Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Villages Of Lake Highlands during CMS and state inspections, most recent first.
A resident with complex medical needs following hip surgery did not have a comprehensive, person-centered care plan that included physician orders for hip precautions, weight bearing status, or advanced directives. The care plan focused on social activities but omitted essential clinical interventions, and staff interviews confirmed that key information from hospital discharge and physician orders was not incorporated.
A resident with diabetes and severe cognitive impairment did not receive required blood sugar checks or insulin administration as ordered. An LPN documented multiple blood sugar readings and insulin administrations without actually performing the assessments, instead using a previous reading from another nurse. The resident was later hospitalized for diabetic ketoacidosis, and the falsification of records was confirmed through interviews and documentation review.
A nurse failed to perform required blood sugar checks and instead documented false readings and insulin administrations for a resident with diabetes and chronic kidney disease. The inaccurate entries in the medical record were based on another nurse's earlier readings, and the resident was later hospitalized with diabetic ketoacidosis. Facility staff confirmed that this constituted falsification of documentation.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors during the review of care practices.
A resident with complex respiratory and cardiac conditions experienced severe respiratory distress following incontinence care, with oxygen saturation dropping to critically low levels. Nursing staff delayed emergency intervention, did not remain at the bedside, and failed to promptly escalate care or utilize available respiratory equipment, resulting in prolonged distress before effective treatment and hospital transfer. Staff interviews revealed confusion about emergency protocols and inconsistent adherence to care standards.
Surveyors found that nursing staff failed to date opened insulin vials and pens in two medication carts, resulting in the use of undated insulin for several residents. Both LVN and RN staff admitted to administering insulin from vials and pens without open dates, contrary to facility policy and accepted pharmaceutical standards, which require opened insulin to be dated and discarded after 28 days.
A nurse failed to wear a gown while providing wound care to a resident on enhanced barrier precautions for a diabetic ulcer, despite facility policy and clear signage requiring both gloves and a gown for high-contact care. The nurse acknowledged knowing the PPE requirements and having access to supplies, but did not use them during the care activity.
A resident with impaired cognition and mobility needs was improperly transferred by a CNA without using a Hoyer lift, as required by her care plan. The CNA, unfamiliar with the resident's transfer needs, attempted the transfer alone, resulting in bruising and a skin tear. The incident was reported by the resident, and the CNA admitted to not following the proper procedure, despite having received training on safe transfers.
A facility failed to include a resident's primary cancer diagnosis in their care plan, which is essential for addressing medical, nursing, and psychosocial needs. Despite the resident's significant health issues, the care plan did not reflect the cancer diagnosis, attributed to a system issue. Staff believed nurses were aware of the diagnosis and relied on physician orders, but the omission could risk inadequate care.
A resident with a complex medical history received Cabozantinib, a cancer medication, three times daily instead of once due to an incorrect order entry by a nurse. The error was discovered after the resident's family raised concerns about his condition. The facility's staff acknowledged the mistake, noting diarrhea as the only observed side effect.
A Licensed Vocational Nurse (LVN) administered Kenalog and lidocaine injections to a resident's arm instead of the physician-ordered intra-articular administration into the knees. The resident, who has multiple diagnoses including influenza, pneumonia, diabetes, and knee pain, was admitted with cognitive intactness and functional limitations in her lower extremities. The error raised concerns about potential adverse effects, infection, and nerve damage. Discrepancies were found in the LVN's actions and statements regarding the injection sites and administration process.
The facility failed to maintain the dignity of two residents during meal assistance by having staff stand over them while feeding, contrary to the facility's policy. Both residents had severe cognitive impairments and required substantial assistance with eating.
Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident following her readmission after hip surgery. The care plan did not include critical physician orders such as hip precautions, toe-touch weight bearing status, or documentation of her Full Code advanced directive status. The resident's medical record indicated multiple complex diagnoses, including aftercare following joint replacement surgery, chronic pain, muscle weakness, and COPD, and she required substantial assistance with activities of daily living. Despite these needs, the care plan lacked individualized interventions and measurable objectives related to her current clinical status. Observations and interviews revealed that the resident was alert, oriented, and able to communicate her needs, including pain management. She reported not being involved in a care plan meeting with staff. The care plan on file focused primarily on social and cognitive engagement, with interventions such as encouraging family involvement and providing activity calendars, but omitted essential clinical care instructions and did not address her advanced directives or recent surgical aftercare requirements. Hospital discharge paperwork and physician orders for weight bearing and code status were present in the record but not incorporated into the care plan. Staff interviews confirmed that the care plan was incomplete and that responsibility for updating it fell to the MDS coordinators, both of whom were unavailable at the time. The part-time MDS coordinator and the ADON acknowledged that the care plan should have included hip precautions, pain management, and advanced directives. The CNO and Director of Social Services also recognized the omission, noting that the care plan was not updated after the resident's readmission and that this oversight resulted in the absence of necessary care information for staff.
Failure to Provide Diabetic Care and Falsification of Documentation
Penalty
Summary
A facility failed to ensure that a resident with a history of Type 2 Diabetes Mellitus, diabetic chronic kidney disease, and end stage renal disease received treatment and care in accordance with professional standards of practice. On the date in question, the resident's blood sugar was found to be critically high (522 mg/dl) in the early morning. The physician was notified and provided orders for insulin administration and further monitoring. However, subsequent blood sugar checks and insulin administrations were documented by a nurse who did not actually perform the required blood glucose testing, instead using a previous reading obtained by another nurse. The nurse documented multiple blood sugar readings and insulin administrations throughout the day without performing the necessary assessments, thereby falsifying medical records. The resident, who was severely cognitively impaired and had a history of non-compliance with her diabetic regimen, began to feel unwell and requested to be taken to the hospital. Her family transported her to the emergency room, where she was diagnosed with diabetic ketoacidosis (DKA), a serious complication of diabetes. Interviews with the resident and her family indicated that the nurse did not check her blood sugar or administer insulin prior to her leaving the facility, despite documentation to the contrary. The falsification of records was later confirmed through interviews with facility staff and review of documentation practices. The incident was identified as past non-compliance, with the nurse admitting to using another nurse's earlier blood sugar reading for documentation and not performing the required care. The facility's investigation determined that the nurse failed to follow physician orders, did not check the resident's blood sugar as required, and falsified documentation regarding both blood sugar checks and insulin administration. This failure resulted in the resident not receiving necessary diabetic care and contributed to her hospitalization for DKA.
Falsification of Blood Sugar and Insulin Administration Documentation
Penalty
Summary
A deficiency occurred when the facility failed to maintain accurate medical records for a resident with multiple complex diagnoses, including Type 2 Diabetes Mellitus with chronic kidney disease, end stage renal disease, and atherosclerotic heart disease. The resident had physician orders for blood sugar checks and insulin administration according to a sliding scale. On the date in question, documentation in the Treatment Administration Record (TAR) reflected multiple blood sugar readings and insulin administrations, all showing the same elevated blood sugar value and corresponding insulin doses, signed by different nurses. However, it was discovered that one nurse did not actually perform the required blood sugar checks and instead used another nurse's earlier readings to document care that was not provided. This resulted in false entries in the resident's electronic health record, including documentation of blood sugar checks and insulin administration that did not occur as recorded. The resident was subsequently admitted to the hospital and diagnosed with diabetic ketoacidosis (DKA), a serious complication of diabetes. Interviews with facility staff and review of records confirmed that the nurse involved admitted to not performing the blood sugar checks and using another nurse's readings for documentation. The facility's leadership and other nursing staff acknowledged that such actions constitute falsification of documentation and are strictly prohibited, as accurate documentation is essential for resident care and safety.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that the care delivered did not align with the prescribed orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Failure to Provide Timely and Appropriate Respiratory Care During Acute Distress
Penalty
Summary
A facility failed to provide safe and appropriate respiratory care to a resident with significant respiratory needs, resulting in a deficiency. The resident, a male with diagnoses including heart failure, renal failure requiring dialysis, COPD, and respiratory failure, was admitted with orders for oxygen therapy and inhaled medications. During incontinence care, the resident developed respiratory distress, with oxygen saturation dropping to 66% while on 5 liters of oxygen via nasal cannula. Despite clear signs of distress, including labored breathing, use of accessory muscles, and rapid respirations, there was a delay in nursing intervention and escalation of care. Staff responses were inconsistent and did not align with professional standards or the resident's care plan. The nurse assigned to the resident did not enter the room until several minutes after being notified, and upon assessment, left the resident multiple times to call the physician rather than staying at the bedside. The nurse administered a nebulizer treatment, but the resident's oxygen saturation remained critically low, and the nurse did not immediately call emergency services. Other staff, including the wound care nurse and ADON, were not fully aware of the resident's status or the duration of his distress. The DON was present in the nurse station but did not assess the resident directly, and there was confusion among staff regarding when to call 911 and the use of available respiratory equipment such as a bi-pap machine. Interviews revealed gaps in staff knowledge and adherence to protocols for acute respiratory events. The facility lacked a rapid response policy, and staff were unclear about the threshold for activating emergency services. The resident remained in respiratory distress for approximately 40 minutes before receiving effective intervention with a non-rebreather mask and transfer to the hospital. The failure to promptly recognize and respond to the resident's acute respiratory needs, as well as to follow established care plans and professional standards, led to the identification of a deficiency by surveyors.
Removal Plan
- Notify Medical Director.
- Conduct emergent QAPI meeting.
- Re-educate staff on Professional Standards of Respiratory Care process.
- Provide one-on-one education to LVN A regarding acceptable standards of practice for residents in respiratory distress. Continue weekly education for LVN A for four weeks, monitored for understanding and implementation of knowledge.
- Educate all licensed nursing staff and certified nurse aides regarding acute change in condition including residents experiencing respiratory distress.
- Audit all patients that require respiratory treatment to ensure care plans and standards of practice are updated and followed.
- Educate new staff upon hire and monthly for 3 months on providing respiratory care according to professional standards of practice.
- Contract Respiratory Therapist to conduct ongoing monthly training and education for all licensed nurses to ensure professional standards of practice are followed for respiratory care needs.
- QAPI team to implement best practices including notifying 911 to transfer a resident to the hospital for respiratory distress with oxygen saturation below 70% and prompt immediate interventions and notification of Medical Doctor for any resident showing signs of respiratory distress.
- Monitor all current patients and newly admitted patients that require respiratory care for appropriate treatment and services.
Failure to Date Opened Insulin Vials and Pens
Penalty
Summary
Surveyors observed that the facility failed to label insulin vials and pens with the date they were opened, as required by professional standards and facility policy. During inspection of medication carts on two separate hallways, multiple insulin vials and pens for several residents were found without open dates. Nursing staff interviewed were unaware of why the insulins were not dated and acknowledged that it was their responsibility to ensure insulins were dated upon opening, as these medications are only effective for 28 days after being opened. Both LVN and RN staff admitted to administering insulin from undated vials and pens, not realizing the absence of open dates. The Director of Nursing confirmed awareness of the issue and stated that it was the responsibility of the charge nurse to check for open dates before administration. The facility's policy, revised in February 2023, requires that multi-dose vials be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer. The failure to date opened insulin vials and pens was identified through observation, interview, and record review, and was found to be inconsistent with both facility policy and accepted pharmaceutical practices.
Failure to Use Required PPE During Wound Care Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow established infection prevention and control protocols while providing wound care to a resident. The resident, a female with diagnoses including endocarditis, type 2 diabetes, end stage renal failure, and hypertension, had a diabetic ulcer on her left heel. Facility records indicated an active order for enhanced barrier precautions, requiring staff to wear gloves and a gown during high-contact care activities. Despite clear signage on the resident's door and the availability of personal protective equipment (PPE) in the hallway, the LVN entered the resident's room and performed wound care without donning a gown. During interviews, the LVN acknowledged awareness of the requirement to wear both gloves and a gown when in contact with the resident, as per facility policy and the resident's care plan. The LVN admitted to not having a reason for failing to use the appropriate PPE, despite having access to it. The Director of Nursing (DON) confirmed that staff were expected to use PPE during wound care and that regular in-services on infection control and enhanced barrier precautions had been conducted. Facility policy reviewed also specified the use of gloves and gowns for high-contact care activities to prevent the spread of multi-drug resistant organisms.
Improper Transfer Procedure Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was transferred from her bed to her wheelchair using a Hoyer lift with two staff members present, as indicated in her care plan. This deficiency was identified during a review of the resident's care plan and interviews with staff. The resident, who had moderately impaired cognition and required maximum assistance for mobility, was transferred by a CNA without the use of the mechanical lift, resulting in bruising and a skin tear. The incident occurred when the CNA, who was not familiar with the resident's specific transfer requirements, attempted to transfer the resident alone. The CNA did not check the care plan or ask for assistance, despite knowing that mechanical lift transfers require two staff members. The resident sustained bruises on her arms and a skin tear on her knee during the transfer, which was reported by the resident to the nursing staff. Interviews with the facility's nursing staff revealed that the CNA admitted to transferring the resident alone and was unaware of the proper procedure. The CNA had received training on safe transfers but failed to follow the facility's policy, which mandates the use of two staff members for mechanical lift transfers. The incident was reported to the facility's administration, and the CNA was removed from the floor immediately after the incident was discovered.
Failure to Address Cancer Diagnosis in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. Specifically, the care plan did not reflect the resident's primary diagnosis of kidney cancer or lymph node cancer, despite these being significant health concerns. The resident's care plan was initiated shortly after admission, but the baseline care plan was not completed, and the cancer diagnosis was not specifically addressed, which could place the resident at risk of not receiving adequate care. Interviews with facility staff, including the Director of Nursing (DON), MDS Nurse, Chief Nursing Officer, and Chief Executive Officer, revealed that the omission was attributed to a system issue where the cancer diagnosis did not populate on the care plan. The staff believed that the nurses were aware of the resident's diagnosis and treated the resident accordingly, relying on physician orders in the system rather than the care plan. The facility's policy requires a comprehensive care plan to be developed within 21 days of admission, but in this case, the care plan did not adequately address the resident's cancer diagnosis.
Medication Error in Cancer Treatment Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Cabozantinib, a cancer medication. The admitting nurse incorrectly added the medication order to the electronic record, resulting in the resident receiving the medication three times a day instead of the prescribed once daily. This error occurred over a period from July 11 to July 13, 2024, and was only identified after the resident's family member raised concerns. The resident involved was a male with a complex medical history, including a diagnosis of malignant neoplasm of the right kidney, pneumonia, acute respiratory failure, and several other serious conditions. The medication error was discovered when the family member noticed the resident's condition deteriorating after dialysis and contacted the facility. The family member was informed by the Assistant Director of Nursing (ADON) that the medication was being administered three times daily, contrary to the oncologist's order. Interviews with facility staff revealed that the nurse responsible for the error did not return to work after the incident. The Director of Nursing (DON) and Chief Nursing Officer (CNO) acknowledged the error and noted that the only observed side effect was diarrhea. The facility's policy on medication errors emphasizes the importance of following physician orders and minimizing adverse consequences, which was not adhered to in this case.
Medication Administration Error Involving Kenalog and Lidocaine Injections
Penalty
Summary
The deficiency identified in the report pertains to the failure of the facility to ensure that residents are free from significant medication errors. Specifically, the incident involved LVN A administering Kenalog and lidocaine injections to Resident #389's arm, contrary to the physician's order to hold the medications for intra-articular administration into the resident's knees. This error put Resident #389 at risk for harm and serious injury. The incident occurred on 02/01/24, and LVN A was immediately suspended pending investigation and later terminated for practicing outside the scope of her practice. The facility reported the incident to the Texas Board of Nursing and initiated corrective actions, including additional training for nursing staff on medication administration and following physician orders. Resident #389, a [AGE] year-old female with multiple diagnoses including influenza, pneumonia, diabetes, and knee pain, was admitted to the facility with cognitive intactness and functional limitations in her lower extremities. The physician had ordered Kenalog and lidocaine injections for bilateral knee pain, to be held for the physician's administration. However, LVN A administered the injections into Resident #389's arm, leading to concerns about potential adverse effects, infection, and nerve damage. The resident reported feeling relief in her shoulder but expressed confusion and concern about not receiving the injections in her knees as intended. The investigation revealed discrepancies in LVN A's actions and statements, with conflicting accounts of the injection sites and administration process. The facility's response included immediate termination of LVN A, reporting the incident to regulatory authorities, and conducting in-service training for nursing staff on medication administration protocols.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to treat two residents with respect and dignity during meal assistance. Specifically, staff members were observed standing over the residents while feeding them, which is against the facility's policy that requires staff to sit next to residents to ensure they feel comfortable and not rushed. This was observed with a [AGE] year-old female resident with Alzheimer's disease and Type 1 diabetes mellitus, and another [AGE] year-old female resident with dementia and hypothyroidism. Both residents had severe cognitive impairments and required substantial assistance with eating. Interviews with the staff involved revealed that they were aware of the proper procedure but did not follow it. One CNA mentioned that she had just returned from lunch and started feeding the resident while standing. Another Med Tech admitted to standing due to back pain, making it uncomfortable for her to sit. An LVN confirmed that staff were trained to sit next to residents during meal assistance to ensure their comfort and dignity. The facility's policy on meal assistance, dated March 2022, explicitly states that residents should not be fed while staff are standing over them.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 873 citations issued within 25 miles in the last 12 months — including the 40 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Five Points At Lake Highlands Nursing And Rehab | 1.5 mi | — | 32 | 2 |
| C C Young Memorial Home | 1.8 mi | — | 6 | 0 |
| Golden Acres Living And Rehabilitation Center | 2.6 mi | — | 22 | 0 |
| Autumn Leaves | 2.7 mi | — | 0 | 0 |
| Pure Health Transitional Care At Texas Health Pres | 2.8 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Villages Of Lake Highlands.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.