Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Highlands Lake Center during CMS and state inspections, most recent first.
Nursing staff did not consistently follow facility policy for handling and documenting controlled substances, leading to inaccurate narcotic audits for three residents receiving pain management. Staff interviews revealed inconsistent practices in receiving, counting, and documenting narcotics, and record reviews showed multiple discrepancies between narcotic control records and MARs. In one case, a narcotic card was missing for several days before being found in a shred box, and in others, medications were signed out without proper documentation of administration.
A resident with a complex medical history did not receive scheduled Oxycontin ER for several days due to lapses in prescription renewal and medication administration. Nursing staff failed to promptly obtain a new order when the supply ran out, and there was no documentation of physician notification or timely refill requests, resulting in multiple missed doses and unmanaged pain.
The facility's grievance program was ineffective, with ongoing issues such as call light response times and staff behavior not being adequately addressed. Despite staff education, complaints persisted, particularly during evening and weekend shifts. The grievance process lacked follow-up and audits, leading to unresolved resident concerns and dissatisfaction.
The facility's grievance program was ineffective, with ongoing issues in acknowledging and resolving resident concerns. Over six months, grievances about call light response times, ADL care, and medication administration were not adequately addressed. Resident Council Minutes showed unresolved issues, and staff interviews revealed gaps in the grievance process, particularly during evening, night, and weekend shifts.
The facility failed to obtain and communicate lab results in a timely manner for two residents. One resident experienced delays in receiving urine analysis results, while another did not have an ordered ultrasound completed for a hematoma. The facility did not adhere to its policy of notifying physicians of changes in residents' conditions, as confirmed by the DON.
The facility failed to obtain timely physician-ordered cultures and complete medical orders for two residents. One resident experienced delays in receiving urine analysis results and treatment, while another had an uncompleted ultrasound order for a hematoma. The DON confirmed the lack of documentation and adherence to procedures, leading to a deficiency in providing adequate care.
A resident reported unsafe therapy equipment, including unsecured parallel bars and a machine missing a handle, in a facility's therapy room. The Physical Therapy Assistant and Rehabilitation Director confirmed these issues, which had persisted for months. The Maintenance Director was aware but had not logged work orders, and the facility lacked a policy for maintaining equipment safety.
A resident with severe cognitive impairment was transferred to the hospital without their family being notified of a fever. The family filed a grievance, but the facility's process was not followed, as the grievance form was incomplete and the family was not informed of the resolution. The DON admitted the grievance was unresolved when the family collected the resident's belongings.
A deficiency was identified in a LTC facility where three residents had unsecured medications at their bedsides without proper assessments for self-administration. One resident with moderate cognitive impairment had a cream on her table, another resident had Acetaminophen and vapor rub without a physician's order, and a third resident had inhalers and a nasal spray. The facility's policy requires medications to be secured unless a self-administration assessment is completed and documented.
Failure to Accurately Audit and Document Narcotic Administration
Penalty
Summary
The facility failed to ensure that its narcotics policy was followed by nursing staff, resulting in inaccurate narcotic audits for three residents who were sampled for pain management. Multiple interviews with nursing staff revealed inconsistent practices regarding the receipt, documentation, and storage of controlled substances. Staff described procedures that did not always align with facility policy, such as not consistently obtaining a second nurse to witness the placement of new narcotic cards in the medication cart and not always updating the narcotic count sheets as required. There were also instances where discontinued narcotic cards remained in the medication cart instead of being promptly removed and processed according to policy. A specific incident involved a resident who was prescribed Hydrocodone-Acetaminophen for pain management. The medication was delivered and signed for by an LPN, but the narcotic card was later found missing. Despite extensive searches by multiple staff members, the card was not located until several days later when it was discovered in a shred box with all tablets missing. Review of the resident's Medication Administration Record (MAR) and the Medication Monitoring Control Record revealed discrepancies, including instances where more tablets were documented as pulled from the narcotic cart than were actually administered to the resident. Similar discrepancies were found in the records of two other residents, where medications were subtracted and signed off in the control records but not documented as administered in the MAR. Interviews with residents indicated that they generally received their pain medications as needed, though one resident reported occasionally refusing medication. However, the record review showed multiple instances where narcotic medications were signed out of the control records without corresponding documentation in the MAR, suggesting a lack of accurate reconciliation and documentation. The facility's own narcotic count sheets and audit records contained missing items, blank spaces, and incomplete tallies, further demonstrating a failure to maintain accurate and complete records as required by policy.
Failure to Administer Scheduled Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident did not receive scheduled pain medication, specifically Oxycontin extended release, as ordered for several days. The resident reported experiencing severe pain and stated that he had not received his pain medication for three days, with one instance where it took over six hours to receive the medication, which he subsequently vomited. Interviews with nursing staff confirmed that the resident missed multiple doses of Oxycontin due to a lapse in obtaining a new prescription when the previous supply ran out. The Medication Administration Record (MAR) corroborated that several scheduled doses were not administered as ordered. The resident had a complex medical history, including metabolic encephalopathy, sepsis, diabetes, chronic heart failure, cellulitis, acute kidney failure, cardiomyopathy, chronic venous hypertension with ulcers, depression, varicose veins, and lymphedema. The resident was cognitively intact and had a care plan in place that included scheduled administration of pain medication to manage chronic pain and minimize interruptions to daily activities. Despite these orders and care plan interventions, the facility failed to ensure the resident received the prescribed Oxycontin for pain management on multiple occasions. Record reviews and staff interviews revealed that the pharmacy dispensed an incomplete supply of Oxycontin, and when the medication ran out, nursing staff did not promptly contact the provider for a new prescription. There was no documentation in the progress notes indicating that the physician was notified about the missed doses or that a refill was requested in a timely manner. The facility's medication administration policy required medications to be administered as ordered and for medication errors to be documented and reported, but these procedures were not followed in this instance.
Ineffective Grievance Program and Unresolved Resident Concerns
Penalty
Summary
The facility failed to implement an effective grievance program, as evidenced by ongoing issues with call light response times and other resident concerns that were not adequately addressed. Over a six-month period, the grievance logs revealed repeated complaints about call light response times, with no clear resolution or improvement. Despite staff education efforts, the problem persisted, particularly during evening and weekend shifts, as noted by resident council members and confirmed by interviews with staff. Additionally, the grievance logs and resident council minutes highlighted other unresolved issues, such as staff behavior, customer service in the dining room, and delays in returning clean clothes. These grievances were marked as resolved with staff education, but the recurring nature of the complaints suggests that the underlying issues were not effectively addressed. The resident council minutes often indicated that old business was reviewed and accepted, but without confirmation that the issues were fully resolved, leading to continued dissatisfaction among residents. Interviews with the Activities Director and Social Service Director revealed gaps in the grievance process, including a lack of follow-up on grievances and insufficient audits during evening, night, and weekend shifts. The facility's grievance policy required prompt resolution of grievances, but the ongoing nature of the complaints and the lack of effective corrective actions indicate a failure to adhere to these guidelines. This deficiency in the grievance process resulted in unresolved resident concerns and a lack of confidence in the facility's ability to address and resolve issues effectively.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was discharged on. On, the NHA/Designee immediately re-educated the Activity Director on the components of F585 with an emphasis on ensuring the Resident Council forms are completed with accuracy and grievances from Resident Council are acknowledged, documented, and resolved. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. On, NHA/Designee completed a quality review on grievances from Resident Council for the past six months () to ensure voiced concerns were acknowledged, documented, and resolved. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. On, Vice President of Operations re-educated the management staff on the components of F585 with an emphasis on ensuring grievances from Resident Council are acknowledged, documented, and resolved. Newly hired management staff will be educated by the NHA or designee on ensuring grievances from Resident Council are acknowledged, documented, and resolved. On, Resident Council meeting will increase in frequency from biweekly to weekly to ensure grievances from Resident Council are acknowledged, documented, and resolved. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. Administrator/Designee to conduct audits weekly for 4 weeks, biweekly for 4 weeks, then monthly for 1 month to ensure the Resident Council forms are completed with accuracy and grievances from Resident Council are acknowledged, documented, and resolved. The findings of these quality monitoring reports are to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Ineffective Grievance Program and Unresolved Resident Concerns
Penalty
Summary
The facility failed to implement an effective grievance program, as evidenced by ongoing issues with acknowledging, documenting, and resolving resident concerns. Over a six-month period, the grievance logs revealed persistent issues with call light response times, which were not adequately addressed. Additionally, there were grievances related to Activities of Daily Living (ADL) care not being provided, medications being left at the bedside, and medications not being administered in a timely manner. Despite staff education efforts, these issues continued to be a concern for residents. The Resident Council Minutes consistently showed unresolved grievances, with recurring complaints about call light response times, staff behavior, and dining services. The minutes also indicated that old business items were not always resolved, as evidenced by unchecked boxes meant to confirm resolution. Residents expressed dissatisfaction with various aspects of care, including the timeliness of laundry services, the availability of snacks, and the responsiveness of staff to their needs. Interviews with facility staff, including the Activities Director and Social Service Director, revealed that the grievance process was not effectively addressing resident concerns. The Social Service Director explained the grievance process, but the facility's performance improvement plan did not include audits for evening, night, and weekend shifts, which were times when grievances were notably unresolved. This lack of comprehensive auditing contributed to the ongoing issues with the grievance program.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was discharged on On , the NHA/Designee provided immediately re-educated to the Activity Director on the components of N042 with an emphasis on ensuring the Resident Council forms are completed with accuracy and grievances from Resident Council are acknowledged, documented, and resolved. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken. On , NHA/Designee completed a quality review on grievances from Resident Council for the past six months ( ) to ensure voiced concerns were acknowledged, documented, and resolved. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur. On , Vice President of Operations re-educated the management staff on the components of N042 with an emphasis on ensuring grievances from Resident Council are acknowledged, documented, and resolved. Newly hired management staff will be educated by the NHA or designee on ensuring grievances from Resident Council are acknowledged, documented, and resolved. On , Resident Council meeting will increase in frequency from biweekly to weekly to ensure grievances from Resident Council are acknowledged, documented, and resolved. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place. Administrator/Designee to conduct audits weekly for 4 weeks, biweekly for 4 weeks, then monthly for 1 month to ensure the Resident Council forms are completed with accuracy and grievances from Resident Council are acknowledged, documented, and resolved. The findings of these quality monitoring reports are to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.
Failure to Timely Obtain and Communicate Lab Results
Penalty
Summary
The facility failed to obtain physician-ordered cultures in a timely manner for two residents, leading to a deficiency in laboratory services. For the first resident, there was a delay in obtaining and processing a urine analysis (UA) sample, which was ordered due to the resident experiencing increased episodes of discomfort. The UA results were not promptly communicated to the medical nurse practitioner, and there was confusion regarding the completion of a culture and sensitivity test. The resident expressed concern about the delay in receiving results, and the medical nurse practitioner had to follow up to ensure the necessary tests were conducted. For the second resident, there was a failure to complete an ordered ultrasound (US) for a large hematoma observed by the rehabilitation nurse practitioner. The resident, who was unable to turn herself and experienced severe discomfort, did not have the US order documented or completed as expected. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of the order and the lack of notification to the physician regarding the resident's condition. The facility's policy and procedures require timely notification of changes in a resident's condition to the attending physician and the resident's representative. However, in these cases, the facility did not adhere to its own standards, resulting in a lack of timely communication and follow-up on critical medical orders. The Director of Nursing confirmed the expectation for orders to be followed and for physicians to be notified of laboratory results, which was not met in these instances.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was discharged on Resident #4 was discharged on On Regional Nurse Consultant re-educated the Director of Nursing on the components of F773 with an emphasis on ensuring physician-ordered cultures are obtained in a timely manner. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On , DON/Designee completed a quality review of current residents on ensuring physician-ordered cultures are obtained in a timely manner. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; By , DON/Designee provided education to the licensed nurses on the components of F773 with an emphasis on ensuring physician-ordered cultures are obtained in a timely manner. Newly hired licensed nurses will be educated by Director of Nurses/Designee on ensuring physician-ordered cultures are obtained in a timely manner. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Director of Nursing/Designee to conduct audits of 5 residents 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure physician-ordered cultures are obtained in a timely manner. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly until committee determines substantial compliance has been met.
Failure to Obtain Timely Cultures and Complete Medical Orders
Penalty
Summary
The facility failed to obtain physician-ordered cultures in a timely manner for two residents, leading to a deficiency in providing adequate and appropriate health care. Resident #1, admitted for short-term rehabilitation, had a physician order for a urine analysis (UA) and culture due to increased episodes of discomfort. However, there was a delay in obtaining the culture, and the results were not promptly communicated to the provider. The resident expressed concern about the delay in receiving results, and the medical nurse practitioner had to be notified to order medication for treatment. Resident #4, also admitted for short-term rehabilitation, had a large hematoma and required an ultrasound (US) as noted by the rehabilitation nurse practitioner. However, the order for the ultrasound was not completed, and there was no documentation of the order in the resident's summary report. During an interview, the rehabilitation nurse practitioner confirmed that if an order was documented, it should have been completed, indicating a lapse in following through with the necessary medical orders. The Director of Nursing (DON) confirmed the absence of information regarding the sample results for Resident #1 and acknowledged the expectation for orders to be followed and for the physician to be notified of results. The failure to obtain timely cultures and complete medical orders for these residents highlights a deficiency in the facility's adherence to established procedures and guidelines for resident care.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #1 was discharged on Resident #4 was discharged on On , Regional Nurse Consultant re-educated the Director of Nursing on the components of N201 with an emphasis on ensuring physician-ordered cultures are obtained in a timely manner. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On DON/Designee completed a quality review of current residents on ensuring physician-ordered cultures are obtained in a timely manner. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur, By , DON/Designee provided education to the licensed nurses on the components of N201 with an emphasis on ensuring physician-ordered cultures are obtained in a timely manner. Newly hired licensed nurses will be educated by Director of Nurses/Designee on ensuring physician-ordered cultures are obtained in a timely manner. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: The Director of Nursing/Designee to conduct audits of 5 residents 2x a week for 4 weeks, then 1x a week for 4 weeks and then monthly for 1 month to ensure physician-ordered cultures are obtained in a timely manner. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance improvement Committee monthly until committee determines substantial compliance has been met.
Therapy Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to maintain therapy gym equipment in a safe and operative manner, as observed in one therapy room. A resident receiving physical therapy reported that the parallel bars used for standing and walking were not secure, with one side moving due to a stripped screw. The resident requested to use the side of the bars that was not affected to avoid falling. Additionally, a machine in the therapy room was missing a handle, which the resident observed being used by others. A Physical Therapy Assistant confirmed the issues, stating that the parallel bars had been broken for a couple of months and the nu-step machine had a missing handle for many months. The Rehabilitation Director acknowledged the issues with the parallel bars and the nu-step machine, noting that the Maintenance Director had previously attempted to fix the bars but the problem persisted. The Maintenance Director admitted to knowing about the issues but had not logged any work orders for the repairs. He mentioned that the staff would verbally report issues rather than using the work order tracking system. The Nursing Home Administrator confirmed the expectation for therapy staff to remove broken equipment from service and submit work orders until repairs were completed. However, there was no policy in place for maintaining equipment in a safe and working order.
Failure to Follow Grievance Process for Resident Notification
Penalty
Summary
The facility failed to adhere to its grievance process for a resident who was admitted with multiple medical conditions, including Parkinson's disease and severe cognitive impairment. The resident's family member was not informed when the resident developed a fever and was shaking, leading to a hospital transfer. The family member filed a grievance regarding the lack of notification, but the grievance form was incomplete, lacking details such as the date of occurrence, the person who completed the form, and the investigator. Additionally, the Nursing Home Administrator's signature on the form was illegible and undated. The Director of Nursing acknowledged the grievance but admitted that the family member had not been contacted about the resolution. The facility's grievance policy requires prompt efforts to resolve grievances, including notifying the resident or their representative of the findings and corrective actions within ten working days. However, this process was not followed, as the grievance was still unresolved when the family member came to collect the resident's belongings.
Medication Security Deficiency in LTC Facility
Penalty
Summary
The facility failed to ensure medications were secured for three residents, leading to a deficiency in medication management. Resident #6, who was admitted with multiple medical diagnoses including pulmonary embolism and type 2 diabetes, was observed with a tube of Triamcinolone Acetonide cream on her bedside table. The medication was not secured, and there was no assessment for self-administration, despite the resident having moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. Resident #7, with diagnoses such as cellulitis and muscle wasting, was found with a bottle of Acetaminophen and vapor rub on her bedside table. The resident, who had no cognitive impairments, stated she took the medication at night to help her sleep. However, there was no physician order for the vapor rub, and the resident's medical record did not show an assessment for self-administration of Acetaminophen. Additionally, the medication administration record indicated that the ordered Acetaminophen was not consistently administered. Resident #8, diagnosed with COPD and asthma, was observed with three medications, including inhalers and a nasal spray, on her bedside table. The resident, who had no cognitive impairments, stated she self-administered these medications. However, there was no documentation of a self-administration assessment for these medications in her medical record. The Director of Nursing confirmed that medications should not be at the bedside unless the resident is assessed for self-administration and has a physician's order permitting it.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lakeland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Scott Lake Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 8 | 3 |
| Bridgewalk On Harden Health And Rehabilitation, Ll | 3.2 mi | ★★★★★ | 0 | 0 |
| Florida Presbyterian Homes Inc | 3.8 mi | ★★★★★ | 0 | 0 |
| Charming Lakes Rehab | 5.8 mi | ★★★★★ | 11 | 0 |
| Lakeland Hills Center | 5.9 mi | ★★★★★ | 17 | 0 |
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