LAKELAND, FL - A federal inspection of Lakeland Nursing & Rehabilitation found that a flooring hazard left unrepaired for more than a month resulted in a memory care resident fracturing her hip and requiring emergency surgery, leading regulators to issue an Immediate Jeopardy citation - the most serious deficiency level a nursing home can receive.
Unrepaired Floor Drain Leads to Serious Injury
The inspection, completed on February 28, 2025, documented how a missing drain cover in the facility's secure memory care unit remained inadequately repaired for 37 days before a resident fell and sustained a serious injury requiring surgical intervention.
According to the inspection report, a resident in the memory care unit pulled off a clean-out drain cap on December 18, 2024. The facility's Director of Maintenance (DOM) responded by placing a metal sheet over the opening and securing it with tape. However, this temporary fix proved inadequate for a high-traffic area housing residents with cognitive impairments.
The affected area was located in what the report described as a "known high-traffic area" - directly outside the secured memory care dining room, adjacent to the nurses' station, and just outside the room of the resident who would later fall. Despite the location and the vulnerability of the population using this hallway, the facility did not complete a proper repair until January 24, 2025 - four days after the fall occurred.
A review of the facility's maintenance log revealed significant gaps in safety monitoring. The inspection documented that the area was not visually inspected on 15 separate days between December 18, 2024, and January 23, 2025. These gaps included weekends, holidays, and multiple consecutive days when no one checked whether the temporary repair remained secure.
The Fall and Its Consequences
On January 20, 2025, a memory care resident identified as Resident #6 was walking in the hallway with a family member when the incident occurred. A Certified Nursing Assistant who witnessed the fall provided a written statement documenting what happened: she "was coming down the hall with a breakfast tray and witnessed Resident #6 trip and fall over an area on the floor. The tape was coming up and Resident #6's foot got caught on it."
The resident, who had dementia and used a walker for mobility, complained of severe pain in her right leg and lower back, rating the pain intensity at 9 out of 10. Due to the severity of her pain, staff left her on the floor until emergency transport arrived.
Hospital imaging revealed an impacted right femoral neck fracture - a break at the top of the thigh bone where it connects to the hip joint. This type of fracture is particularly serious in elderly patients and typically requires surgical intervention to restore mobility and prevent complications.
The resident underwent a right hip hemiarthroplasty the following day - a surgical procedure that replaces the ball portion of the hip joint with a prosthetic. Hip fractures in elderly patients carry significant risks during and after surgery, including infection, blood clots, adverse reactions to anesthesia, and chronic pain.
A physical therapy evaluation conducted after surgery documented substantial functional decline. The resident, who had previously been able to walk with a walker, was now "very confused, unable to follow commands, dep[endent] for all mobility." The evaluation listed multiple new impairments including ambulation deficits, bed mobility deficits, transfer deficits, and safety awareness deficits.
Medical Significance of the Injury
Femoral neck fractures represent one of the most consequential injuries an elderly nursing home resident can experience. The femoral neck is the narrow section of bone that connects the ball of the hip joint to the shaft of the thigh bone, and fractures in this location typically require prompt surgical intervention because the blood supply to the femoral head can be compromised, leading to bone death if not addressed.
For elderly patients, particularly those with dementia, hip fractures often mark a turning point in functional status. The combination of surgical trauma, anesthesia effects, post-operative pain management, and required immobilization frequently accelerates cognitive decline in patients with pre-existing dementia. Many patients never return to their previous level of independence.
The inspection report documented that this resident had a history of osteopenia - a condition of reduced bone density that increases fracture risk. This made the presence of a known tripping hazard in her immediate living environment particularly dangerous.
Standard fall prevention protocols in long-term care facilities emphasize environmental safety as a fundamental component. Residents with dementia face elevated fall risk due to impaired judgment, difficulty recognizing hazards, and gait abnormalities. The inspection noted that a Licensed Practical Nurse/Unit Manager stated she "doubted the residents in the memory care unit would have recognized the tape as a caution area."
Delayed Repairs and Cost-Cutting Attempts
The inspection revealed that the Director of Maintenance acknowledged attempting to handle the repair in-house to save money rather than promptly engaging professional plumbers. During an interview, the DOM stated he "had put a metal plate on the area trying to save the company money in December 2024" and was "researching it to try to fix it himself before calling the plumbers in."
After the resident's fall, the DOM finally contacted plumbers, who completed their portion of the repair on January 24, 2025. However, the repair remained incomplete at the time of the February inspection because a diamond grinding wheel needed to smooth the concrete was backordered. The grinding wheel order was placed on January 27, 2025, but the DOM went on vacation after it arrived on February 14, leaving the concrete surface rough and uneven.
When surveyors toured the facility on February 24, 2025 - more than a month after the fall - they observed "an area of rough and uneven concrete approximately 3ft x 2ft in the middle of the corridor" with a raised drain cap. The DOM confirmed during the survey that "the area where Resident #6 had fallen was still uneven due to the concrete patch."
The facility's own Nursing Home Administrator acknowledged the unacceptable nature of the delays. During a tour with surveyors, the NHA stated "her expectation was an immediate fix for any hazard affecting residents" and that "it was unacceptable to wait to repair the floors."
Additional Issues Identified
The inspection documented multiple other flooring hazards throughout the facility:
Second Memory Care Location: A separate area in the 200-hall had 12 missing floor tiles with a raised drain. A Certified Nursing Assistant confirmed this area "had been in disrepair for a long time" and estimated approximately 6 to 8 months. A work order for this issue was created on December 3, 2024, but was not acknowledged by maintenance until December 27, 2024, and remained incomplete until the survey prompted repairs.
400-Hall Entrance Ramp: The entrance ramp to another unit was missing five full carpet squares and five half carpet squares, exposing concrete with an uneven drain. This area served as the inside entrance for residents, staff, and visitors, with frequent use by residents using wheelchairs and walkers.
Ongoing Tile Problems: During the survey, inspectors observed that replacement tiles in the 200-hall were "popping up on the edges." The NHA confirmed this represented a hazard for residents with shuffling gaits - a common characteristic of elderly residents and those with neurological conditions.
Immediate Jeopardy Determination and Corrective Actions
The severity of these findings led regulators to issue an Immediate Jeopardy citation on January 20, 2025, indicating conditions that posed immediate risk of serious harm or death to residents. The facility was required to implement immediate corrective actions.
The facility's response included:
- Completing floor repairs throughout the affected areas - Assigning a dedicated "Hallway Safety Monitor" to the memory care unit 24 hours a day, 7 days a week - Re-educating 99.5% of staff on hazard recognition and reporting procedures - Implementing daily environmental rounds by the Administrator and Plant Operations Director - Establishing a Performance Improvement Plan with ongoing monitoring
Surveyors verified the facility's corrective actions on February 28, 2025, and the Immediate Jeopardy was removed. However, the facility remained out of compliance at a reduced severity level.
Interviews with 77 staff members confirmed they had received training on the new procedures for identifying and reporting environmental hazards. The facility also implemented a system to ensure any staff members not reached during the initial education would be trained before their next working shift.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lakeland Nursing & Rehabilitation from 2025-02-28 including all violations, facility responses, and corrective action plans.
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