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Complaint Investigation

Five Points At Lake Highlands Nursing And Rehab

May 26, 2026 · 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 May 26, 2026.

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

FF0677
Quality of Life and Care Deficiencies

carry out activities of daily living received the necessary services to maintain nutrition, grooming and

ensure Resident #1 had her fingernails cleaned and trimmed on 05/26/26.

This failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. A record review of Resident #1's annual MDS assessment, dated 02/21/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnosis which included: hypertension (elevated blood pressure), type 2 diabetes mellitus (elevated blood sugar), non-Alzheimer's dementia (brain disorders causing cognitive decline due to factors other than Alzheimer's), and multiple sclerosis (a chronic autoimmune disease of the central nervous system in which the immune system mistakenly attacks myelin).

Resident#1 BIMS score was 7/15, which indicated severe cognitive impairment.

The resident was dependent with ADL's (activity of daily living). A record review of Resident #1's Comprehensive Care Plan, dated 03/04/26, reflected Focus: [Resident#1] has an ADL self-care performance deficit r/t disease process.

Goal: [Resident#1] will maintain current level of function through the review date.

Intervention: personal hygiene: The resident requires assistance by (X1) staff with personal hygiene and oral care. An observation and interview on 05/26/26 at 08:02 AM revealed Resident #1 was up in a wheelchair in the TV area.

Both of Resident #1's hands were severely contracted with supportive devices (Contracted hands sponge pads). Resident #1 had a long fingernail approximately 0.6 centimeter on both hands, with a brown matter underneath the left-hand thumb Resident#1 was asked if she wanted her fingernails trimmed and cleaned, she replied yes. In an observation and interview on 05/26/26 at 10:52 AM revealed CNA A physically assessed Resident #1's fingernails and stated they needed trimming and the left thumb needed to be cleaned due to brown matter underneath. CNA A stated nail care for the residents was performed by CNAs on shower days and it was the responsibility of the nurses and CNAs to ensure the resident's nails kept clean and trimmed to prevent infection, and skin injury through scratching.

CNA A stated the risk to Resident #1 could be infection development, skin integrity, and dignity issues. In an interview on 05/26/26 at 10:55 AM, LVN B stated the CNAs were responsible for nail care on the residents, unless they were diabetic, and the LVNs were responsible for the diabetics.

She stated CNAs, and nurses were supposed to do rounds on the residents daily and checked their nails to make sure they were cleaned and trimmed, to the residents liking.

She stated long dirty nails could pose a risk for infections, or skin tears.

Interview and observation on 05/26/26 at 1:22 PM, the DON stated, she expected resident nail care to be provided during the shower days, and if the resident was diabetic the nurses had to trim the nails.

The DON stated the resident was at risk of infection development and skin break down if she scratched herself.

Record review of the facility's, undated, policy titled, Nursing Policy & Procedure Manual-Nail Care reflected, Nail management is the regular care of the toenails and fingernails to promote cleanliness, and skin integrity of tissues, to prevent infection, and injury from scratching by fingernails . It includes cleansing, trimming, smoothing, and cuticles are and is usually done during the bath.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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.