Inspection·October 31, 2024

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 observations and interviews, the facility failed to maintain a clean and sanitary environment in the shower rooms, soiled utility rooms, and laundry room (photographic evidence obtained). Residents Affected - Few The findings include: A tour of the facility was conducted on 10/31/24 at 11:00 AM with the facility's Administrator and Maintenance Director. During this tour, the following areas of concern were identified: In the East Side Shower Room, 3 of 3 shower stalls were observed to have a large build-up of dark matter on the walls, grout lines, and floors. In the [NAME] Side Shower Room, 2 of 3 shower stalls were observed to have a large build-up of dark matter on the walls, grout lines, and floors. In the East Side Soiled Utility Room, 2 garbage cans were observed without lids. One laundry cart was observed without a cover. Within the laundry cart, the surveyor observed soiled linen present which was not secured in a bag. Also within the laundry cart was a large amount of garbage present under the moveable bottom of the cart. A large build-up of ice in the freezer of the specimen refrigerator located in this soiled utility room was also observed. In the [NAME] Side Soiled Utility Room, 1 laundry cart was observed without a cover. Within the laundry cart, there was soiled linen present which was not secured in a bag. Also within the laundry cart was a large amount of garbage present under the moveable bottom of the cart. The surveyor observed a large build-up of ice in the freezer of the specimen refrigerator located in this soiled utility room as well. In the soiled area of the laundry room, 2 uncovered garbage cans and 2 uncovered laundry bins were observed. The inner liner of 1 of the 2 laundry bins was observed to have numerous rips around the top edge of the bin. Both laundry bins had a large build-up of dirt and debris present in the bottoms. In the dryer room, 2 of 3 dryers had a large build-up of lint and other foreign substances, such as nuts, coins, razor guards, drinking straws, water bottle caps, and plastic lighter parts were present in the lint trap areas. An interview was conducted with Staff A, Laundry Aide, during the laundry room tour. She stated the laundry staff clean the lint traps every 2 hours and the maintenance department cleans the lint (continued on next page) 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: 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 10/31/2024 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)