Lake Montgomery Health And Rehabilitation Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

five doses of the medication not being administered due to the resident's refusal.Review of Resident #1's medical record for 12/01/2025 through 12/20/2025, the record did not contain documentation the resident's representative was notified of the resident's refusal of the medication. Review of Resident #1's MAR for 12/1/2025 through 12/20/2025 read, HumaLOG KwikPen 100 UNIT/ML solution pen-injector Inject as per sliding scale: if 151 - 200 = 2; 201 - 250 = 4; 251 - 300 = 6; 301 - 350 = 8; 351 - 400 = 10 Call MD, subcutaneously before meals and at bedtime for DM - Start Date 09/08/2025 0630 (6:30 AM) - D/C Date 12/22/2025 1232 (12:32 PM). For the Hours of 0630 dated 12/02/2025, 12/03/2025, 12/13/2025, 12/16/2025, and 12/17/2025 the MAR was documented as NA. For the Hours of 1130 dated 12/05/2025, 12/07/2025, 12/08/2025, 12/10/2025, and 12/11/2025 the MAR was documented as NA. For the hours of 1630 dated 12/08/2025 the MAR was documented as NA. For the Hours of 2100 Dated 12/02/2025, 12/10/2025, 12/11/2025, and 12/14/2025 the MAR was documented with an X. This resulted in 15 occurrences of the resident's blood sugar value not being monitored.Review of Resident #1's medical

record for 12/01/2025 through 12/20/2025, the record did not contain documentation the resident's representative was notified of the resident's refusal of and/or staff not monitoring the resident's blood sugar value to determine if insulin administration was required. During an interview on 1/29/2026 at 11:52 AM Resident #1's Representaitve stated, I was not aware that he was refusing his blood sugar checks. I was never told that he was not compliant or that he was refusing.During an interview on 1/29/2026 at 3:38 PM Staff B, LPN (Licensed Practical Nurse) stated, From what I'm understanding when a patient refuses their medications, if it's often, we call the doctor. I have called family, but not for him. I didn't notify the family.During an interview on 01/29/2026 at 5:01 PM the Director of Nursing stated, The expectation is that

the nurses notify family and the provider and document it [if a resident refuses medications or treatments].

We had discussed him [Resident #1] refusing his insulin in morning meeting.Review of the policy and procedure titled Notification of Changes, with an implementation date of 11/2020 and a revision date of 8/16/2022 read, Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Compliance Guidelines: The facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such notification. Circumstances requiring notification include: Clinical complications. Additional considerations: 1. Competent individuals: a. The facility must still contact the resident's physician and notify residents representative, if known. c. When a resident is mentally competent, such a designated family member should be notified of significant changes in the resident's health status because the resident may not be able to notify them personally.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Montgomery Health and Rehabilitation Center

1270 SW Main Blvd Lake City, FL 32055

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interview, the facility failed to ensure resident care plans regarding advanced directives were updated for 1 of 4 residents, Resident #1, reviewed for accuracy of care plans.Findings include:Review of Resident #1's admission Data documented the resident was admitted into the facility on [DATE REDACTED] with an Advanced Directive of Full Code status (if a resident is absent of life the health care team is to use all available and necessary life-saving measures to resuscitate).Review of Resident #1's Care Plan read, Focus: Advanced Directives: Resident has an established CPR [cardiopulmonary resuscitation] (Full Code) order in place. Date Initiated: [DATE REDACTED]. Created on: [DATE REDACTED].During an interview on [DATE REDACTED] at 1:09 PM

the DON (Director of Nursing) stated, I see that his [Resident #1] Care Plan was not updated. He came in as a Full Code, and he changed it in October to a DNR [Do Not Resuscitate]. During an interview on [DATE REDACTED] at 5:14 PM the MDS LPN (Minimum Data Set Licensed Practical Nurse) stated, When the order [for code status] changes we should be updating the care plan, but that didn't happen. It's discussed in morning meetings and then we update the care plans.During an interview on [DATE REDACTED] at 5:27 PM the Social Worker Director stated, I recall [Resident #1's name]. I attend the morning clinical meetings. We look at advanced directives. 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. Care plans are reviewed and updated through the clinical meetings.Review of the policy and procedure titled Advanced Directives Code Status, with an implementation date of 1/2024 and a revision date of 1/2026 read, Standard: It is the policy of the facility to honor advanced directives, code status and do not resuscitate orders in accordance with state and federal regulations. Guideline: Change of code status/review of code status: Social Services and nursing must document in a progress note that code status was changed as per resident/representative request and orders were obtained. Code status/advanced directives care plan must be updated.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

01/29/2026

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lake Montgomery Health and Rehabilitation Center

1270 SW Main Blvd Lake City, FL 32055

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview on 01/29/2026 at 2:37 PM the APRN (Advanced Practice Registered Nurse) stated, I've known him [Resident #1] for quite some time. That was something he [Resident #1] also did at [Name of a different facility], refuse blood sugar monitoring and/or insulin. He was stubborn and fairly independent. I saw him a couple of days prior to him going out. I had just gotten notification from the nurses that he had again refused his insulin. I told him that his wound would not heal. They definitely would notify me. Maybe they didn't document it. I had quite a few conversations. They would call me after he refused. Any time they give

a higher dose, they spoke with me. I don't typically have a concern regarding notification of refusal of medications. They notify me pretty often. I am in constant contact with the DON and the unit managers, and

the wound care nurse. He would take his insulin if he was feeling bad. During an interview on 01/29/2026 at 3:38 PM Staff B, LPN (Licensed Practical Nurse) stated, Usually he [Resident #1] would take his medications, but on certain days he would refuse his insulin and accu-checks (used to measure blood sugar levels). It was usually on my shift. I would call his doctor. It should be documented when I called. For

the most part we called her [Resident #1's Primary Care Physician/Advanced Practice Registered Nurse].

There are probably times, I'm not going to lie, that I didn't document it. From what I'm understanding, when

a patient refuses their medications, if it's often, we call the doctor and document it.During an interview on 01/29/2026 at 5:01 PM the DON (Director of Nursing) stated, The expectation is that the nurses notify family and the provider and document it [if a resident refuses medications or treatments].Review of the policy and procedure titled Physician Services, read, Intent: it is the policy of the facility to provide physician services in accordance with state and federal regulations. Procedure: 8. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record during that shift.Review of the policy and procedure titled Medication Administration, read, Policy: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy explanation and compliance guidelines: 22. Report and document any adverse side effects or refusals.

Event ID:

Facility ID:

If continuation sheet