Health inspection·August 28, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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. While the IJ was removed on 08/28/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal.This failure could place residents at risk of experiencing a medical emergency and transfer to the hospital for treatment.Findings included:Record review of Resident #1's quarterly MDS, dated [DATE], revealed a [AGE] year-old female who admitted on [DATE]. Her cognitive skills for decision making were that she sometimes understood and sometimes was able to make her needs understood, she had no BIMS score documented. Her diagnoses included mechanical complication of surgically created arteriovenous fistula(complications that can cause issues such as poor fistula function, limb swelling(edema) or heart failure due to increased workload of the heart), methicillin-susceptible Staphylococcus aureus (a bacterial infection caused by Staphylococcus aureus bacteria), dependency on renal dialysis (a life-sustaining treatment that filters waste and excess fluid from the blood when the kidneys can no longer do), heart failure (a condition where the heart cannot pump blood effectively enough to meet the body's needs), renal insufficiency (a condition where the kidneys do not function properly, leading to a decreased ability to filter waste products from the blood and maintain fluid balance), diabetes mellitus (a chronic metabolic disease characterized by persistently high blood sugar (glucose) levels), and cerebrovascular accident (a medical condition that occurs when blood flow to the brain is interrupted, causing brain tissue damage). Record review of Resident #1's care plan, initiated 08/13/2025, reflected the following: Focus: Risk for Infection. Intervention: Administer antibiotic therapy as prescribed, Educate Resident/Representative on infection control practices. Record review of Resident #1's physician orders for August 2025 reflected the following: Please check fingerstick BID. Verbal . Active .Order date of 08/06/25 and no start date.Record review of Resident #1's physician orders for August 2025 reflected the following: ceFAZolin Sodium(antibiotic primarily used to treat bacterial infection used before, during or after surgery) Injection Solution Reconstituted 1GM (Cefazolin Sodium) Use 1 gram intravenously in the morning every Mon, Tue, Wed, Thu for bacteremia until 09/12/2025 23:59 Administered via HDVerbal Active 08/08/2025 08/11/2025 with stop date 09/12/2025. ceFAZolin Sodium Injection Solution Reconstituted 1GM (Cefazolin Sodium) Use 2 gram intravenously one time a day every Fri for Infection Administered via HD Verbal Active 08/08/2025 08/15/2025. Record Residents Affected - Some Page 1 of 5 676268 676268 08/28/2025 Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some review of Resident# 1's MAR dated 08/26/2025 reflected Insulin Degludec FlexTouch Subcutaneous Solution Pen injector 200 UNIT/ML (Insulin Degludec) Inject 20 unit subcutaneously (under the skin) one time a day for DM -Start Date- 08/06/2025 0800.The only FSBS documented was with insulin administration. The was no order noted on the MAR for FSBS BID. Record review of Resident #1's Progress Notes, written by LVN A, reflected the following:08/13/25 at 7:10AM - The Resident was noted to be unresponsive to verbal stimuli. Resident opened her eyes to physical stimuli but was unable to respond to verbal questions. Resident could normally interact fully with staff at baseline. B/P 138/64, pulse 82, O2 at 95 on 2L via nasal cannula with crackles noted on exhalation FSBS noted to be 34 (considered dangerously low) administered fast acting carbohydrate orally, blood sugar remained low. Resident was noted to have redness to bilateral feet and hands. 911 emergency call and resident was transported to [Name] hospital for a further evaluation. I spoke with [NAME](daughter) via phone to inform her regarding this situation. During a telephone interview on 08/26/2025 at 10:10 AM, Resident #1's FM revealed that Resident#1 was admitted [DATE] to the facility because she needed to be on antibiotics for an infection in her dialysis shunt. The FM stated that the facility called her the morning of 08/13/2025 and told her Resident #1 was found unresponsive, her blood sugar was low and was transferred to [Name] a hospital in Dallas. She stated after the hospital stay, Resdient#1 did not return to the facility but was transferred home on hospice. She stated Resident #1 had a diagnosis of Diabetes Mellitus with end renal stage disease, yet the facility did not check Resident #1's blood sugar for more than twelve hours. She stated she was told the doctor had orders for Resident#1 to be check every 12 hours. During a telephone interview on 08/26/25 at 12:31 PM, the MD C revealed an order was given on 08/06/25 to check blood sugar twice a day. She stated that on 8/13/2025 the DON notified her the order to check blood sugar twice a day was not followed because the order was entered under other category; therefore, it did not flag in the system to alert the nurses there was a new order. MD C stated the DON had corrected the issue in the EMR system. MD C stated she had given orders to the facility that any resident admitted with diagnosis of diabetes must have FSBS BID for the first week. MD C stated that risk to the resident if the EMR failed to communicate physician orders to the nurses to follow orders to check FSBS BID was the resident could suffer from hyperglycemia (high blood sugar) and/or hypoglycemia(low blood sugar), which could be serious, and lead to hospitalization of the resident. During a telephone interview on 08/27/2025 at 12:26 PM, with RN B, revealed he worked a double shift on 08/12/2025. He stated that he checked the resident's blood sugar at bedtime as a precaution because he had given Resident#1 insulin in the morning. RN B stated that he did not know there was an order for blood sugar checks twice a day. RN B stated he did a late entry remotely to document that he had checked the Resident #1's blood sugar, but it did not reflect on EMR. 8/26/25 at 12:38 PM Phone interview with LVN A revealed that on 08/13/2025 he observed Resident #1 was not responding to verbal stimuli. He checked Resident #1's blood sugar and vital signs. Resident #1's blood sugar was 34. He followed the hypoglycemic oral protocol (oral glucose paste rubbed onto the buccal mucosa (inner lining of the cheek) called the doctor and sent the resident to the emergency room. 08/26/2025 at 1:18PM Interview with DON revealed that Resident#1 admitted with complex medical issues. The DON stated Resident#1 was on hemodialysis for follow up care and an antibiotic for infection in her dialysis shunt. She stated Resident#1 started having redness to her lower extremities and her hands, MD C talked to the FM, and we were to send Resident #1 to the ER. The DON stated the ER said it was vascular, not an allergic reaction to the antibiotic. The DON stated that on 08/13/2025 Resident#1 had a change in condition, a drop in blood sugar, and was sent to the hospital. She stated Resident #1's FM was upset that Resident #1's blood sugar was low. The DON stated that Resident#1's 676268 Page 2 of 5 676268 08/28/2025 Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some blood sugar was checked the night before on 08/12/2025 by RN B. 08/26/2025 at 2:50PM Phone interview with RN M revealed he worked at night and Resident#1 did not have an order to check FSBS at night. RN M stated all residents with diagnosis of diabetes got a bedtime snack. He stated the nurses' entered orders on the EMR. RN M stated the risk to the patient when the EMR fails to communicate with the nurse to check blood sugar on a resident that was diabetic could have serious complications, including hospitalization. 08/26/25 at 4:43 PM Interview with DON revealed that on 08/13/2025 she noted there was an order entered on 08/06/2025 by the physician to check Resident #1's blood sugar twice a day but the system did not alert the nurses to confirm the order and that was the reason the order was not added to the MAR and not followed by the nurses. 08/26/25 at 4:43 PM interview with CNO revealed that the physician, MD D, entered the order, incorrectly, so the EMR did not alert for the nurse to confirm so it could go on the MAR. She stated the DON had educated the physicians and changed the physicians EMR access so physicians cannot enter the orders. She stated the risk to the patient was a missed high or low blood sugar. An interview on 08/27/2025 at 1:56 PM, MD D revealed Resident #1 had a lot of comorbidities. She stated that blood glucose levels were based on resident's oral intake so even if the nurses checked Resident #1's blood sugar and her oral intake was poor it would not have made a difference. She stated that with aging and with Resident #1 having had a serious infection that could alter blood sugar levels. Review of facility policy titled Medication and Treatment Orders dated 07/2016, and reviewed on 8/27/25 with no identified changes required, reflected, Verbal Orders must be recorded immediately in the residents' chart by the person receiving the order . Record review of the facility's policy titled Diabetes - Clinical Protocol revised November 2022, reflected:As indicated the Physician will order appropriate lab test (for example periodic finger sticks or A1C) and adjust treatments based on these results and other parameter, such as glycosuria, weight gain, or loss hypoglycemia episode, etc.The Physician will order desired parameters for monitoring and reporting information related to blood sugar management.a. The staff will incorporate such parameters into the Medication Administration Record and care plan .5. The staff will identify and report issues that may affect, or be affected by, a patient's diabetes and diabetes management such as foot infections, skin ulceration, increased thirst, or hypoglycemia.a. For example, urgent notification may be indicated if the individual has not eaten well or consumed sufficient fluids for 2 or more days and has fever, hypotension, lethargy, or confusion.b. The Physician will help the staff clarify and respond to these episodes.6. The staff and Physician will manage hypoglycemia appropriately.a. It is important to avoid excessive diabetes management that leads to recurrent episodes of hypoglycemia. For example, a realistic target for AIC in frail older individuals is between approximately 7 and 8, while A1C consistently under 7 is unlikely to provide significant additional benefits but may expose the individual to recurrent hypoglycemia.b. It is important to avoid over-treatment of hypoglycemia, which can result in rebound hyperglycemia and hamper subsequent glucose control.(1) For example, a borderline low blood sugar in the absence of signs and symptoms may not need any acute intervention and may or may not suggest the need to modify oral hypoglycemia medications or insulin.(2) An example of appropriate treatment of hypoglycemia for a responsive individual would be 15 g to20 g of carbohydrate in the form of glucose, sucrose tablets, or juice, combined with a sandwich, crackers, or other light snack containing protein.(3) For someone who is lethargic but not comatose, treatment might include oral glucose paste rubbed onto the buccal mucosa, intramuscular glucagon, or intravenous 50% dextrose. This was determined to be an Immediate Jeopardy (IJ) on 08/27/2025 at 4:43PM. The Administrator, CNO and DON were notified on 08/27/2025 at 5:00PM. The Administrator was provided with the IJ template on 08/27/2025 at 5:13PM. The following Plan of Removal submitted by the 676268 Page 3 of 5 676268 08/28/2025 Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some facility was accepted on 08/28/25 at 10:13AM. The facility POR for Immediate Jeopardy reflected the following: 1.All current physician orders for all residents were immediately reviewed by DON and Unit Managers on 8/27/25 to ensure accuracy and that orders populate correctly to the MAR/TAR. Any orders entered in the Other category were corrected and properly linked to the MAR/TAR.2.CNO educated DON on proper procedure for receiving, documenting, and verifying physician orders, including recording verbal/telephone orders immediately; ensuring orders are entered under the correct category; verifying that orders populate to the MAR/TAR; and immediate notification to DON/charge nurse if an order does not appear on the MAR. Completed 08/27/25.3.DON/Designee began education to all licensed nurses on 8/27/25 and were immediately in-serviced on the proper procedure for receiving, documenting, and verifying physician orders, including: recording verbal/telephone orders immediately; ensuring orders are entered under the correct category; verifying that orders populate to the MAR/TAR; and immediate notification to DON/charge nurse if an order does not appear on the MAR. Nursing staff unavailable for education will not be allowed to work until in servicing is completed. Education is in progress for all nursing staff and will be required to be completed prior to working their next scheduled shift.4.The EHR system order entry process was corrected to ensure all physician orders trigger a flag for nurse confirmation and MAR placement. The Director of Nursing /designee verified on 8/27/25 that all pending and new orders populate correctly.5.Facility policy Medication and Treatment Orders was reviewed on 8/27/25 and no identified changes required.6.All licensed nurses and providers will be re-educated by DON/Designee on revised order-entry procedures, verification steps, and accountability for ensuring orders are implemented. Physicians and NP/PA staff were notified of updated procedures to ensure clarity of documentation.7.DON/Unit Managers will perform 100% audits of all new physician orders daily for 14 days, then 5x weekly for 30 days, and then weekly for 60 days to verify correct entry and MAR/TAR population. Any discrepancies will be corrected immediately, and staff responsible will receive re-education.8.DON/designee will review all new orders during daily clinical meetings to ensure timely communication and implementation. A monthly QA review will include order-entry accuracy, with findings reported to QAPI committee for ongoing oversight.9.DON/Designee educated Providers their security role in PCC was changed so Providers are no longer able to activate orders within the EMR system. Any order entered by an MD would trigger the nurse to activate. Education for Providers reviewing that they no longer have permissions to enter any orders into PCC was completed by 08/27/25. Monitoring of the facility's Plan of Removal included the following:Interviews with the following staff from 08/28/25 at 10:33 AM to 3:04 PM who worked all shifts and all days of the week revealed they had been in-serviced on the proper procedure for receiving, documenting, and verifying physician orders, including: recording verbal/telephone orders immediately; ensuring orders are entered under the correct category; verifying that orders populate to the MAR/TAR; and immediate notification to DON if an order does not appear on the MAR. LVN A, RN B, LVN F, LVN H, RN I, RN J, RN K.Record review of Emergency QAPI Agenda titled order entry and documentation, dated 08/27/25, reflected Medical Director, Administrator, CNO and DON were in attendance.Record review of in-service sign in sheets, dated 08/27/25, and titled Order Entry Education reflected the DON had signed.Record review of in-service sign in sheets, dated 08/27/25, and titled Order Entry Monitoring Process reflected 26 staff including nurse managers had been in-serviced.Record review of Physician order Confirmation in-service dated 08/14/25 revised on 08/28/2025, reflected 20 staff had been in-serviced.Record review of Chart/New order audit report dated 8/27/2025. 08/28/2025 Interview with CNO and DON reflected that all practitioners have been educated that they no longer have the privilege to confirm orders on PCC. Interview 8/28/2025 11:10am with MD E revealed that he was notified of the Immediate 676268 Page 4 of 5 676268 08/28/2025 Villages of Lake Highlands 8615 Lullwater Dr Dallas, TX 75238

F 0684 Level of Harm - Immediate jeopardy to resident health or safety Jeopardy, and he approved of the plan of removal. He stated that now the physicians had been in serviced that doctors cannot confirm orders and only the nurses will confirm all new orders, and he agreed with the POR. An IJ was identified on 08/27/25 at 4:43PM. The IJ template was provided to the facility on [DATE] at 5:13 PM. While the IJ was removed on 08/28/25, the facility remained out of compliance at a scope of pattern and a severity level of potential for more than minimal harm, because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. Residents Affected - Some 676268 Page 5 of 5