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Health Inspection Summary

Lakeland Hills Center

610 E Bella Vista Dr

Lakeland, FL 33805

(863) 688-8591

Deficiency Category	Inspection Date: 9/28/23 Complaint Reporting Period: 4/1/24 - 3/31/25	Inspection Date: 8/19/21 Complaint Reporting Period: 4/1/23 - 3/31/24	Inspection Date: 11/22/19 Complaint Reporting Period: 4/1/22 - 3/31/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	0	0	0
Quality of Life and Care Deficiencies	1	2	0
Infection Control Deficiencies	1	0	0
Resident Assessment and Care Planning Deficiencies	3	0	0
Nursing and Physician Services Deficiencies	0	0	0
Resident Rights Deficiencies	2	0	3
Nutrition and Dietary Deficiencies	1	0	1
Pharmacy Service Deficiencies	2	1	1
Environmental Deficiencies	1	0	0
Administration Deficiencies	1	0	0

Detailed result for inspection on 9/28/23

Date of last standard health inspection:	9/28/23Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/24 - 3/31/25	1/14/25Read the full report (PDF) 8/12/24Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/24 - 3/31/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	12
Average number of Health Deficiencies in Florida:	7.2
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide enough food/fluids to maintain a resident's health.	9/28/23	10/28/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	9/28/23	10/28/23	2 - Minimal harm or potential for actual harm	Many

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	1/14/25	2/14/25	2 - Minimal harm or potential for actual harm	Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	9/28/23	10/28/23	2 - Minimal harm or potential for actual harm	Few
PASARR screening for Mental disorders or Intellectual Disabilities	9/28/23	10/28/23	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Honor the resident's right to organize and participate in resident/family groups in the facility.	9/28/23	10/28/23	2 - Minimal harm or potential for actual harm	Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	1/14/25	2/14/25	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	8/12/24	9/11/24	2 - Minimal harm or potential for actual harm	Many

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	9/28/23	10/28/23	2 - Minimal harm or potential for actual harm	Few
Ensure medication error rates are not 5 percent or greater.	9/28/23	10/28/23	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Keep all essential equipment working safely.	1/14/25	2/14/25	2 - Minimal harm or potential for actual harm	Some

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Have a plan that describes the process for conducting QAPI and QAA activities.	9/28/23	10/28/23	2 - Minimal harm or potential for actual harm	Some

Detailed result for inspection on 8/19/21

Date of last standard health inspection:	8/19/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/23 - 3/31/24	9/28/23Read the full report (PDF) 7/18/23Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/23 - 3/31/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	3
Average number of Health Deficiencies in Florida:	6.2
Average number of Health Deficiencies in the United States:	9.4

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide care and assistance to perform activities of daily living for any resident who is unable.	7/18/23	8/18/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/28/23	10/28/23	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
No Resident Rights Deficiencies were found during this inspection period.

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure medication error rates are not 5 percent or greater.	8/19/21	9/19/21	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 11/22/19

Date of last standard health inspection:	11/22/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 4/1/22 - 3/31/23	11/16/22Read the full report (PDF)
Date(s) of infection control inspection(s) between 4/1/22 - 3/31/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	5
Average number of Health Deficiencies in Florida:	5.8
Average number of Health Deficiencies in the United States:	8.7

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
No Quality of Life and Care Deficiencies were found during this inspection period.

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
No Resident Assessment and Care Planning Deficiencies were found during this inspection period.

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Give residents a notice of rights, rules, services and charges.	11/16/22	12/16/22	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	11/22/19	12/22/19	2 - Minimal harm or potential for actual harm	Few
Keep residents' personal and medical records private and confidential.	11/22/19	12/22/19	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	11/22/19	12/22/19	2 - Minimal harm or potential for actual harm	Few

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	11/22/19	12/22/19	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Complaints and facility-reported incidents in the past 3 years
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	1/14/25	2/14/25	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	1/14/25	2/14/25	2 - Minimal harm or potential for actual harm	Few
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	8/12/24	9/11/24	2 - Minimal harm or potential for actual harm	Many
Keep all essential equipment working safely.	1/14/25	2/14/25	2 - Minimal harm or potential for actual harm	Some
Provide care and assistance to perform activities of daily living for any resident who is unable.	7/18/23	8/18/23	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	9/28/23	10/28/23	2 - Minimal harm or potential for actual harm	Few
Give residents a notice of rights, rules, services and charges.	11/16/22	12/16/22	2 - Minimal harm or potential for actual harm	Few

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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