Lake Eustis Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Lake Eustis Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF807Aug 29, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents were served appropriate thickened liquid consistency for 2 of 7 residents, Residents #46 and #71, with physician orders for thickened liquids.On 6/1/2025, Resident #46 was ordered to have thickened liquids. On 8/19/2025, Resident #71 was ordered to have thickened liquids. On 8/27/2025 at 5:42 PM, Resident #71 was served apple juice on ice at a thin consistency. Resident #71 took sips of the apple juice, resulting in the resident coughing. Staff C, Scheduling Manager, served coffee at thin consistency to Resident #71. On 8/27/2025 at 6:01 PM, Resident #46 was served a cup that had a straw in it and contained ice and a clear thin liquid on the meal tray. […]

• Immediate jeopardy, isolatedF835Aug 29, 2025

  Based on observation, interview, and record review, the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to implement policy and procedures related to the provision of thickened liquids. The facility failed to ensure residents were served liquids to meet their needs. On 6/1/2025, Resident #46 was ordered to have thickened liquids. On 8/19/2025, Resident #71 was ordered to have thickened liquids. On 8/27/2025 at 5:42 PM, Resident #71 was served apple juice on ice at a thin consistency. Resident #71 took sips of the apple juice, resulting in the resident coughing. […]

• No harm, potential for more than minimal, widespreadF812Jan 26, 2023

  Based on observation, interview, and record review, the facility failed to ensure foods in the refrigerator, freezer, and storeroom were covered, dated, labeled, and placed to ensure safety and sanitation. Findings include: On 1/23/2023 at 9:12 AM, during a walk-through of the kitchen with the Certified Dietary Manager (CDM), the surveyor observed the following: 1. Multiple food items in the walk-in cooler with no use by dates or identifier labels, just a current date, 2. The dry storage area had stock sitting on the floor, 3. Seventy seven 4 oz. health shakes on a sheet pan that were thawed without a pulled to thaw or use by date, 4. A box of partially thawed ground beef stored on the 2nd shelf next to a bag of fully cooked meatballs, 5. […]

• No harm, potential for more than minimal, widespreadF812Jul 22, 2021

  Based on observation, interview, and record review, the facility failed to ensure food was prepared in accordance with professional standards for food service safety. Findings: An observation of the facility kitchen on 7/19/2021 beginning at 8:21 AM with the Certified Dietary Manager showed a flaky brown reddish substance in each of the four steam table compartments, black and brown flaky substance on the bottom surface of two ovens, flaky brown and black buildup surrounding each of the elements of the six-burner gas stove, and tan and dark brown splatter on the floor under the front bottom rim of the oven (Photographic evidence obtained). […]

• No harm, potential for more than minimal, patternF761Aug 29, 2025

  Based on observation, interview, and record review, the facility failed to secure medications when unattended.Findings include:During an observation on 8/25/2025 at 10:24 AM, Resident #102 was sitting on the bed in his room. There was a bottle of nasal decongestant and a bottle of saline nasal spray on his bedside table.1) During an interview on 8/25/2025 at 11:13 AM, Staff I, Registered Nurse (RN), stated, [Resident #102's name] does not have an order to self-administer [medications]. The medication must be kept in the medication cart, and the nurses will bring the medication to the resident when they are ready for the medication. None of the residents are able to keep any medications in their room. […]