The oversight left contradictory instructions in the resident's file for months. Their official care plan still directed medical staff to use "all available and necessary life-saving measures to resuscitate" if the resident stopped breathing or their heart stopped beating. Meanwhile, their actual medical orders said the opposite.
Federal inspectors discovered the discrepancy during a January complaint investigation at the 120-bed facility on Southwest Main Boulevard.
The resident, identified only as Resident #1 in inspection records, was admitted to Lake Montgomery with full code status. Under that directive, medical staff would perform CPR and use all available interventions if the person's vital signs stopped.
But sometime in October, the resident changed their mind. They switched to DNR status, meaning they did not want resuscitation attempts if they experienced cardiac or respiratory arrest.
Nobody updated the care plan.
"I see that his Care Plan was not updated," the Director of Nursing told inspectors during a January interview. "He came in as a Full Code, and he changed it in October to a DNR."
The care plan still read: "Resident has an established CPR (Full Code) order in place."
Care plans serve as roadmaps for daily resident care, detailing everything from medication schedules to dietary restrictions to emergency medical preferences. Staff rely on them to make split-second decisions about treatment.
"When the order changes we should be updating the care plan, but that didn't happen," the facility's Minimum Data Set Licensed Practical Nurse acknowledged to inspectors. "It's discussed in morning meetings and then we update the care plans."
The Social Worker Director said the change "must have been missed" despite multiple staff reviewing advanced directives during clinical meetings.
"We all look at it in the clinical meeting," the director said. "It was just probably missed."
Lake Montgomery's own policy, revised as recently as January, requires immediate documentation when residents change their code status. The policy states that "Social Services and nursing must document in a progress note that code status was changed" and that the "advanced directives care plan must be updated."
The facility failed to follow its own written procedures.
Advanced directive mix-ups can have devastating consequences in emergency situations. When a resident experiences cardiac arrest, medical staff have minutes to decide whether to begin resuscitation efforts. Outdated care plans can lead to unwanted medical interventions that violate a resident's expressed wishes about end-of-life care.
The inspection found that clinical meetings were happening regularly and staff were supposed to review advanced directives during those sessions. But the system designed to catch such changes failed.
Federal regulations require nursing homes to honor residents' advanced directives and maintain accurate care plans that reflect current medical orders. The regulations exist to ensure residents receive care consistent with their personal values and medical preferences.
Lake Montgomery serves residents requiring both short-term rehabilitation and long-term care. The facility is located in Columbia County, about 60 miles west of Jacksonville.
The January inspection was conducted in response to a complaint, though federal records do not specify the nature of the complaint that triggered the investigation.
Inspectors classified the violation as causing "minimal harm or potential for actual harm" and affecting "few" residents. But the finding highlights a fundamental breakdown in the facility's care planning process.
The resident's actual medical status remained unclear from inspection records. Federal privacy rules prevent disclosure of specific resident conditions or outcomes.
Lake Montgomery was required to submit a plan of correction detailing how it would prevent similar care plan failures. The facility had to demonstrate that staff would properly update care plans when residents change their advanced directive preferences.
The inspection revealed a facility where morning clinical meetings discussed advanced directives but failed to ensure those discussions translated into accurate documentation in resident care plans.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lake Montgomery Health and Rehabilitation Center from 2026-01-29 including all violations, facility responses, and corrective action plans.