-01-09
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Survey Date: 2022-12-09
Correction Date: 2023-01-09
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2022-12-09
Correction Date: 2023-01-09
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2022-12-09
Correction Date: 2023-01-09
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Survey Date: 2021-02-04
Correction Date: 2021-03-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Survey Date: 2021-02-04
Correction Date: 2021-03-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2021-02-04
Correction Date: 2021-03-04
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2021-02-04
Correction Date: 2021-03-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2021-02-04
Correction Date: 2021-03-04
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2020-07-16
Correction Date: 2020-08-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2020-07-16
Correction Date: 2020-08-06
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2019-05-23
Correction Date: 2019-06-23
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2019-05-23
Correction Date: 2019-06-23
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Survey Date: 2019-05-23
Correction Date: 2019-06-23
Category: Pharmacy Service Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**