Villages of Lake Highlands

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #14) out of 5 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure that Resident #14's Comprehensive Care Plan included the following:1. The facility failed to ensure that Resident #14's Comprehensive Care Plan included physician orders for hip precautions.2. The facility failed to ensure that Resident #14's Comprehensive Care Plan included physician orders for her toe-touch weight bearing status.3. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 20 residents reviewed for quality of care. The facility failed to provide Resident #1 with diabetic treatments on 09/10/25 which included checking blood sugars and administering insulin. The non-compliance was identified as past non-compliance (PNC). The IJ began on 09/10/25 and ended on 09/12/25 and the facility had corrected the non-compliance before the state's investigation began. This failure could place residents' health and safety at risk.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #1) of 5 residents reviewed for administration. The facility failed to ensure Resident #1 had accurate TAR documentation in the EHR on 09/10/25 for Resident #1's blood sugar checks, Humalog Kwik pen injection, and insulin lispro 100 unit/ml injection by LVN A . The non-compliance was identified as past non-compliance (PNC). The PNC began on 09/10/25 and ended on 09/12/25 and the facility had corrected the non-compliance before the state's investigation began. This failure could place residents at risk of not receiving the proper care or treatment and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices when they failed to ensure physician orders were communicated and carried out in a timely manner for 1 of 4 residents reviewed (Resident #1). The facility failed to check Resident #1's blood sugar twice a day per physician orders from 08/06/25 to 08/13/25. On 08/13/25 Resident #1 had a FSBS of 34 resulting in her being sent to the hospital for emergency interventionAn IJ was identified on 08/27/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 Residents (Residents #99) reviewed for respiratory care. The facility failed to promptly notify emergency services when Resident #99 developed respiratory distress following incontinence care on [DATE] at 2:00 PM. The resident's oxygen saturation was 66% and he was on 5 liters of oxygen via nasal cannula. The resident remained in respiratory distress until emergency medical services arrived at 2:45 PM on [DATE] and transferred him to the hospital. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 11:00 AM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the facility's two (400 and 500 halls) of four medication cart reviewed for storage. The facility failed to ensure Residents #23, #13, #68's insulin lispro vials, Resident #95's insulin lispro pen, Resident #103's glargibe-yfgn insulin vial and Resident #68 Tresiba flex touch insulin were dated when opened. This failure could affect residents and staff resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #209) reviewed for infection control. LVN R failed to wear the appropriate PPE while assessing Resident #209's wound. This failure could place residents at risk of being infected by staff in contact with other residents with infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of four residents (Resident #1) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 was transferred from her bed to her wheelchair utilizing a Hoyer lift (mechanical lift) with two staff members present as indicated on her care plan. 2. The facility failed to ensure CNA A transferred Resident #1 using a hoyer lift, bruising Resident #1's right arm and left wrist and a skin tear to her left knee. The noncompliance was identified as PNC. The noncompliance began on 07/02/24 and ended on 07/02/224. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for neglect, harm, pain, and injuries .

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents, (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected the resident's primary diagnosis of cancer. This failure could place the residents at risk of not receiving adequate care.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident was free of any significant medication errors for one (Resident #1) of five residents reviewed in that: The facility failed to ensure Admitting Nurse E added Resident #1's medication order correctly for Cabozantinib, a medication for cancer, to the electronic record. As a result, the facility did not administer the correct amount of Cabozantinib to Resident #1 from 07/11/24-07/13/24. These failures could place residents at risk of not receiving their medications as ordered or possible illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents were free of any significant medication errors for 1 (Resident #389) of 8 residents reviewed for pharmacy services. The facility failed to prevent LVN A from injecting an unknown amount of Kenalog (a steroid for pain relief) and lidocaine (numbing medicine) medication into Resident #389's arm despite an order to hold the medications on the medication cart for the physician to administer into the resident's knees. The non-compliance was identified as past non-compliance. The Immediate Jeopardy (IJ) began 02/01/24 and ended on 02/02/24. The facility corrected the non-compliance before the survey began. This failure placed residents at risk for harm and/or serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (Residents #71 and #62) of 12 residents reviewed for dignity. The facility failed to ensure Residents #71 and #62 had the right to a dignified existence when staff stood over the resident while feeding the resident. This failure could affect the residents by placing them at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 5 residents (Residents #1, #2, #3 and #4,) reviewed for infection. 1. LVN C failed to clean the blood pressure cuff between Residents #1, #2, #3 and #4. 2. LVN C failed to clean the pulse oximeter between Residents #3 and #4. These failures could place residents at risk of cross contamination and exposure to infectious diseases.