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Complaint Investigation

Scott Lake Health And Rehabilitation Center

Inspection Date: October 23, 2025
Total Violations 1
Facility ID 106120
Location LAKELAND, FL
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Inspection Findings

F-Tag F0656

Resident Assessment and Care Planning Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

ability to sit to stand was either substantial/maximum assist with staff doing more than half the effort or dependent upon staff for sit to stand and chair/bed-to-chair transfer. The documentation provided did not reveal the number of staff required to assist the resident with transferring. During an interview on 10/23/25 at 2:40 p.m. with the ADON and the Risk Manager (RM), the ADON stated the care plan should be updated if there was a change in status or a new order. The ADON stated if in therapy they noticed the resident appeared weaker, or the CNA reported the resident required more assistance, the resident was evaluated by therapy and the care plan was updated. The ADON reported nurses and nursing managers can update

the care plan, but typically MDS will make updates to keep the notes uniform for audits. The ADON reported staff would look on the Kardex to see if a resident was a 1 or 2 person assist. The ADON stated staff cannot downgrade from a 2 person to 1 person assist but can go from 1 person to a 2 person or more assist. The ADON stated if a care plan instructs to assist with 1-2 persons, staff could potentially do a 1 person but can do a 2 person assist The ADON said, I don't think any of the care plans say that. It is up to

the CNA to make the decision if that is what the care plan says. The ADON stated CNAs are not technically making an assessment, but they see what the resident can and cannot do and if a resident was having trouble transferring the CNA could determine if they need 1- or 2-person assistance. Review of the policy titled, Resident Assessment Instrument Comprehensive Care Plan, effective September 2024, showed the purpose was - To ensure that each resident in the facility receives individualized and appropriate care based on a thorough assessment using the Resident Assessment Instrument (RAI) and to comply with state and federal regulations. The facility will utilize the RAI process to assess residents' needs, develop individualized care plans, and ensure their delivery of quality care period this process will involve interdisciplinary team members and be revised to reflect resident condition changes. The procedure, Care Area Assessment (CAA) Process included:Based on the MDS findings, potential issues will trigger the completion of the Care Area Assessment (CAA). This ensures that the facility considers all possible care needs and risks identified during the MDS process.The interdisciplinary team (IDT) will evaluate the triggered areas and develop interventions as necessary.The developing the Care Plan revealed The care plan will address physical, emotional, social, and cognitive needs, as well as any other relevant areas (e.g., nutritional, safety, mobility, (and) medication management).The Interdisciplinary Team Collaboration consisting of nursing, dietary, therapy, social services, and other relevant staff, will collaborate to create and

review the care plan.The policy showed: The care plan will be reviewed quarterly and revised as necessary.The care plan must be updated in response to changes in the resident's condition, new assessments, or input from the resident/family.Significant changes in the resident's condition will trigger a new MDS assessment, guiding further revisions to the care plan.

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📋 Inspection Summary

SCOTT LAKE HEALTH AND REHABILITATION CENTER in LAKELAND, FL inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LAKELAND, FL, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SCOTT LAKE HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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