Tag 0760 · Severity J
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2026-02-06For-profit
Lady Lake Specialty Care Center and Rehab
630 Griffin Avenue, Lady Lake, FL 32159
(352) 750-6619 · Gold Fl Trust II
At a glance
CMS data snapshot: 2026-08-01 · Sources and limitations
| Ownership | For profit - Limited Liability company | Certified beds | 145 |
|---|---|---|---|
| Estimated occupancy | 91.1% | Latest inspection | 2025-12-18 |
County and Florida comparison
Navy: facility · Teal: county · Gray: Florida
Overall rating
Facility: 1 of 5
Health-inspection score
Facility: 176.5 points
Total nurse staffing
Facility: 3.52 hours/day
RN staffing
Facility: 0.49 hours/day
Staff turnover
Facility: 60.2%
Latest health deficiencies
Facility: 7 deficiencies
View data table
| Metric | Facility | County | Florida |
|---|---|---|---|
| Overall rating | 1 of 5 | 4 of 5 | 3 of 5 |
| Health-inspection score | 176.5 points | 35.0 points | 38.5 points |
| Total nurse staffing | 3.52 hours/day | 3.66 hours/day | 3.63 hours/day |
| RN staffing | 0.49 hours/day | 0.51 hours/day | 0.62 hours/day |
| Staff turnover | 60.2% | 46.0% | 41.8% |
| Latest health deficiencies | 7 deficiencies | 7 deficiencies | 6 deficiencies |
Comparisons describe CMS data; they are not recommendations.
Inspection history
2025-12-18
7 deficiencies
Highest severity: J
Immediate-jeopardy citations: 2
Tag 0835 · Severity J
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Administration Deficiencies · Deficient, Provider has date of correction 2026-02-06Tag 0645 · Severity D
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2026-02-06Tag 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 2026-02-06Tag 0698 · Severity D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2026-02-06Tag 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 2026-02-06Tag 0880 · Severity D
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2026-02-062024-07-17
8 deficiencies
Highest severity: E
Immediate-jeopardy citations: 0
Tag 0812 · Severity E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction 2024-08-23Tag 0880 · Severity E
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2024-08-23Tag 0584 · Severity D
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.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2024-08-23Tag 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 2024-08-23Tag 0759 · Severity D
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies · Deficient, Provider has date of correction 2024-08-23Tag 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 2024-08-23Tag 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 2024-08-23Tag 0732 · Severity C
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction 2024-08-232023-03-09
11 deficiencies
Highest severity: E
Immediate-jeopardy citations: 0
Tag 0625 · Severity E
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Resident Rights Deficiencies · Deficient, Provider has date of correction 2023-04-17Tag 0695 · Severity E
Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-04-17Tag 0761 · Severity E
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 2023-04-17Tag 0880 · Severity E
Provide and implement an infection prevention and control program.
Infection Control Deficiencies · Deficient, Provider has date of correction 2023-04-17Tag 0641 · Severity D
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2023-04-17Tag 0645 · Severity D
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2023-04-17Tag 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 2023-04-17Tag 0658 · Severity D
Ensure services provided by the nursing facility meet professional standards of quality.
Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction 2023-04-17Tag 0692 · Severity D
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Deficient, Provider has date of correction 2023-04-17Tag 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 2023-04-17Staffing composition
2.19 hours/dayNurse aide
0.84 hours/dayLPN
0.49 hours/dayRN
- Total staffing
- 3.52 hours/day
- County median
- 3.66 hours/day
- Florida median
- 3.63 hours/day
- Weekend total
- 3.27 hours/day
- Staff turnover
- 60.2%
- RN turnover
- 57.9%
Reported averages, not a real-time staffing schedule.
Resident outcomes
Lower is generally better
Hospitalizations
1.2 per 1,000 daysbetterFlorida: 2.1 per 1,000 days · County: 1.8 per 1,000 days20250101-20251231
Emergency-department visits
1.4 per 1,000 daysworseFlorida: 1.0 per 1,000 days · County: 1.3 per 1,000 days20250101-20251231
Falls with major injury
3.0%worseFlorida: 2.2% · County: 1.8%2025Q2-2026Q1
Pressure ulcers
2.0%betterFlorida: 4.2% · County: 4.6%2025Q2-2026Q1
Urinary tract infections
0.0%unavailableFlorida: 0.0% · County: 0.0%2025Q2-2026Q1
Antipsychotic medication use
4.4%betterFlorida: 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
What caused the immediate-jeopardy citation from 2025-12-18, and how was it corrected?
Suggested because of: latest immediate jeopardyHow many RNs are typically on site during days, nights, and weekends?
Suggested because of: rn staffingWhat is driving staff turnover, and what is being done to retain nurses and aides?
Suggested because of: staff turnoverWhat fall-prevention program is used, and how are families notified after a fall?
Suggested because of: falls major injuryHow 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
- 145
- Average daily residents
- 132.1
- Ownership
- For profit - Limited Liability company
- Provider type
- Medicare and Medicaid
- In hospital
- No
- Date certified
- 1999-03-30
- CCN
- 106003
Staffing Data
| Reported measure | Value |
|---|---|
| Nurse aide hours | 2.18978 |
| Lpn hours | 0.84126 |
| Rn hours | 0.48553 |
| Reported total hours | 3.51656 |
| Weekend total hours | 3.27155 |
| Weekend rn hours | 0.49783 |
| Adjusted total hours | 3.46296 |
| Total turnover percent | 60.2 |
| Rn turnover percent | 57.9 |
| Administrators left | 1 |
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
7Health citations
5Fire 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.
2
Ensure that residents are free from significant medication errors.
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Ownership & Operators
| Name | Role | Share |
|---|---|---|
| LADY LAKE SNF HOLDCO LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| FL HUD MASTER OPCO HOLDCO LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% |
| OLIVER, TONYA | W-2 MANAGING EMPLOYEE | NOT APPLICABLE |
| ELLENBOGEN, MOSS | CORPORATE OFFICER | NOT APPLICABLE |
Helpful resources
Educational information, not medical or legal advice. Data & methodology