Data from CMS, updated September 1, 2026. How we rate · Report a correction
CMS file
CCN 455895
Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.
Adjusted total nurse hours: 3.14. Adjusted RN hours: 0.39. Case-mix total: 4.10. Case-mix index: 1.498.
Total nursing staff turnover: 64.0%. RN turnover: 64.3%. Administrators who left: 2.
Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
CMS reports 5 fines totaling $58,149, and 0 payment denials.
| Date | Type | Amount or days |
|---|---|---|
| December 11, 2025 | Fine | $16,149 |
| September 19, 2025 | Fine | $10,361 |
| July 8, 2025 | Fine | $15,143 |
| May 18, 2024 | Fine | $8,985 |
| October 11, 2023 | Fine | $7,511 |
Cycle 1 standard survey: March 31, 2026. Health deficiencies counted in cycle 1: 20. Cycle 1 total health score: 162.
Cycle 2 standard survey: December 10, 2024. Cycle 2/3 health deficiencies: 26. Total weighted health survey score: 182.25.
Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
The Health Deficiencies file lists 53 citations for this home, including 4 at immediate jeopardy and 1 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 27, 2026 |
10 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F657 | 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 · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 1, 2026 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 1, 2026 |
| F804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 1, 2026 |
| F809 | 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 · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 1, 2026 |
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 1, 2026 |
| F656 | 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 · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 1, 2026 |
| F695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 1, 2026 |
| F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 1, 2026 |
| F761 | 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 · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 1, 2026 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · April 1, 2026 |
6 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Past Non-Compliance · September 30, 2025 |
| F580 | 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 · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2025 |
| F584 | 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 · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2025 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2025 |
| F849 | 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 · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2025 |
| F914 | Provide bedrooms that don't allow residents to see each other when privacy is needed. Environmental Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2025 |
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 7, 2025 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 7, 2025 |
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F627 | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. Resident Rights Deficiencies · Complaint survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · September 20, 2025 |
3 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | J: isolated, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · July 9, 2025 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 9, 2025 |
| F761 | 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 · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · July 9, 2025 |
4 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Complaint survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 16, 2025 |
| F656 | 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 · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 16, 2025 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 16, 2025 |
| F678 | 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 · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 16, 2025 |
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Complaint survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 25, 2025 |
| F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Complaint survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 25, 2025 |
9 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2024 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Standard survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2024 |
| F584 | 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 · Complaint survey · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2024 |
| F645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · Complaint survey · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2024 |
| F656 | 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 · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2024 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2024 |
| F690 | 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 · Complaint survey · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2024 |
| F761 | 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 · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2024 |
| F805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · Complaint survey · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 12, 2024 |
3 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F584 | 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 · Complaint survey · Cycle 2 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 8, 2024 |
| F583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 8, 2024 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · December 8, 2024 |
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | J: isolated, immediate jeopardy to resident health or safety | Past Non-Compliance · June 2, 2024 |
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F790 | Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 20, 2024 |
4 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F584 | 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 · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 22, 2024 |
| F677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 22, 2024 |
| F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 22, 2024 |
| F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · January 22, 2024 |
5 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 24, 2023 |
| F926 | Have policies on smoking. Environmental Deficiencies · Standard survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 24, 2023 |
| F693 | 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 · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 24, 2023 |
| F759 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 24, 2023 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 24, 2023 |
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|---|---|---|
| F686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3 | G: isolated, actual harm that is not immediate jeopardy | Deficient, Provider has date of correction · November 24, 2023 |
Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Five Points at Lake Highlands Nursing and Rehab has an overall rating of 1 out of 5. The health inspection rating is 1, staffing is 1, and the quality measure rating is 3.
The Health Deficiencies file lists 53 health citations for this home. 4 are coded immediate jeopardy (J, K, or L) and 1 are coded actual harm that is not immediate jeopardy (G, H, or I).
CMS reports 3.36 total nurse hours per resident per day, including 0.42 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.