Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Five Points at Lake Highlands Nursing and Rehab
Dallas, TX · 280 certified beds · Last Life Safety survey March 31, 2026
CMS Certification Number 455895 · first certified October 1990
Ownership
Operated by CREATIVE SOLUTIONS IN HEALTHCARE · For profit - Limited Liability company
- Ownership changed February 1, 2023 (change of ownership)from DIVERSICARE DOCTORS LLC
Position within TX
30 citations — more than 99% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 13 citations; the earlier surveys in the window averaged 8.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens May 2027 — about 7 months from now. This facility’s last Life Safety survey was March 2026. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 30 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
16 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 30 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0926 Have policies on smoking.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 30 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 7, 2023 | 7 |
| December 10, 2024 | 10 |
| March 31, 2026 | 13 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2026-03-31 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2026-03-31 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2026-03-31 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 2 | 2026-03-31 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-12-10 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 2 | 2026-03-31 |
| E-0037 | Establish staff and initial training requirements. | 2 | 2026-03-31 |
| K-0351 | Install an approved automatic sprinkler system. | 2 | 2026-03-31 |
What the citations cover
- Smoke Deficiencies 13
- Egress Deficiencies 6
- Miscellaneous Deficiencies 4
- Emergency Preparedness Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 13 |
| Egress Deficiencies | 6 |
| Miscellaneous Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
March 31, 2026 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0753 | Have restrictions on the use of highly flammable decorations. | Deficient, Provider has date of correction (April 3, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 3, 2026) |
December 10, 2024 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (December 12, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (December 12, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 12, 2024) |
November 7, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 24, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 24, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 24, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 24, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 24, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (November 24, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 24, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.