Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0584
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.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, record reviews and interviews, the facility failed to ensure safe and comfortable temperatures
were maintained in residents' bedrooms by failing to repair one of eight rooftop air-conditioning (A/C) units
resulting in temperature readings between 89.8- and 90.0-degrees Fahrenheit (F) on 06/23/2025, for one
resident (#5) of twenty sampled residents. These failures resulted in physical discomfort for a dependent
resident and the likelihood of significant harm due to unsafe temperatures exceeding 81-degrees
Fahrenheit.
Findings included:
During the tour of the facility on 06/23/2025 at 8:32 a.m. Resident #5 was observed in a private bedroom.
Upon entering the room, noticeable uncomfortable room air temperature was identified due to excessive
warmth with palpable humidity present. A fan, approximately 18 inches, was observed operating on an over
the bed table. Resident #5 was observed in a low bed, in a curled position, eyes open, observed to be
watching the television in the corner of the room. Two windows, that were approximately the length of the
bed, were observed to be open approximately 1 inch. The room was observed to have no wall cooling A/C
units. An air vent was observed to be located in the ceiling, right inside the resident's room door. During this
tour, there was no noticeable cool air flow. During this tour, Resident #5 was noted not interviewable and
could not speak of his temperature preferences.
A review of Resident #5's admission Record revealed a re-admission date of 05/23/2025. The diagnosis
information included, but not limited to: Severe intellectual disabilities, acute and chronic respiratory failure;
contracture, unspecified joint, cognitive communication deficit, muscle weakness (generalized); and need
for assistance with personal care.
Review of a progress note dated 06/04/2025 at 4:13 p.m. revealed Resident #5 was unable to speak on
behalf of self. It showed, Social Determinations of Health note by the Minimum Data Set Coordinator:
Resident is unable to respond regarding ethnicity. Resident is unable to respond regarding race. Language:
English. Residents do not need or want an interpreter to communicate with doctor or health care staff.
Resident is unable to respond to lack of transportation. How often do you need to have someone help you
when you read instructions, pamphlets, or other written material from your doctor or pharmacy: Resident
unable to respond. How often do you feel lonely or isolated from those around you: Resident unable to
respond.
On 06/23/2025 at 10:33 a.m., an interview was conducted with the Maintenance Director. He stated the
facility had three ground unit air conditioners (A/C) and eight rooftop A/Cs. He stated, Yes, they are all
keeping temperatures. He stated he checks the working order of the A/Cs by using the
(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 4
Event ID:
106069
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
106069
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Wales Health and Rehabilitation Center
730 N Scenic Hwy
Lake Wales, FL 33853
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 0584
thermal gun, pointing it at the vents for temperature. He said he did this about once per month.
Level of Harm - Actual harm
On 06/23/2025 at 10:47 a.m., observations were conducted of Resident #5's room with the Maintenance
Director. The windows were observed open in the same position. The Maintenance Director stated he was
unaware of the warmth of the room, and he did not know why the residents' windows were open. He was
observed to close the windows. When asked if he had a tool to measure the temperature in the room, he
said he did and he was observed to leave to retrieve it. During the Maintenance Director's absence, at
10:50 a.m. Staff C, Licensed Practical Nurse (LPN) was observed outside of Resident #5's room, she
confirmed she was assigned to Resident #5. When asked about the temperature in Resident #5's room,
she said, it was warm in the room. She said, It has been like that for about one month. All of them are
aware.
Residents Affected - Few
On 06/23/2025 at 11:55 a.m., the Maintenance Director returned with a thermal temperature gun. He
pointed the thermal gun at the ceiling and the reading on the tool was 90.0 degrees Fahrenheit. He pointed
the thermal gun at the floor, approximately two and a half feet from Resident #5's bed, and the reading on
the tool was 89.8 degrees Fahrenheit. The Maintenance Director said, It is very warm, we can see about
moving him.
On 06/23/2025 at 11:13 a.m. an interview was conducted with Staff C, LPN. When asked if and how the
temperature was monitored in Resident #5's room, she stated she did not know how to take temperatures.
She stated they were aware of it. She said, for maintenance issues, they enter maintenance requests
electronically through a portal.
An interview was conducted with Staff A, Certified Nursing Assistant (CNA) on 06/23/2025 at 11:38 a.m.
She stated the Maintenance Assistant and Director knew about the warm temperatures in Resident #5's
room. She said, He (The Maintenance Director) has been aware of it. I asked them if they are going to do
anything about it. She said, (referring to Resident #5) you can go in there and he will be hot visibly, but he
will say he is cold. Staff A stated, hot visibly, meant sweat. She stated the resident has a ten-word
vocabulary and would not go in there expecting him to answer.
On 06/23/2025 at 11:48 a.m., the Maintenance Director stated they were going to move Resident #5 out of
the room today and they were currently working on another room for him. He stated this was the first time
he had taken temperatures in the resident's room. He said his goal for the temperature level was to be no
more than 82 degrees or below.
On 6/23/2025 at 12:00 p.m., a telephone interview was conducted with the Maintenance Assistant. He
stated (Resident #5)'s room was hooked up to a roof top unit; it should be cooling. When asked his
expectation for the temperature of the air coming out of the vent in the room, he stated he would expect the
temperature of the air coming out of the vent to be 75 degrees. He stated he was unaware of any problems
in the last 30 days with Resident #5's room, hallway, or the A/C unit serving the area. He stated, Not that I
am aware of. He stated, Yes he should be aware of any problems. He said, For the temperature in the room,
the goal is to be 74 to 75 degrees; the maximum, believe it to be 80 degrees. He stated he had not received
any concerns about warm temperatures in the resident's room. He stated, Not that I am aware of. When
asked about the temperature obtained from (Resident #5's) room, the floor at 89.9 degrees Fahrenheit, the
ceiling at 90.0 degrees Fahrenheit, he said, that is not suitable for a resident in there; it is definitely too hot.
The Maintenance Assistant stated he had measured the temperature coming out of the vent at the end of
last month but had not written it down.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106069
If continuation sheet
Page 2 of 4
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
106069
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Wales Health and Rehabilitation Center
730 N Scenic Hwy
Lake Wales, FL 33853
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 0584
Level of Harm - Actual harm
A second observation of air vent temperature located in Resident #5's room and vents in the hallway near
Resident #5's room was conducted on 06/23/2025 at 12:10 p.m. with the Maintenance Director. The
following was observed:
Residents Affected - Few
Resident #5's doorway ceiling vent air output temperature reading was 87.4 degrees Fahrenheit.
The ceiling vent air output for the vent in the hall outside of room [ROOM NUMBER] was 84.2 degrees
Fahrenheit.
The ceiling vent air output for the vent in the hall outside of room [ROOM NUMBER] was 86.4 degrees
Fahrenheit.
Observed outside of the resident's room was a thermostat on the wall which read a temperature of 79
degrees Fahrenheit, with a setting of 74 degrees Fahrenheit. The Maintenance Director was observed to
remove the cover of the thermostat and lower the setting to 72 degrees Fahrenheit.
A review of the facility's electronic communication log dated 04/01/2025 through 06/23/2025 revealed there
were no listings for concerns of temperature submitted by staff.
On 06/23/2025 at 2:15 p.m., an interview was conducted with the Director of Nursing (DON). She reported
she had not been in (Resident #5's) room. She stated she had not noticed the temperature in the hall (near
Resident #5's room) being warm. When asked what she would expect a staff member to do if they noticed a
warm temperature in a resident room, she said, first find out if it is a preference; report it to management
and maintenance that there may be a problem.
On 06/23/2025 at 3:15 p.m., Staff C, LPN, was observed sitting at the nursing station between the 100 and
the 200 halls, she was using a piece of paper to fan herself. She stated, it is very hot here, the west side is
cooler. She stated, This is the east side. I have noticed it getting warm in May. When asked if she had
reported the warm temperature, she stated Yes, everyone knows it is warm, it is an older building.
On 06/23/2025 at 3:20 p.m. Staff E, CNA was observed standing at the nurses' station between the 100
and 200 halls. She confirmed she was assigned rooms in the 200 hall. She said regarding Resident #5's
room, It is hot in his room; I think I had him last week. The Maintenance Assistant said they were working
on it. An observation was conducted at this time of a digital wall clock on the wall at the end of the nursing
station. The temperature of the wall clock read 83.3 degrees Fahrenheit. Staff E, CNA, said, the wall clock
will register over 80 degrees frequently.
On 06/23/2025 at 3:30 p.m., an interview was conducted with Staff F, Housekeeper. She confirmed she
performed housekeeping on certain days of the week. She said regarding the temperature in Resident #5's
room, Sometimes the room is cooler, sometimes warmer. I do not know if there is air conditioning in here
(pointed to the ceiling). Staff F stated lately it has been warmer.
On 06/24/2025 at 11:30 a.m., an observation and interview confirmed Resident #5 had been moved to
another room. The Maintenance Director stated the roof top A/C unit, which was responsible to source the
cool air for Resident #5's room, the fan was running, but he was not sure if it was cooling. He stated the
thermostat in the hall was set at 72 degrees and the temperature in the hall had been between 76- and
77-degrees during frequent checks this morning. He stated he was told the A/C technician cannot come out
today and is going to call back and see if another technician can come out. During
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106069
If continuation sheet
Page 3 of 4
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
106069
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lake Wales Health and Rehabilitation Center
730 N Scenic Hwy
Lake Wales, FL 33853
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 0584
Level of Harm - Actual harm
Residents Affected - Few
the interview, the temperature in the room felt warm and the air coming from the vent was at a sparse rate.
The Maintenance Director stated this air vent was sourced by the roof top A/C unit. He immediately used
his thermal temperature gun, pointed at this air vent and obtained a temperature of 87 degrees Fahrenheit.
Another temperature measurement was obtained inside the middle of Resident #5's room, by pointing the
thermal temperature gun at the ceiling, which measured 87 degrees Fahrenheit, and then mid-floor, which
measured 85 degrees Fahrenheit. The Maintenance Director confirmed air temperatures were not checked
routinely. He stated they only checked if the A/C system goes out, then there would be frequent
temperature checks done.
On 06/24/2025 at 1:14 p.m. an interview was conducted with the Nursing Home Administrator (NHA). When
asked if the facility had a policy for testing temperatures in the building, or what the process was to ensure
temperatures were appropriate, the NHA said, if we have a loss of A/C, then we take temperatures, on a
daily, weekly, monthly basis. She stated they just walk through. The NHA did not provide documentation to
show they were monitoring temperatures. The NHA stated they can monitor temperatures by looking at the
thermostats on the walls, and staff can tell if it is warm. The NHA stated she was not aware of an A/C unit
that was not working. The NHA said, No, not that I'm aware of, no one had brought anything to me, and no
one had voiced concerns about temperatures. The NHA stated for staff reporting maintenance issues, she
said, they should use (the electronic communications) system, she stated it is a reporting system where
you can put work orders in. She stated all staff had access to the generic login. She stated all staff were
trained in the Electronic Communication System. The NHA said, Yes, they were trained on hire. I don't know
the last time they were trained; I have to go look. The NHA stated her expectation for temperatures in
resident rooms was to be between 71 and 81 degrees, unless it is resident preference to have it warmer.
The NHA stated they were waiting on a technician to fix the roof-top unit located near 200 hall. The NHA
stated she was not aware of Resident #5's room being warm. The NHA said, No. I have been in that room
two-three times a week doing spot checks. The HNA stated she was in there and the window was not open.
The NHA stated the window being open would have brought more heat inside. The NHA stated her
expectation was when maintenance becomes aware of a non-functional A/C unit, they should get quotes
and get it fixed.
On 06/23/2025 at 12:40 p.m. the Maintenance Director was requested to provide the policy and procedure
for monitoring temperatures in the building, and the policy and procedure for how staff communicate
concerns to the maintenance personnel. The policies were not provided.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
106069
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F584 - Safe Environment
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.
FAQ · About this visit
Common questions about this visit
What happened during the June 24, 2025 survey of Lake Wales Health and Rehabilitation Center?
This was a inspection survey of Lake Wales Health and Rehabilitation Center on June 24, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Lake Wales Health and Rehabilitation Center on June 24, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receivin..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.