Villages of Lake Highlands

In the surveyor’s words

From the most serious findings on record at Villages of Lake Highlands, in the surveyor’s own words.

• Immediate jeopardy, patternF684Aug 28, 2025

  Based 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. […]

• Immediate jeopardy, patternF695May 16, 2025

  Based 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]. […]

• Immediate jeopardy, isolatedF684Sep 13, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF760Apr 18, 2024

  Based 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. […]

• Actual harm, isolatedF689Oct 24, 2024

  Based 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. […]