F 0584
Level of Harm - Minimal harm
or potential for actual harm
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.
Based on observation and interview, the facility failed to maintain a clean and homelike environment for
residents (Photographic evidence obtained).
Residents Affected - Few
The findings include:
During an observation of laundry room on 4/10/2024 at 2:50 PM with the Maintenance Director, Director of
Housekeeping and Laundry, and Staff C, Laundry Assistant, one of the two washing machines was not
working. In the washing machine room, there were linen cans with no covers, a large buildup of garbage,
debris, and lint behind the washing machines, a window screen propped on the floor next to the working
washing machine with a large amount of garbage and debris around it, and on debris and lint on the air
conditioning unit. In the lint area of Dryer #1 and Dryer #2, there was a large buildup of dust and lint. In the
drum of Dryer #2, there was a large buildup of brown, melted, unidentified matter. Dryer #2's door did not
latch. In the bottom of the clean linen cart, there was a buildup of garbage and debris. The carts in the dryer
room which held the clean linens were uncovered.
During an interview on 4/10/2024 approximately at 2:55 PM, the Director of Housekeeping and Laundry
stated the washing machine had been broken for a couple of weeks and it was affecting their ability to keep
up with laundry needs.
During an interview on 4/10/2024 approximately at 2:57 PM, the Maintenance Director stated there was a
window air conditioning unit in the window, preventing the screen from fitting into the window properly, and
stated that the facility never cleaned and scraped the dryer drums.
During an interview on 4/10/2024 approximately at 3:00 PM, Staff C, Laundry Assistant, stated that the
latch was broken.
During an observation on 4/10/2024 approximately at 3:10 PM, inside the shower room on the C-Hallway,
there was one disinfectant cleaner with bleach spray lying near a stack of towels, a drink, a package of
cookies, and a cell phone on the sink counter. The freezer section of the specimen refrigerator located in
the dirty utility room of the C-Hallway had a buildup of ice. Three ceiling vents located on the C-Hallway had
a buildup of dust, lint, and a black substance. In the Medication Room on the C-Hallway, there were supply
boxes stacked on top of the upper cabinets, reaching the ceiling. The wash sink in the soiled room on the
B-Hallway was broken.
During an interview on 4/10/2024 approximately at 3:15 PM, the Maintenance Director confirmed the
findings and was unable to tell how long the wash sink had been broken.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
105346
Printed: 05/28/2026
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
105346
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/11/2024
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure nutritional interventions were provided
in a timely manner for 1 of 6 residents reviewed for nutrition, Resident #4.
Residents Affected - Few
The findings include:
During an interview on 4/8/2024 at 10:27 AM, Resident #4 stated the food at the facility was cold and over
seasoned and that she often asked for a substitute which was normally a sandwich. The resident stated she
had lost weight since being admitted to the facility.
Review of Resident #4's admission record showed the resident was admitted to the facility on [DATE] with
diagnoses including diabetes, gastroesophageal reflux disease, and pressure injuries.
Review of Resident #4's Minimum Data Set, dated [DATE] showed a Brief Interview of Mental Status score
of 15, which indicated intact cognition.
Review of Resident #4's care plan, last reviewed on 1/24/2024, showed the resident was at nutritional risk
and was experiencing weight loss despite having a fair to good oral intake.
Review of Resident #4's care plan, last reviewed on 3/12/2024, showed the resident was care planned for
alteration in skin integrity related to stage 4 pressure ulcer on her sacrum with history of wound infection
and is at ongoing risk for further breakdown.
Review of Resident #4's weights showed 188 pounds on 10/10/2023, and 150 pounds on 4/9/2024, which
indicated the resident had 20.21% weight loss since she was admitted to the facility.
Review of Resident #4's Skin and Wound Notes documented by the Wound Nurse Practitioner revealed the
post-debridement measurement of the wound was 2.1 x 0.9 x 0.2 centimeters (cm) on 4/9/2024 at 9:18 AM,
2.1 x 1.3 x 0.3 cm on 3/19/2024 at 8:30 AM, and 2.3 x 2.1 x 0.4 cm on 2/20/2024 at 8:27 AM.
Review of Resident #4's Nutrition/Dietary Notes dated 11/16/2023 and 2/23/2024 revealed the Registered
Dietitian was aware that the resident had lost weight and that her intervention was to provide snacks.
Review of Resident #4's meal consumption log documented by the Certified Nursing Assistants revealed
the resident ate 50-100% of all meals with the exception of three meals during a 30-day look back period.
During observations on 4/8/2024, 4/9/2024, and 4/10/2024, Resident #4 consumed 60-80% of each of her
meals.
During an interview on 4/10/2024 at 8:45 AM, the Consultant Dietitian stated she was aware that Resident
#4 had a significant weight loss and that she had not started supplements for her yet. She stated she saw
the weight that had been done on 4/9/24.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105346
If continuation sheet
Page 2 of 2
