Tag 0641 · Severity D
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2026-04-13At a glance
CMS data snapshot: 2026-08-01 · Sources and limitations
| Ownership | Non profit - Corporation | Certified beds | 120 |
|---|---|---|---|
| Estimated occupancy | 86.7% | Latest inspection | 2026-03-12 |
County and Florida comparison
Navy: facility · Teal: county · Gray: Florida
Overall rating
Facility: 4 of 5
Health-inspection score
Facility: 29.0 points
Total nurse staffing
Facility: 4.11 hours/day
RN staffing
Facility: 0.51 hours/day
Staff turnover
Facility: 40.4%
Latest health deficiencies
Facility: 8 deficiencies
View data table
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 4 of 5 | 4 of 5 | 3 of 5 |
| Health-inspection score | 29.0 points | 35.0 points | 38.5 points |
| Total nurse staffing | 4.11 hours/day | 3.66 hours/day | 3.63 hours/day |
| RN staffing | 0.51 hours/day | 0.51 hours/day | 0.62 hours/day |
| Staff turnover | 40.4% | 46.0% | 41.8% |
| Latest health deficiencies | 8 deficiencies | 7 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Inspection history
2026-03-12
8 deficiencies
Highest severity: D
Immediate-jeopardy citations: 0
Tag 0656 · Severity D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2026-04-13Tag 0756 · Severity D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2026-04-13Tag 0757 · Severity D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2026-04-13Tag 0760 · Severity D
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2026-04-13Tag 0761 · Severity D
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2026-04-13Tag 0842 · Severity D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2026-04-13Tag 0880 · Severity D
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2026-04-132024-09-25
5 deficiencies
Highest severity: D
Immediate-jeopardy citations: 0
Tag 0656 · Severity D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2024-10-23Tag 0761 · Severity D
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-10-232023-06-02
5 deficiencies
Highest severity: D
Immediate-jeopardy citations: 0
Tag 0641 · Severity D
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2023-06-05Tag 0684 · Severity D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-06-27Tag 0695 · Severity D
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-06-27Tag 0761 · Severity D
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.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2023-06-27Tag 0847 · Severity D
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Administration Deficiencies · Deficient, Provider has date of correction 2023-06-28Staffing composition
2.28 hours/dayNurse aide
1.32 hours/dayLPN
0.51 hours/dayRN
- Total staffing
- 4.11 hours/day
- County median
- 3.66 hours/day
- Florida median
- 3.63 hours/day
- Weekend total
- 3.63 hours/day
- Staff turnover
- 40.4%
- RN turnover
- 10.0%
Reported averages, not a real-time staffing schedule.
Resident outcomes
Lower is generally better
Hospitalizations
2.0 per 1,000 dayssimilarFlorida: 2.1 per 1,000 days · County: 1.8 per 1,000 days20250101-20251231
Emergency-department visits
0.7 per 1,000 daysbetterFlorida: 1.0 per 1,000 days · County: 1.3 per 1,000 days20250101-20251231
Falls with major injury
1.8%betterFlorida: 2.2% · County: 1.8%2025Q2-2026Q1
Pressure ulcers
3.1%betterFlorida: 4.2% · County: 4.6%2025Q2-2026Q1
Urinary tract infections
2.6%unavailableFlorida: 0.0% · County: 0.0%2025Q2-2026Q1
Antipsychotic medication use
10.5%worseFlorida: 7.0% · County: 5.1%2025Q2-2026Q1
These group measures do not predict an individual resident’s experience.
Questions to ask
Use these prompts during a tour or phone call
How many RNs are typically on site during days, nights, and weekends?
Suggested because of: rn staffingHow are antipsychotic medications reviewed, reduced when appropriate, and discussed with families?
Suggested because of: antipsychotic useHow will the care plan be developed, reviewed, and shared with our family?
Suggested because of: general care planning
Facility Details
- County
- Lake County
- Certified beds
- 120
- Average daily residents
- 104
- Ownership
- Non profit - Corporation
- Provider type
- Medicare and Medicaid
- In hospital
- No
- Date certified
- 1998-09-10
- CCN
- 105796
Staffing Data
| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.28257 |
| Lpn hours | 1.32277 |
| Rn hours | 0.50533 |
| Reported total hours | 4.11067 |
| Weekend total hours | 3.63029 |
| Weekend rn hours | 0.30347 |
| Adjusted total hours | 4.25182 |
| Total turnover percent | 40.4 |
| Rn turnover percent | 10 |
| Administrators left | 2 |
Hours are per resident per day; turnover values are percentages. Missing values are not zero.
Penalties & Enforcement
$0.00Total fines
0Number of fines
0Payment denials
No matching penalties in the supplied CMS records.
Totals reflect the supplied CMS records, not a lifetime total.
Citations
8Health citations
9Fire safety citations
Health counts describe the latest rating cycle. Fire counts cover supplied fire-safety records.
Serious Deficiencies
FL counts scope/severity G–L as serious deficiencies. Immediate jeopardy is J–L; these are not interchangeable.
0
Ownership & Operators
| Name | Role | Share |
|---|---|---|
| DUJON, ANDREW | CORPORATE OFFICER | NOT APPLICABLE |
| LARSON, DAVID | CORPORATE OFFICER | NOT APPLICABLE |
| BUCHANAN, YVONNE | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| DUJON, ANDREW | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE |
| BUCHANAN, YVONNE | ADP OF THE SNF | NOT APPLICABLE |
Helpful resources
Educational information, not medical or legal advice. Data & methodology