Nursing home in Dallas, Texas
Five Points at Lake Highlands Nursing and Rehab
Medicare and Medicaid
315 East 19th Street, Dallas, TX 75238
(214) 355-3300
CMS star ratings
CMS gives this nursing home an overall star rating of 1 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home1
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home1
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
- This nursing home1
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home3
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Mar 31, 2026. CMS counts 20 health deficiencies in rating cycle 1.
- This nursing home20
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 53 health deficiencies on 15 inspection dates since Sep 30, 2023. By level of harm: 4 immediate jeopardy, 1 actual harm, 48 potential for harm.
- 4 Immediate jeopardy to resident health or safety
- 1 Actual harm
- 48 No actual harm, potential for more than minimal harm
- 0 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| May 26, 2026 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction May 27, 2026 |
| Mar 31, 2026 | F0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 1, 2026 |
| Mar 31, 2026 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 1, 2026 |
| Mar 31, 2026 | F0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 1, 2026 |
| Mar 31, 2026 | F0809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 1, 2026 |
| Mar 31, 2026 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Apr 1, 2026 |
| Mar 31, 2026 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 1, 2026 |
| Mar 31, 2026 | F0695 | Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 1, 2026 |
| Mar 31, 2026 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 1, 2026 |
| Mar 31, 2026 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 1, 2026 |
Show the other 43 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Mar 31, 2026 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Apr 1, 2026 |
| Dec 11, 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Past Non-Compliance Sep 30, 2025 |
| Dec 11, 2025 | F0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Dec 11, 2025 | F0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Dec 11, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Dec 11, 2025 | F0849 | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.Administration Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Dec 11, 2025 | F0914 | Provide bedrooms that don't allow residents to see each other when privacy is needed.Environmental Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 12, 2025 |
| Nov 6, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Nov 7, 2025 |
| Nov 6, 2025 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Nov 7, 2025 |
| Sep 19, 2025 | F0627 | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.Resident Rights Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction Sep 20, 2025 |
| Jul 8, 2025 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Deficient, Provider has date of correction Jul 9, 2025 |
| Jul 8, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jul 9, 2025 |
| Jul 8, 2025 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jul 9, 2025 |
| May 14, 2025 | F0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.Environmental Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction May 16, 2025 |
| May 14, 2025 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction May 16, 2025 |
| May 14, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction May 16, 2025 |
| May 14, 2025 | F0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction May 16, 2025 |
| Jan 23, 2025 | F0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and Exploitation Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jan 25, 2025 |
| Jan 23, 2025 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jan 25, 2025 |
| Dec 10, 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Dec 12, 2024 |
| Dec 10, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Dec 12, 2024 |
| Dec 10, 2024 | F0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 12, 2024 |
| Dec 10, 2024 | F0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 12, 2024 |
| Dec 10, 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 12, 2024 |
| Dec 10, 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 12, 2024 |
| Dec 10, 2024 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 12, 2024 |
| Dec 10, 2024 | F0761 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Dec 12, 2024 |
| Dec 10, 2024 | F0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and Dietary Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Dec 12, 2024 |
| Dec 6, 2024 | F0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident Rights Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Dec 8, 2024 |
| Dec 6, 2024 | F0583 | Keep residents' personal and medical records private and confidential.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 8, 2024 |
| Dec 6, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Dec 8, 2024 |
| Jun 3, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Past Non-Compliance Jun 2, 2024 |
| May 18, 2024 | F0790 | Provide routine and 24-hour emergency dental care for each resident.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction May 20, 2024 |
| Jan 20, 2024 | F0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident Rights Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jan 22, 2024 |
| Jan 20, 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Jan 22, 2024 |
| Jan 20, 2024 | F0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jan 22, 2024 |
| Jan 20, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jan 22, 2024 |
| Nov 7, 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Nov 24, 2023 |
| Nov 7, 2023 | F0926 | Have policies on smoking.Environmental Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Nov 24, 2023 |
| Nov 7, 2023 | F0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Nov 24, 2023 |
| Nov 7, 2023 | F0759 | Ensure medication error rates are not 5 percent or greater.Pharmacy Service Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Nov 24, 2023 |
| Nov 7, 2023 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Nov 24, 2023 |
| Oct 11, 2023 | F0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and Care Deficiencies | G Actual harm, isolated | Complaint | Deficient, Provider has date of correction Nov 24, 2023 |
Staffing
Total nurse staffing
Reported hours per resident per day.
- This nursing home3.36 hours
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.
- This nursing home0.42 hours
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home64.0%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 5 penalties for this nursing home: 5 fines totaling $58,149, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 280 |
|---|---|
| Average residents per day | 173.8 |
| Ownership | For profit - Limited Liability company |
| Provider type | Medicare and Medicaid |
| Inside a hospital | Yes |
| Continuing care retirement community | No |
| Resident and family council | Both |
| Automatic sprinklers in all required areas | Yes |
| Chain | Creative Solutions in Healthcare (149 facilities) |
| Legal business name | WEST WHARTON COUNTY HOSPITAL DISTRICT |
| First approved for Medicare and Medicaid | Oct 4, 1990 |
| County | Dallas |
| CMS certification number | 455895 |
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| Brentwood Place Three | 120 | For profit - Corporation | ||
| Fair Park Health & Rehabilitation Center | 114 | For profit - Corporation | ||
| South Dallas Nursing & Rehabilitation | 91 | For profit - Limited Liability company | ||
| The Highlands Guest Care Center | 116 | For profit - Limited Liability company |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Baylor University Medical Center | Acute Care Hospitals | Yes | |
| Texas Health Presbyterian Hospital Dallas | Acute Care Hospitals | Yes | |
| UT of Texas Southwestern University Hospital - William P. Clements Jr. | Acute Care Hospitals | Yes | |
| Dallas Medical Center | Acute Care Hospitals | Yes | |
| Medical City Dallas Hospital | Acute Care Hospitals | Yes | |
| Methodist Dallas Medical Center | Acute Care Hospitals | Yes | |
| Parkland Health & Hospital System | Acute Care Hospitals | Yes | |
| Baylor Scott and White Medical Center Uptown | Not available | Acute Care Hospitals | Yes |