Lakeland Health Care CTR

In the surveyor’s words

From the most serious findings on record at Lakeland Health Care CTR, in the surveyor’s own words.

• Immediate jeopardy, patternF600Nov 21, 2023

  Based on interview and record review, the facility failed to prevent 5 (R3, R4, R6, R1, and R5) of 6 residents reviewed for abuse to be free from sexual abuse from R2. The facility failed to prevent 3 (R4, R1, and R8) of 6 residents reviewed to be free from sexual or physical abuse from R7. R2 had an identified history of inappropriate sexual behaviors with peers and staff. The facility did not have effective interventions in place to prevent sexual abuse of peers. When sexual abuse of peers did occur, the interventions were not revised, new interventions were not put in place, and monitoring was not increased; R2 continued to sexually abuse his peers. R2 attempted to enter R3's room multiple times uninvited (6/27/23, 8/8/23.) On 8/8/23, R2 entered R3's room while she was undressed. […]

• Immediate jeopardy, isolatedF600Sep 2, 2025

  Based on interview and record review, the facility did not ensure residents were free from physical and verbal abuse for 1 (R1) of 3 residents reviewed for abuse.R1, who is diagnosed with dementia, started displaying aggressive behaviors and being resistive to cares within the first 2 weeks of being admitted to the facility. The facility did not develop or implement a behavior care plan with resident specific interventions to help guide staff in how to care for R1. On 8/11/25, R1 was being cared for by Certified Nursing Assistant (CNA)-C and Registered Nurse (RN)-D. R1 was agitated, aggressive and resistive to cares. CNA-C was working to calm R1. RN-D entered R1's room and was yelling at R1 to let them take care of R1. […]

• Immediate jeopardy, isolatedF744Nov 21, 2023

  Based on record review and interview, the facility did not provide appropriate treatment and services for 2 (R2 and R7) of 2 resident reviewed with a diagnosis of dementia with behavioral symptoms to allow them to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. R2 was admitted to the facility with a diagnosis of dementia with behaviors. Shortly after admission, R2 started exhibiting behavior symptoms included wandering into female peers' rooms and making sexual comments, propositioning and gesturing to staff and peers. The R2 was seen by psych services to assist with behavior concerns and pharmacological interventions which were not effective. […]

• Actual harm, isolatedF744Sep 2, 2025

  Based on interview and record review, the facility did not ensure residents with dementia received the appropriate treatment and services to attain their highest practical physical, mental and psychological well-being for 1 (R1) of 1 resident reviewed with dementia.*R1 has a diagnosis of dementia. R1 started displaying aggressive behaviors and being resistive to cares within the first 2 weeks of being admitted to the facility. The facility did not develop or implement a behavior care plan with resident specific interventions to help guide staff in how to care for R1. The facility did not document that R1's Medical Doctor (MD) was made aware of R1's increase in aggressive and resistive care behaviors. […]

• Actual harm, isolatedF686Feb 24, 2022

  Based on interview and record review, the Facility did not ensure that a resident who enters the Facility with a pressure injury receives necessary care and treatment to prevent the development of pressure injuries and Residents without a Pressure Injury (PI) receive appropriate care, treatment and preventative measures to promote healing for 2 (R46 and R7) of 4 Residents reviewed for pressure injuries. * R46 who has a history of pressure injuries and is at risk for pressure injuries was observed to have a dark brown scabbed area to the planter left foot under the great toe on 7/22/21. This area was not assessed by a RN (Registered Nurse) for 6 days by which time it was identified as 100% necrotic tissue on 7/28/21. […]