Scott Lake Health and Rehab: Medication Failures - FL
Federal inspectors cited the facility for an immediate jeopardy violation, the most serious level of harm in the inspection system, after finding that Resident #1 had not received medications that had been ordered for her following her admission.
The resident, described in hospital records as a woman with diabetes, high blood pressure, high cholesterol, prior breast cancer in remission, and serious vascular disease involving two major abdominal arteries, was transferred to the emergency department on August 30, 2025. Her glucose was greater than 600. Staff had already given her 15 units of insulin at the facility before calling for transport.
At the hospital, the picture that emerged from her lab work was alarming. Her white blood cell count was elevated. Her troponin, the protein that leaks into the blood when heart muscle is damaged, came back critically high, at 60 nanograms per liter, and a follow-up reading came back at 54. Her lactate was 3.3 millimoles per liter, more than one and a half times the upper limit of normal, a sign the body's tissues were not getting enough oxygen. Her sodium was low. Her potassium was low. Her kidneys were functioning at reduced capacity. Her electrocardiogram showed lateral ST depressions, a pattern associated with cardiac ischemia.
The hospitalist's notes described a patient with diffuse abdominal pain rated 8 out of 10, a glucose that had only come down to the 400s after insulin and fluids in the emergency department, and a white count of 17. She was started on vancomycin and Zosyn for possible sepsis. Blood cultures were sent. She was admitted to the cardiac floor for management of what the hospitalist described as a possible NSTEMI, a type of heart attack that does not show the classic ST elevation on an EKG but is associated with elevated troponins and ischemic changes.
Among the medications Resident #1 had not received was carbamazepine, which can be prescribed for seizures or depression, and lactulose, which can be used for constipation or to manage abnormal ammonia levels. Her carbamazepine blood level at the hospital came back below 2.0 micrograms per milliliter, flagged as low.
The facility's pharmacist, interviewed during the inspection, said she had never seen anything like this happen before. She explained that when a new resident is admitted, she reviews the medications entered into the facility's system to check for interactions or problems, but she does not routinely pull the hospital discharge medication list to compare it against what was actually entered. Her expectation, she said, is that the facility enters the medication orders correctly in the first place.
That did not happen here.
The pharmacist said her level of concern about the missed medications would depend on why the resident had been prescribed each one. For a patient with the vascular history described in the hospital records, the reasons behind each medication on that list carried real weight.
Hospital records showed the resident had occlusion of the inferior mesenteric artery and stenosis of the superior mesenteric artery, two vessels that supply blood to the intestines. The CT angiogram at the hospital showed no evidence of ischemic colitis, but the cause of her abdominal pain remained unclear. Her calcium was elevated. Her alkaline phosphatase and lipase were both high. Her free T4 was elevated.
The hospitalist admitted her with diagnoses of hyperglycemia due to type 2 diabetes, abnormal EKG, elevated troponin, lactic acidemia, hypertension, and abdominal pain.
A woman with that many compounding conditions, admitted to a nursing home for care, had not been given the medications she came in with. The pharmacist reviewing her orders had no way to catch the gap because she was only looking at what the facility had entered, not at what the hospital had sent her there on.
What the facility had entered was not complete. And by the time anyone knew, she was on a cardiac floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Scott Lake Health and Rehabilitation Center from 2025-10-01 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
SCOTT LAKE HEALTH AND REHABILITATION CENTER in LAKELAND, FL was cited for violations during a health inspection on October 1, 2025.
Her glucose was greater than 600.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.