Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to develop and implement a comprehensive person-centered
care plan for each resident, consistent with the resident rights, that included measurable objectives and
timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified
in the comprehensive assessment for 1 of 5 residents, (Resident #1) reviewed for care plans.
The facility failed to ensure Resident #1's care plan reflected the resident's primary diagnosis of cancer.
This failure could place the residents at risk of not receiving adequate care.
Findings included:
Record review of Resident #1's face sheet, date 08/19/24, reflected Resident #1 was a [AGE] year-old
male, who admitted to the facility on [DATE]. Resident #1 had a diagnoses which included Malignant
Neoplasm of Right Kidney (cancer of the kidney), Pneumonia (bacterial infection of the lungs), Acute
Respiratory Failure with Hypoxia (low oxygen level of body tissue), Severe Protein/Calorie Malnutrition,
Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Secondary and Unspecified Malignant
Neoplasm of Lymph Nodes of Multiple Regions (cancer of the lymph nodes), Anemia, Thrombocytosis
(high platelet count in blood), Hypercalcemia (too much calcium in the blood), Hyperkalemia (too much
potassium in the blood), Essential Hypertension (High Blood Pressure), Myocarditis (inflammation of the
heart wall), Pleural Effusion (build up of fluid between the lungs and chest wall), Malignant Pleural Effusion
(cancer between the lungs and chest wall cavity), Multisystem Inflammatory Syndrome (inflamed internal
and external body parts), Acute Kidney Failure (sudden decline of kidney function), Chronic Kidney Disease
Stage 3 (damaged kidneys), and Hematuria (blood or blood cells in the urine).
Record review of Resident #1's Care Plan with an initial date of 07/11/24 did not address Resident #1's
diagnosis of Kidney Cancer or Lymph Node Cancer.
Record review of Resident #1's MDS, dated [DATE], did not reflect a BIMS score or the cancer diagnosis.
In an interview on 08/19/24 at 2:54 PM, The DON stated the cancer diagnosis was addressed by
addressing some symptoms of the cancer. She stated they did not address the cancer specifically on the
care plan.
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
676268
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676268
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villages of Lake Highlands
8615 Lullwater Dr
Dallas, TX 75238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In a follow-up interview on 08/20/24 at 2:32 PM, the DON stated the facility had an RN initiated care plan
that is tailored by MDS Nurse B for each resident. The DON stated MDS Nurse B signed off on the care
plans once the plans were completed. The DON stated Resident #1 did not have a baseline care plan. She
stated they started the comprehensive care plan a day or so after he admitted to the facility, so the baseline
care plan was not done. The DON stated she believed the system generated the care plan from the
resident's listed diagnoses, and it pulled the cancer diagnosis over as a general diagnosis. The DON stated
that was when it was up to a nurse to go in and specify and that is where MDS Nurse B would have started.
The DON stated she believed it was a system issue, as to why the cancer did not populate on Resident
#1's care plan. She stated the issue now had their attention, and they were working on ensuring the care
plans are more detailed. The DON stated she felt there was no risk, because the nurses knew the resident's
diagnosis and treated Resident #1. The DON stated the physician orders were in the system, so they did
not have to look at the care plan. The DON stated the care plan provided an overall view of care for
Resident #1 and set goals.
In an interview on 08/20/24 at 2:55 PM, MDS Nurse B stated she was responsible for the resident care
plans. She stated she did not generate the care plans. MDS Nurse B stated RNs generated the initial care
plans for residents. She stated the initial part of the care plans was not her responsibility, but cancer should
have been listed on the care plan for Resident #1. MDS Nurse B stated she was at the end of the care plan
process and was not sure if Resident #1's care plan was completed, as he had recently admitted to the
facility.
In an interview on 08/20/24 at 3:05 PM, Chief Nursing Officer C stated she did not feel there was a risk of
Resident #1's cancer not being addressed on his care plan. She stated all nurses were aware of his
diagnosis, and she did not feel the staff would have done anything differently. Chief Nursing Office C stated
the triggers on the care plan are completed by nursing staff. She stated the comprehensive assessment is
completed within 14 days of admission, and Resident #1's comprehensive care plan was initiated within
24-48 hours of his admission.
In an interview on 08/20/24 at 3:18 PM, Chief Executive Officer D stated he did not feel there was a risk
with the cancer not being addressed on Resident #1's comprehensive care plan. He stated he believed
chronic illness was addressed on the care plan.
Record review of the facility's policy, dated 2001, with a revision date of 03/22 and titled, Care Plans
Comprehensive-Person Centered, reflected the following:
Policy Statement
A comprehensive person-centered care plan that includes measurable objectives and timetable to meet the
resident's physical, psychosocial and functional needs is developed and implemented for each resident.
Policy Interpretation and Implementation
1.
The interdisciplinary team, in conjunction with the resident and his/her family or legal representative,
develops and implements a comprehensive, person-centered care plan for each resident.
2.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676268
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676268
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villages of Lake Highlands
8615 Lullwater Dr
Dallas, TX 75238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
The comprehensive, person-centered care plan is developed within 7 days of the completion of the required
MDS assessment (Admission, Annual or Significant Change in status), and no more than 21 days after
admission.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676268
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676268
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villages of Lake Highlands
8615 Lullwater Dr
Dallas, TX 75238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to ensure the resident was free of any significant medication
errors for one (Resident #1) of five residents reviewed in that:
Residents Affected - Few
The facility failed to ensure Admitting Nurse E added Resident #1's medication order correctly for
Cabozantinib, a medication for cancer, to the electronic record. As a result, the facility did not administer the
correct amount of Cabozantinib to Resident #1 from 07/11/24-07/13/24.
These failures could place residents at risk of not receiving their medications as ordered or possible illness.
Findings included:
Record review of Resident #1's face sheet, date 08/19/24, reflected Resident #1 was a [AGE] year-old
male, who admitted to the facility on [DATE]. Resident #1 had a diagnoses which included Malignant
Neoplasm of Right Kidney (cancer of the kidney), Pneumonia (bacterial infection of the lungs), Acute
Respiratory Failure with Hypoxia (low oxygen level of body tissue), Severe Protein/Calorie Malnutrition,
Type 2 Diabetes Mellitus with Diabetic Chronic Kidney Disease, Secondary and Unspecified Malignant
Neoplasm of Lymph Nodes of Multiple Regions (cancer of the lymph nodes), Anemia, Thrombocytosis
(high platelet count in blood), Hypercalcemia (too much calcium in the blood), Hyperkalemia (too much
potassium in the blood), Essential Hypertension (High Blood Pressure), Myocarditis (inflammation of the
heart wall), Pleural Effusion (buildup of fluid between the lungs and chest wall), Malignant Pleural Effusion
(cancer between the lungs and chest wall cavity), Multisystem Inflammatory Syndrome (inflamed internal
and external body parts), Acute Kidney Failure (sudden decline of kidney function), Chronic Kidney Disease
Stage 3 (damaged kidneys), and Hematuria (blood or blood cells in the urine).
Record review of Resident #1's MDS, dated [DATE], did not reflect a BIMS score or the cancer diagnosis.
Record review of the Resident #1's hospital document dated 06/15/24, reflected an order for Cabozantinib
(Cabometyx) 60 MG tablet, to be given daily before dinner.
Record review of Resident #1's orders noted on the facility's electronic record, dated 08/19/24, reflected the
following:
Cabozantinib S-Malate oral tablet 60 MG
Give one tablet by mouth before meals related to dependence on renal dialysis
Order date 07/10/24
Start date 07/11/24
End date 07/13/24
Cabozantinib S-Malate oral tablet 60 MG
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676268
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676268
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villages of Lake Highlands
8615 Lullwater Dr
Dallas, TX 75238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Give one table by mouth in the afternoon related to dependence on renal dialysis
Level of Harm - Minimal harm
or potential for actual harm
Order date 07/13/24
Start date 07/14/24
Residents Affected - Few
Administrative order to hold 07/13/24
Record review of Resident #1's Medication Administration Record, dated July 2024, on the resident's
electronic record reflected the following:
Canzantinib S-Malate oral tablet 60 MG was marked as given to Resident #1 on:
07/11/24 at 7:30 and 16:30 (4:30 PM)
07/12/24 at 11:30 and 16:30 (4:30 PM)
07/13/24 at 7:30 and 16:30 (4:30 PM)
Starting on 07/16/24, the medication was marked as given once a day at 16:00 (4:00 PM)
There was an exception marked on 07/11/24 at 11:30 as 1.
There was an exception marked on 07/12/24 at 7:30 as 9
There was an exception marked on 07/13/24 at 11:30 as 1
The exception codes noted on the medication administration record for 1 was absent from home without
meds and 9 was Other/ See progress notes
Record review of the progress notes on Resident #1' electronic record for 07/12/24, reflected no progress
note for the medication exception.
In an interview on 08/19/24 at 11:46 AM, Family Member stated the resident admitted to the facility on
[DATE], and from 07/10/24 to 07/13/24 the facility had been giving Resident #1 his cancer medications 3
times a day instead of once a day. Family Member stated the family provided the order and the cancer
medication to the facility. Family Member staed the medication was mail ordered to the family's house.
Family Member stated Resident #1 was not doing well after dialysis, so a call was made to the facility to
check on Resident #1. Family Member stated ADON mentioned giving Resident #1 cancer medications
three times a day, and Family Member said it should have only been once a day. Family Member said
ADON said they would check into it. Family Member stated on 07/22/24 Resident #1 went to the hospital
from the facility, and he was diagnosed with mini strokes. Family Member stated Resident #1 did not return
to the facility and passed away on 07/28/24.
In a group interview on 08/19/24 at 2:54 PM, the DON stated Nurse E was the one responsible for adding
the order incorrectly for Cabozantinib, to Resident #1's electronic record. Chief Nursing Officer C stated she
was never able to get a statement from Nurse E, because she was a no call no show. Chief Nursing Officer
C stated she never returned to work. Chief Nursing Officer C stated Nurse E is the one that documented
the admission of Resident #1. The DON stated Resident #1's family member was
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676268
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676268
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villages of Lake Highlands
8615 Lullwater Dr
Dallas, TX 75238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Minimal harm
or potential for actual harm
the one that let the staff know the medication order was incorrect and the resident should only receive one
dose per day of the Cabozantinib. The DON stated the facility contacted the oncologist, and the oncologist
told the facility to hold the medication and to watch for side effects like blood pressure. The DON stated the
only side effect noted and observed was diarrhea. The DON stated a couple of days later the oncologist
told the facility to start the medication back as ordered.
Residents Affected - Few
In a follow-up interview on 08/20/24 at 2:32 PM, the DON stated the nurse managers were generally
responsible for adding the admission orders, but any nurse could do it. She stated all nurses were trained
on how to properly add new medication orders to the resident's electronic record. She stated the assistant
directors of nursing were responsible for verifying orders were added correctly. The DON stated the
verification should happen daily. She stated she encouraged the nurses to go over medications with the
resident's responsible party as well. The DON stated since the incident with Resident #1's medication, all
nurses had been retrained on adding orders, neglect, and medication administration. The DON stated the
risk of Resident #1 receiving the wrong amount of the medication varied, and one risk was the resident's
blood pressure increasing.
In a follow-up interview on 08/20/24 at 3:05 PM, Chief Nursing Officer C stated there was always a risk to
the resident when a higher than ordered dosage was given. She stated the only side effect noted for
Resident #1 was diarrhea.
In a follow-up interview on 08/20/24 at 3:18 PN, Chief Executive Officer D stated he felt it was not a major
risk of Resident #1 receiving the wrong dosage of medication, because the oncologist was contacted, and
the resident was monitored for adverse effects. He stated the only adverse effect was diarrhea. Chief
Executive Officer stated Nurse E did not return to work after being a no call no show. He stated all other
staff were retrained on medication administration, adding admitting orders, and following the physician's
orders.
Record review of the policy titled, Adverse Consequences and Medication Errors dated 2001 with a revision
date of 02/2023 reflected the following:
Policy Statement
The interdisciplinary team monitors medication usage in order to prevent and detect medication-related
problems such as adverse drug reactions and side effects.
Policy Interpretation and Implementation
2. The staff and practitioner strive to minimize adverse consequences by:
a.
Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration,
duration, and monitoring of the medication;
Medication Errors
1.
A 'medication error' is defined as the preparation or administration of drugs or biological which
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676268
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676268
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/20/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villages of Lake Highlands
8615 Lullwater Dr
Dallas, TX 75238
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
is not in accordance with physician's orders, manufacturer specifications, or accepted professional
standards and principles of the professional(s) providing services.
Level of Harm - Minimal harm
or potential for actual harm
2.
Residents Affected - Few
Examples of medication errors include:
c. Wrong dose
3. A 'significant medication-related error' is defined as:
a. Requiring medication discontinuation or dose modification
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676268
If continuation sheet
Page 7 of 7
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
FAQ · About this visit
Common questions about this visit
What happened during the August 20, 2024 survey of Villages of Lake Highlands?
This was a inspection survey of Villages of Lake Highlands on August 20, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Villages of Lake Highlands on August 20, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.