Skip to main content
Complaint Investigation

Five Points At Lake Highlands Nursing And Rehab

September 19, 2025 · Dallas, TX · 315 East 19th Street
Citations 1
CMS Rating 1/5
Beds 280
Provider ID 455895
Healthcare Facility
Five Points At Lake Highlands Nursing And Rehab
Dallas, TX  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Five Points at Lake Highlands Nursing and Rehab in Dallas, TX — inspection on September 19, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0627
Resident Rights Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

K (overnight), LVN L (second shift), LVN M (double weekends) and SW N, SW O indicated they all participated in in-services on resident rights, discharge process and documentation and proficiency test prior to starting their shifts.

All staff knew their responsibilities.

All staff were knowledgeable, who were a part of the IDT.

All staff were able to state that the facility's discharge process to ensure all residents' discharges were safe, all know what was required to be documented and who was responsible for each task and understand that the Administrator would oversee the entire process to make sure it was complete, and he would report any immediate discharges to the ADO.

The Administrator was informed that the Immediate Jeopardy was removed on 9/18/2025 at 3:11 p.m.

The facility remained out of compliance at a severity level of that was not Immediate Jeopardy and a scope of isolated, due to staff needing more time to monitor the effectiveness of the plan of removal for inappropriate discharge.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Dallas, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Five Points at Lake Highlands Nursing and Rehab or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.