Blue Lake Post Acute
Blue Lake Post Acute in DELAND, FL — inspection on April 8, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 4/07/25 at 3:30 p.m., Registered Nurse (RN) A stated she had been employed by the facility for about a year as a floor nurse. In November 2024 she was promoted to evening supervisor. As of Friday (4/4/25), she was asked to be the interim Director of Nursing (DON) since the previous DON had resigned.
When asked if she was familiar with Residents #1 and #2, she stated Resident #1 was confused, verbally and physically aggressive towards staff, and refused care and medications.
She stated the resident had not had any sexually inappropriate behaviors before this incident with Resident #2. Resident #2 was alert and oriented x3 (person, place and time). He had no behaviors except noncompliance with diet orders.
She stated on 4/1/24 she was working on the floor on the 200 hall. At 5:30 p.m., Residents #1 and #2 were observed in the dining area watching television.
She was at the nurses' station with Licensed Practical Nurse (LPN) C, and they were completing their daily documentation.
She stated at approximately 6:00 p.m., Resident #1 was seated on Resident #2's walker. LPN C separated the two residents.
The residents were again observed holding hands, and she approached both residents and explained to Resident #2 that he could not hold hands with resident #1 because she was not alert and oriented.
The residents were separated again.
She then left the area to attend to another resident and left LPN C at the nurses' station.
She stated she was not present in Resident #2's room when the two residents were found there.
A telephone interview was conducted on 4/7/25 at 3:50 p.m., with LPN B.
She stated she had worked in the facility for about a year and on 4/1/25, she was coming in to work her 7:00 p.m. to 7:00 a.m. shift when the assigned nurse mentioned that Residents #1 and #2 were having behaviors. At that time, they noticed that neither Resident #1 nor Resident #2 were in the dining area. LPN B and LPN C then went to Resident #2's room together at approximately 6:55 p.m. looking for the residents. As they walked into Resident #2's room, they saw that his right hand was inside of Resident #1's pants. LPN B stated she and LPN C separated the residents and LPN C notified the Administrator (referring to the Administrator in Training (AIT).
105262
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 105262 B.
Wing 04/08/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Blue Lake Post Acute 991 E New York Ave Deland, FL 32724
During an interview on 4/07/25 at 3:30 p.m., Registered Nurse (RN) A stated she had been employed by the facility for about a year as a floor nurse. In November 2024 she was promoted to evening supervisor. As of Friday (4/4/25), she was asked to be the interim Director of Nursing (DON) since the previous DON had resigned.
When asked if she was familiar with Residents #1 and #2, she stated Resident #1 was confused, verbally and physically aggressive towards staff, and refused care and medications.
She stated the resident had not had any sexually inappropriate behaviors before this incident with Resident #2. Resident #2 was alert and oriented times three (person, place and time). He had no behaviors except noncompliance with diet orders.
She stated on 4/1/24 she was working on the floor on the 200 hall. At 5:30 p.m., Residents #1 and #2 were observed in the dining area watching television.
She was at the nurses' station with Licensed Practical Nurse (LPN) C, and they were completing their daily documentation.
She stated at approximately 6:00 p.m., Resident #1 was seated on Resident #2's walker. LPN C separated the two residents.
The residents were again observed holding hands, and she approached both residents and explained to Resident #2 that he could not hold hands with resident #1 because she was not alert and oriented.
The residents were separated again.
She then left the area to attend to another resident and left LPN C at the nurses' station.
She stated she was not present in Resident #2's room when the two residents were found there.
A telephone interview was conducted on 4/7/25 at 3:50 p.m. with LPN B who stated she had worked in the facility for about a year and on 4/1/25, she was coming in to work her 7:00 p.m. to 7:00 a.m. shift when the assigned nurse (LPN C) mentioned that Residents #1 and #2 were having behaviors. At that time, they noticed that neither Resident #1 nor Resident #2 were in the dining area. LPN B and LPN C then went to Resident #2's room together at approximately 6:55 p.m. looking for the residents. As they walked into Resident #2's room, they saw that his right hand was inside of Resident #1's pants. LPN B stated she and LPN C separated the residents and LPN C notified the Administrator (referring to the AIT). LPN B explained that she completed a witness statement and pushed it under the Administrator's door.
When asked if the written statement was in addition to/followed by a telephone interview, she replied, No one called me. I typed up my observations.
She provided a copy of her statement.
105262
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 105262 B.
Wing 04/08/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Blue Lake Post Acute 991 E New York Ave Deland, FL 32724