Villages of Lake Highlands

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The facility failed to ensure that Resident 14's Comprehensive Care Plan included physician orders for Full Code Advanced Status. These failures could place residents at risk of having received inadequate interventions not individualized to their care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings included:Record review of Resident #1's face sheet, dated 09/12/25 reflected, she was a [AGE] year-old female who was admitted [DATE] and diagnosed with but not limited to: Type 2 Diabetes Mellitus (chronic disease characterized by high blood sugar) with diabetic chronic kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings included: Observation on [DATE] at 12:21 PM with LVN Q in the 400-hallway's medication cart revealed vials of insulin and insulin pen without an open date. The insulin lispro 100unit/ml vials were for Residents #23, #13, and #95. The insulin lispro 100units/ml…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #209's face sheet dated 05/16/25 revealed she was a [AGE] year-old female, she was admitted on [DATE]. Admitting diagnoses included, endocarditis, type 2 diabetes, end stage renal failure and hypertension. Review of Resident #209's care plan dated 05/13/25 reflected, the resident had a diabetic ulcer to left heel related to diabetes. Goal, the resident will have no complications related to ulcer. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of Resident #1's face sheet, date 08/19/24, reflected Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had a diagnoses which included Malignant Neoplasm of Right Kidney (cancer of the kidney), Pneumonia (bacterial infection of the lungs), Acute Respiratory Failure with Hypoxia (low oxygen level of body tissue), Severe Protein/Calorie…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of Resident #1's face sheet, date 08/19/24, reflected Resident #1 was a [AGE] year-old male, who admitted to the facility on [DATE]. Resident #1 had a diagnoses which included Malignant Neoplasm of Right Kidney (cancer of the kidney), Pneumonia (bacterial infection of the lungs), Acute Respiratory Failure with Hypoxia (low oxygen level of body tissue), Severe Protein/Calorie Malnutrition, Type 2 Diabetes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of the face sheet for Resident #62 revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. Primary diagnosis of Alzheimer's disease with early onset and secondary diagnosis and Type 1 diabetes mellitus with hyperglycemia (high blood glucose). Review of Resident #62's MDS quarterly assessment, dated 01/09/2024, revealed Resident #62 had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The findings include: During an observation on 01/30/24 from 9:06 AM through 10:35 AM of blood pressure checks, pulse oximeter checks, and medication pass with LVN C revealed the following: * LVN C sanitized hands, walked into Resident #1's room, put on gloves and did not sanitize the blood pressure cuff. LVN C took Resident #1's blood pressure, disposed of gloves and placed the blood pressure machine on top of medication cart. LVN C administered medications and washed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview, and record review, the facility failed to maintain an infection prevention and control program that must include, at a minimum, written standards, policies, and procedures for the program which included standard and transmission-based precautions to be followed to prevent spread of infections for one (LVN A) of seven staff reviewed for infection control. LVN A failed to perform hand hygiene and between glove changes while providing wound care for Resident #1. This failure could affect residents by placing them at risk for the spread of infection. Findings included: An observation on 08/10/23 at 11:42 AM of LVN A performing wound care for Resident #1 with the DON present revealed, LVN A entered the resident's room and placed a wax paper barrier on the resident's bedside table between the table and her wound care supplies. LVN A sanitized her hands with ABHR and donned gloves and removed wound dressings to Resident #1's bilateral feet. Resident #1 had wounds noted to both the right and left 5th toes. LVN A disposed of dressing and her gloves and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.