The resident was admitted with a "Full Code" status, meaning healthcare staff should use all available life-saving measures if the person stopped breathing or their heart stopped. But the resident changed their preference to DNR in October, and staff never updated the care plan to reflect the new orders.
"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The outdated care plan created a dangerous contradiction. While the resident's medical orders specified do-not-resuscitate, their official care plan still read: "Resident has an established CPR (Full Code) order in place." In an emergency, staff following the care plan could have performed unwanted resuscitation on a resident who had specifically requested otherwise.
The facility's own policy requires updating care plans when code status changes. "Social Services and nursing must document in a progress note that code status was changed as per resident/representative request and orders were obtained," the January 2026 policy states. "Code status/advanced directives care plan must be updated."
But that didn't happen.
The MDS Licensed Practical Nurse acknowledged the failure during interviews. "When the order changes we should be updating the care plan, but that didn't happen," she told inspectors. "It's discussed in morning meetings and then we update the care plans."
Multiple staff members were supposed to catch such errors. The Social Worker Director explained that advanced directives are reviewed during daily clinical meetings attended by various department heads. "We look at advanced directives," she said. "If the care plan was not updated, it must have been missed. We all look at it in the clinical meeting. It was just probably missed."
The contradiction persisted for months. Records show the resident's care plan was created on their admission date and initiated the same day, but never revised despite the October code status change. Federal inspectors discovered the discrepancy during a January 29 complaint investigation.
Advanced directive documentation serves as a critical safety mechanism in nursing homes, where residents may be unable to communicate their wishes during medical emergencies. Care plans guide staff decisions about everything from daily medications to life-or-death interventions. When these documents contain outdated information, staff may take actions directly contrary to a resident's expressed preferences.
The facility operates a formal system designed to prevent such oversights. Morning clinical meetings bring together nursing leadership, social services, and other departments to review resident needs and update care plans accordingly. Despite this multi-layered review process, the error went undetected for months.
Lake Montgomery Health and Rehabilitation Center is located on Southwest Main Boulevard in Lake City, a rural community in north-central Florida. The facility provides both short-term rehabilitation and long-term care services to residents in Columbia County and surrounding areas.
Federal regulations require nursing homes to honor residents' advanced directives and maintain accurate care plans that reflect current medical orders. The Centers for Medicare and Medicaid Services classify failures to update care plans as potential safety violations, even when no immediate harm occurs to residents.
The inspection found the facility violated federal requirements for creating and maintaining comprehensive care plans within 48 hours of admission and updating them as residents' conditions or preferences change. Inspectors reviewed four residents' care plans for accuracy and found the advanced directive error affected one person.
Staff interviews revealed the facility has established procedures for handling code status changes, including documentation requirements and regular reviews during clinical meetings. However, the system failed to capture this resident's October preference change, leaving their care plan months out of date when inspectors arrived.
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.