F 0636
Level of Harm - Minimal harm
or potential for actual harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
Based on interviews and record review, the facility failed to complete a comprehensive assessment for 1 of
5 residents sampled for nutrition. (Resident #54)
Residents Affected - Few
The findings include:
A review of Resident #54 electronic medical record revealed the following recorded weights:
2/1/23- 113.8 pounds (lbs.)
3/4/23- 111.6 lbs.
4/5/23- 106.0 lbs.
5/4/23-106.2 lbs.
6/4/23- 102.4 lbs.
7/5/23- 94.6 lbs.
These weights indicate that Resident #54 had a weight loss of 16.9% of the resident's total body weight
within a six month time frame. A review of the Minimum Data Set (MDS- a comprehensive standardized
assessment of each residents' functional capabilities and health needs) dated 5/3/23 revealed that the
facility marked No/Unknown for the question asking if the person has experienced a weight loss, loss of 5%
or more in the last month or loss of 10% or more in the last 6 months.
On 7/20/23 at approximately 12:04 PM, an interview was conducted with the Chief Operating Officer, who
confirmed that the MDS quarterly assessment on 5/3/23 did not appropriately capture the significate weight
loss for Resident #54.
A review of the Policy titled MDS 3.0 Completion provided by the facility which did not have a date
reviewed/revised or date implemented stated, Policy: Residents are assessed, using a comprehensive
assessment process, in order to identify care needs and to develop an interdisciplinary care plan.
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 10
Event ID:
105892
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
105892
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Park of Madison Nursing and Rehabilitation Ce
259 SW Captain Brown Rd
Madison, FL 32340
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to develop a comprehensive care plan for 1 of
5 residents sampled for nutrition. (Resident #38).
The findings include:
A review of the electronic medical record for Resident #38 revealed that the resident's weight on 2/17/23
was documented as 117.6 pounds. On 7/17/23, the resident's weight was documented as 103.2 pounds,
which is a 12.24% weight loss. Review of the Minimum Data Set (MDS) dated [DATE] revealed that the
facility did record that the resident experienced significant weight loss, but was not on a
physician-prescribed weight loss regimen. Review of the Comprehensive Care Plan for Resident #38
revealed no documentation concerning significant weight loss or nutritional needs.
On 7/20/23 at approximately 10:30 AM, an interview was conducted with the MDS coordinator in reference
to the care plan for Resident #38. The MDS coordinator confirmed that the resident was coded on the MDS
for weight loss but that there was not a care plan for nutritional needs or weight loss for Resident #38. The
MDS coordinator agreed that weight loss should have been included and stated, It somehow got missed.
On 7/20/23 at approximately 10:35 AM, an interview was conducted with the Director of Nursing (DON),
who stated that it was her expectation that residents with weight loss to be care planned for nutrition.
Review of the facility policy titled Comprehensive Care Plans date reviewed/revised 1/4/23 revealed:
Policy: It is the policy of this facility to Develop and Implement a Comprehensive Person-Centered Care
Plan for each resident consistent with resident rights, that includes measurable objectives and timeframes
to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the
resident's Comprehensive Assessment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105892
If continuation sheet
Page 2 of 10
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
105892
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Park of Madison Nursing and Rehabilitation Ce
259 SW Captain Brown Rd
Madison, FL 32340
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 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews, and record review, the facility failed to provide quality of care for the
treatment of a skin tear for 1 of 2 residents sampled for skin conditions (non-pressure). (Resident #48)
Residents Affected - Few
The findings include:
Observations of Resident # 48 were made for the following dates and times:
On 7/18/23 at approximately 1:30 PM, a skin tear was noted to the top of the left hand which appeared to
be scabbed over and redness was noted to the base of the area. At this time, an interview was conducted
with Resident #48, who stated that he was being changed by the staff and holding onto the rail. However,
when he went to turn over, he hit his hand on the over bed table.
On 7/19/23 at approximately 8:45 AM, Resident #48 was observed to be lying in bed watching television
with no dressing observed to the top of the resident's left hand.
On 7/19/23 at approximately 11:20 AM, Resident #48 was observed lying in bed watching television, still
with no dressing to the top of his left hand observed.
A review of Resident #48's medical records revealed that there was no order written for the treatment of the
top of the left hand. A review of the nurses progress notes revealed no documentation concerning the area
to the top of the left hand.
On 7/19/23 at approximately 2:10 PM, an interview was conducted with Nurse B, a Licensed Practical
Nurse (LPN), concerning the area to the top of Resident #48's left hand. Nurse B stated, I think he got the
skin tear to his hand a couple of weeks ago. Nurse B confirmed there was no order for treatment in the
resident's medical record.
On 7/19/23 at approximately 2:30 PM, an interview was conducted with the Director of Nursing (DON).
When informed that there was no documentation concerning the area to the top of Resident #48's left
hand, and no treatment orders noted in the resident's records, the DON stated she would look into that.
On 7/19/23 at approximately 3:30 PM, a follow up interview was conducted with the DON, who stated that
there was an incident report filled out for the skin tear by the night nurse and that the family and physician
were notified. The DON went on to state that the night nurse did not write the treatment order for the skin
tear in Resident #48's chart, so it was missed. The DON went on to state that the nurse was given a verbal
counseling and that they have already started an in-service for the staff concerning skin tears and incident
reports.
A review of the incident report, dated 7/11/23 at 11:56 PM, revealed, Aid notified this writer that resident
had blood to hand. When entered room noted skin tear to left hand. Resident stated he hit his hand on
bedside table. Notified provider of skin tear. Clean left hand with NS (normal saline) applied steri-strips
(tape that holds the skin together) and three layers of Visco paste and dry dressing. Made several attempts
to notify family with no answer and no call back. Notified resident of new treatment order to hand.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105892
If continuation sheet
Page 3 of 10
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
105892
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Park of Madison Nursing and Rehabilitation Ce
259 SW Captain Brown Rd
Madison, FL 32340
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 0684
Level of Harm - Minimal harm
or potential for actual harm
The policy titled Incidents and Accidents (dated 1/4/23) revealed: Policy: It is the policy of this facility for
staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility
property and may involve or allegedly involve a resident.
Compliance Guidelines:
Residents Affected - Few
6. in the event of an incident or accident, immediate assistance will be provided, or securement of the area
will be initiated unless it places one at risk of harm.
7. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be
moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions.
9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any
injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital
dependent upon the nature of the injury(ies).
12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours
of occurrence and will documents all pertinent information.
13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate
interventions, notifications and orders obtained or follow-up interventions.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105892
If continuation sheet
Page 4 of 10
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
105892
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Park of Madison Nursing and Rehabilitation Ce
259 SW Captain Brown Rd
Madison, FL 32340
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, interview, and policy review, the facility failed make ashtrays made of
noncombustible materials accessible to all residents in the smoking area for 4 of 4 sampled residents for
observation during smoking. (Resident #21)
The findings include:
On 7/17/23 at approximately 1:15 PM, an observation of residents in the designated smoking area was
conducted. Staff Member A, a Restorative Certified Nursing Assistant (CNA), was present to assist and
observe the residents during smoking. There were 4 residents (Residents #8, # 20, # 21, and #25) who
were smoking around a dust pan. The surveyor observed all 4 of the residents bumping cigarette ashes into
the dust pan. The dust pan had multiple extinguished cigarettes in it. The smoking area had 2 other
ashtrays located on the other side of the smoking porch. The nearest safety ashtray was more than 15 feet
away from the 4 residents during the observation. 2 of the 4 residents who were using the dust pan utilized
a wheelchair for mobility. An interview was conducted with Resident #21. He was asked why the residents
were using the dust pan. He explained that the other ash trays were difficult to reach.
(Photographic evidence was obtained)
On 7/17/23 at approximately 1:25 PM, an interview was conducted with Staff Member A, CNA. She was
asked if she was responsible for observing the residents during the smoking. The surveyor pointed out to
Staff Member A that 4 of the residents were utilizing a dust pan as an ash tray. The surveyor explained that
it appeared that the residents might not be able to reach an ashtray. She was asked if they should be
utilizing a dust pan instead of a safe ashtray. Staff Member A did not respond but immediately went out to
the smoking porch to move an ashtray closer to the 4 residents.
On 7/20/23 at approximately 9:15 AM, a second observation was made in the designated smoking area.
The same 4 residents were smoking around a dustpan and using it as an ashtray. The dustpan had multiple
extinguished cigarettes and ashes in it. Staff Member A was again supervising smoking.
The Facility Administrator (FA) was notified. An interview was conducted in the designated smoking area
with the FA at approximately 9:20 AM. During the interview, Residents #8, # 20, # 21, and #25 continued to
utilize the dust pan as an ashtray. The FA immediately removed the dust pan. She asked Residents #8, #
20, #21, and #25 not to utilize a dustpan for cigarettes or ashes any more. She placed a safety ashtray next
to the 4 residents. The administrator was asked for a copy of the facility smoking policy. The FA was asked if
the residents should be utilizing a dust pan as an ashtray. She said: Absolutely, no they should not.
On 7/20/23 at approximately 10:15 AM the FA provided a copy of the facility's smoking policy along with a
purchase order for an additional new flip top floor ashtray that had just been ordered for the smoking area.
The FA also provided a copy of a retraining that was just conducted with Staff Member A regarding safety
on the smoking porch. The training stated that residents on the smoking porch are not to utilize anything but
smoking urns to extinguish cigarettes and ashes. A review of the facility policy titled Resident Smoking was
conducted. The policy listed that the facility would provide ashtrays made of non-combustible materials and
safe design.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105892
If continuation sheet
Page 5 of 10
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
105892
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Park of Madison Nursing and Rehabilitation Ce
259 SW Captain Brown Rd
Madison, FL 32340
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based on observation, interviews and policy review, the facility failed to assure that services being provided
meet professional standards of quality for 1 of 6 residents sampled for Medication Administration review.
(Resident #61)
The findings include:
A record review was conducted for Resident #61 which revealed orders for Metoprolol Tartrate Tablet 25
milligrams (MG), give 1 tablet by mouth one time a day for atrial fibrillation (A-fib, an abnormal heart
rhythm) and Digoxin (medication to maintain normal heart rate) 125 micrograms (MCG), give 1 tablet by
mouth one time per day, and Midodrine HCl (medication to treat low blood pressure) Tablet 10 MG, give 1
tablet by mouth every 8 hours as needed for Hypotension (low Blood Pressure).
On 07/19/23 at approximately 09:30 AM, an medication administration observation was made of Nurse B, a
Licensed Practical Nurse (LPN). Nurse B was observed to dispense all routine medication into a medication
cup and approached Resident #61 who was sitting upright in bed. A Blood Pressure (BP) was obtained by
wrist cuff with residents' right arm lying at her side with a reading of 74/44. The nurse prepared to assist
Resident #61 to take her medications as ordered. After observing the BP reading, Nurse B was asked if
she thought she should give the Metoprolol, as this medication is usually contraindicated for anyone with a
low blood pressure reading. Nurse B responded, this lady has a history of low BP, and she is getting
Metoprolol for her A-Fib not her BP. Nurse B was asked if there were BP Parameter orders to hold the drug.
Nurse B then reviewed the orders and verified that there were no parameters.
On 07/19/23 at approximately 10:50 AM, an interview with the LPN Unit Manager was completed. The Unit
Manager reported that Nurse B had informed her of Resident #61's BP of 74/44 and that she had repeated
the BP with a standard arm cuff but there was no documentation of the result. The BP obtained with a
standard cuff was 90/60. Nurse B was asked if she had called care provider to advise of findings of BP
74/44. She responded she had notified the Assistant Director of Nursing (ADON) of the findings, and he
was to notify the APRN (Advanced Practice Registered Nurse) to obtain follow up orders so she could
continue with medication administration.
On 07/19/23 at approximately 11:00 AM, an interview was conducted with the ADON. He reported that he
had notified the APRN of the resident's BP and that the Metoprolol was being held. He stated that the
APRN wanted to review residents record before giving any further orders.
On 07/19/23 at approximately 11:49 AM, the Director of Nursing (DON) was interviewed regarding her
expectations for nursing staff if they assess a BP of 74/44. She responded, I would expect them to lay the
patient down, verify BP, if still low, hold the drug, notify the physician.
On 07/19/23 at approximately 12:07 PM, a telephone interview was conducted with the APRN, who stated
We do not typically write parameter orders for Metoprolol; I would expect a nurse to hold the drug and call
me. I would expect them to repeat the BP reading with a manual cuff or Dynamap (an automatic machine
used to assess blood pressure electronically). The APRN verified that the Midodrine order should have
parameters for administration. She reports that the order had been given by a previous provider. She
stated, I am not certain what the outcome would have been had the drug been given because I am not
certain that the BP obtained was accurate, but if was it could have sent her to the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105892
If continuation sheet
Page 6 of 10
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
105892
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Park of Madison Nursing and Rehabilitation Ce
259 SW Captain Brown Rd
Madison, FL 32340
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 0755
hospital.
Level of Harm - Minimal harm
or potential for actual harm
A further review of the Electronic Medication Record (EMAR) for Resident #61 revealed a new order per
APRN dated 7/19/2023 stating, 11:56 a.m.: Metoprolol Tartrate Tablet 25 MG Give 1 tablet by mouth one
time a day for A-fib HOLD IF SYSTOLIC IS LESS THAN 100.
Residents Affected - Few
On 07/20/23 01:03 PM, the DON provided a document titled Teachable Moment dated 7/19/2023 which
revealed a written nursing in-service on what to do for a patient with a BP less than 100/60. (photographic
evidence obtained).
A review of the Medication Administration Policy (Revised date 1/2/2023) revealed: 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:
8.
Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication
for those vital signs outside the physician's prescribed parameters.
9.
Position resident to accommodate administration of medication.
17.
Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the
MAR.
18.
Report and document any adverse side effects or refusals.
20.
Correct any discrepancies and report to nurse manager .
A review of article dated February 19, 2023, in Stat Pearls for the National Institute of Health National
Library of Medicine reveals, Hypotension is a decrease in systemic blood pressure below accepted low
values. While there is not an accepted standard hypotensive value, pressures less than 90/60 are
recognized as hypotensive.
Review of Libre Text Nursing Pharmacology (Open RN) 11.04, Chapter 4 revealed:
5.a. Before administering metoprolol, the nurse should always assess the patient's blood pressure and
pulse.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105892
If continuation sheet
Page 7 of 10
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
105892
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Park of Madison Nursing and Rehabilitation Ce
259 SW Captain Brown Rd
Madison, FL 32340
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
5.b. If the systolic blood pressure is less than 100 mm Hg or the apical heart rate is less than 60 beats per
minute, the medication should be withheld and the provider notified unless other parameters are provided
in the order.
Review of Proper use of a wrist cuff instructions presented by the American Medical Association (AMA)
revealed:
Using a wrist cuff to measure your blood pressure 1. Apply the cuff to your wrist 2. Keep your elbow on
table or desk with your forearm bent 3. Place your wrist at the level of your heart 4. Keep your arm relaxed
and your hand resting against your body 5. Measure your wrist blood pressure without moving your arm
from seated position.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105892
If continuation sheet
Page 8 of 10
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
105892
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Park of Madison Nursing and Rehabilitation Ce
259 SW Captain Brown Rd
Madison, FL 32340
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interviews and policy review, the facility failed to maintain its infection prevention and
control program for 2 of 6 residents sampled for Medication Administration review. (Residents # 27 and #61)
Residents Affected - Few
The findings include:
On 7/19/2023 at approximately 9:08 AM, an observation was made of Nurse B, a Licensed Practical Nurse
(LPN), taking a blood pressure on Resident #27 with a wrist cuff (a piece of medical equipment designed to
measure blood pressure on the wrist of a patient). This wrist cuff was taken from the med pass cart prior to
providing Resident #27 with her morning medications. Nurse B then placed the wrist cuff on top of
medication cart while she prepared medications for Resident #61 in the next room. The nurse then picked
up the medication cup and the same wrist cuff and proceeded into Resident #61's room, where she then
obtained a blood pressure with wrist cuff for Resident #61. The wrist cuff was not wiped down with
disinfectant between the use for these two residents.
On 7/19/2023 at approximately 9:40 AM, an interview was conducted with Nurse B concerning infection
control policy for multiuse equipment. When asked if there was a policy for cleaning of multiuse equipment
between residents, Nurse B stated I'm not sure. When asked if the equipment should be disinfected
between residents, Nurse B replied probably.
On 7/19/2023 at approximately 10:00 AM, an interview was conducted with the Assistant Director of
Nursing (ADON) concerning the policy for disinfection of multiuse equipment. The ADON responded I will
check.
On 7/19/2023 at approximately 10:10 AM, a follow up interview was conducted with the ADON, who verified
that multiuse equipment was to be disinfected between residents with each use per facility policy. A copy of
the policy was requested.
Review of the Policy titled Cleaning and Disinfection of Resident-Care Equipment (revision date 01/04/23)
revealed: Policy: Resident-care equipment can be a source of indirect transmission of pathogens. Reusable
resident-care equipment will be cleaned and disinfected in accordance with current CDC recommendations
in order to break the chain of infection.
1.
Staff shall follow established infection control principles for cleaning and disinfecting reusable, noncritical
equipment. General guidelines include:
a.
Verify whether the equipment is single-use or reusable. Discard single-use items after use.
b.
Each user is responsible for routine cleaning and disinfection of multi-resident items after each use. c.
Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according
to routine schedule (where applicable).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105892
If continuation sheet
Page 9 of 10
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
105892
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/20/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Park of Madison Nursing and Rehabilitation Ce
259 SW Captain Brown Rd
Madison, FL 32340
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 0880
d. Multiple-resident use equipment shall be cleaned and disinfected after each use.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
105892
If continuation sheet
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