Lakeland Health Care Ctr

Penalties

• Nov 21, 2023 — Fine ($84,168)

Inspection findings

1. Jan 26, 2026 Health · 5 findings
   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 13, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0311 Smoke Deficiencies

     Have an enclosure around a vertical opening shaft.

     Corrected Feb 2, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jan 28, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     CMS fire safety

   • Not serious Scope/severity E

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Feb 12, 2026 · CMS fire safety

2. Sep 2, 2025 Health · 2 findings
   • Serious Scope/severity J Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Aug 25, 2025 · CMS health inspection

   • Serious Scope/severity G Complaint

     F0744 Quality of Life and Care Deficiencies

     Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

     Corrected Sep 17, 2025 · CMS health inspection

3. Jul 7, 2025 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jul 29, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jul 29, 2025 · CMS health inspection

4. Aug 29, 2024 Fire Safety · 13 findings
   • Not serious Scope/severity F

     E0035 Emergency Preparedness Deficiencies

     Provide family notifications of emergency plan.

     Corrected Sep 27, 2024 · CMS fire safety

   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Sep 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Sep 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Sep 30, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Sep 30, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Sep 30, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 30, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Sep 20, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Sep 18, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     CMS fire safety

   • Not serious Scope/severity C

     K0354 Smoke Deficiencies

     Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

     Corrected Sep 18, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Sep 20, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Sep 19, 2024 · CMS fire safety

5. Nov 21, 2023 Health · 4 findings
   • Serious Scope/severity K Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Dec 15, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Dec 15, 2023 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Respond appropriately to all alleged violations.

     Corrected Dec 15, 2023 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0744 Quality of Life and Care Deficiencies

     Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

     Corrected Dec 15, 2023 · CMS health inspection

6. Aug 8, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Aug 18, 2023 · CMS health inspection

7. Jun 7, 2023 Fire Safety · 11 findings
   • Not serious Scope/severity F

     E0024 Emergency Preparedness Deficiencies

     Establish policies and procedures for volunteers.

     Corrected Jun 23, 2023 · CMS fire safety

   • Not serious Scope/severity D

     F0686 Quality of Life and Care Deficiencies

     Provide appropriate pressure ulcer care and prevent new ulcers from developing.

     Corrected Jun 26, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jun 26, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0791 Quality of Life and Care Deficiencies

     Provide or obtain dental services for each resident.

     Corrected Jun 26, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 23, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jun 26, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0342 Smoke Deficiencies

     Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

     Corrected Jul 7, 2023 · CMS fire safety

   • Not serious Scope/severity C

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jun 19, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 20, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Jun 19, 2023 · CMS fire safety

   • Not serious Scope/severity D

     K0927 Gas, Vacuum, and Electrical Systems Deficiencies

     Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

     Corrected Jun 23, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• JOHNSON, DENISE — adp of the snf, NOT APPLICABLE, since 02/24/2020
• JOHNSON, DENISE — operational/managerial control, NOT APPLICABLE, since 02/24/2020
• JOHNSON, DENISE — corporate director, NOT APPLICABLE, since 02/24/2020
• MONROE, KENNETH — corporate officer, NOT APPLICABLE, since 01/01/2017
• COUNTY OF WALWORTH — 5% or greater direct ownership interest, 100%, since 07/19/2006
• COUNTY OF WALWORTH — adp of the snf, NOT APPLICABLE, since 12/31/1973