Nursing homeActive
Villages of Lake Highlands
8615 Lullwater Dr, Dallas, TX 752382142210444126 certified beds · 111 residentsFor profit - CorporationMedicare and Medicaid
Surveys on file
10
since 2023
Deficiencies
14
● 0● 9● 5
Penalties · 3 yrs
$29,022
3 fines
Last survey
2025-12-01
Complaint
CMS overall
2 / 5
stars as published by CMS
CMS overall 2/5
Health 1
Staffing 4
Quality 5
Star ratings as published by CMS · CMS’s caveats
Survey history
Source: CMS · Texas Health and Human Services Commission · data as of 2026-08-01| Date | Kind | Deficiencies | Official record | Archived PDF |
|---|---|---|---|---|
| 2025-12-01 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2025-09-13 | Complaint | 011 | CMS-2567 (Care Compare) | — |
| 2025-08-28 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2025-05-16 | Standard | 021 | CMS-2567 (Care Compare) | — |
| 2024-10-24 | Complaint | 001 | CMS-2567 (Care Compare) | — |
| 2024-08-20 | Complaint | 020 | CMS-2567 (Care Compare) | — |
| 2024-04-18 | Standard | 011 | CMS-2567 (Care Compare) | — |
| 2024-01-30 | Infection control | 010 | CMS-2567 (Care Compare) | — |
| 2023-08-10 | Complaint | 010 | CMS-2567 (Care Compare) | — |
| 2023-02-09 | Standard | 000 | CMS-2567 (Care Compare) | — |
Counts by class: paperwork · standard · harm.
Deficiencies
CMS · Texas Health and Human Services Commission publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-11-05Record 676268-20251201-F656
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity JHarm
Care planning
Isolated; immediate jeopardy to resident health or safety.Correction not yet recordedRecord 676268-20250913-F684
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Correction not yet recordedRecord 676268-20250913-F842
F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2025-08-29Record 676268-20250828-F684
F695Provide safe and appropriate respiratory care for a resident when needed.Scope/severity KHarm
Care planning
Pattern; immediate jeopardy to resident health or safety.Corrected 2025-05-20Record 676268-20250516-F695
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2025-05-20Record 676268-20250516-F761
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2025-05-20Record 676268-20250516-F880
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-07-02Record 676268-20241024-F689
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-25Record 676268-20240820-F656
F760Ensure that residents are free from significant medication errors.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-08-21Record 676268-20240820-F760
F760Ensure that residents are free from significant medication errors.Scope/severity JHarm
Medication
Isolated; immediate jeopardy to resident health or safety.Corrected 2024-02-02Record 676268-20240418-F760
F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-05-22Record 676268-20240418-F550
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-02-23Record 676268-20240130-F880
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2023-09-04Record 676268-20230810-F880
Penalties & enforcement
| Date | Action | Amount | Source |
|---|---|---|---|
| 2025-08-28 | Civil money penalty | $11,879 | CMS · Penalties |
| 2024-10-24 | Civil money penalty | $8,976 | CMS · Penalties |
| 2024-04-18 | Civil money penalty | $8,167 | CMS · Penalties |
Staffing
CMS Payroll-Based Journal · PBJ, as published Aug 2026 · explainerRN hours per resident day0.52
Facility
Texas
National
Texas 0.43 · National 0.69
Total nurse hours per resident day4.48
Facility
Texas
National
Texas 3.39 · National 3.86
Weekend total nurse hours4.05
Facility
Texas
National
Texas 2.98 · National 3.42
Total nursing staff turnover35%
Facility
Texas
National
Texas 55% · National 46%
Registered nurse turnover56%
Facility
Texas
National
Texas 55% · National 43%
Quality measures
CMS MDS quality measures · 2025Q2-2026Q1 · definitions| Measure | Facility | Texas | National |
|---|---|---|---|
| Percentage of long-stay residents with pressure ulcers lower is better | 5.2% | 3.8% | 4.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury lower is better | 3.0% | 3.3% | 3.2% |
| Percentage of long-stay residents who received an antipsychotic medication lower is better | 5.4% | 9.6% | 15.4% |
| Percentage of long-stay residents with a urinary tract infection lower is better | 0.0% | 0.8% | 1.6% |
| Percentage of long-stay residents who were physically restrained lower is better | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose need for help with daily activities has increased lower is better | 17.1% | 15.8% | 13.9% |
| Percentage of long-stay residents who lose too much weight lower is better | 6.7% | 3.0% | 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication lower is better | 13.4% | 18.0% | 19.5% |
Figures verbatim from CMS, with the state and national figures from the same release. The direction that counts as better is CMS’s own and is stated on every row.
Ownership
As reported to CMS (Provider Enrollment)| Entity | Role | Interest | Since | Registry |
|---|---|---|---|---|
| Jsc Lake Highlands I Senior Living, LP Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | — | — |
| Javelin Group Funding I, LP Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Jsc Lake Highlands I Senior Living, LP Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | — | — |
| Kamran, Mubashir Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Village Senior Care LLC Organization | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Wolfe, Kelly Individual | OPERATIONAL/MANAGERIAL CONTROL | NOT APPLICABLE | — | — |
| Eden, Kevin Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Kamran, Mubashir Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Naul, Alan Individual | ADP OF THE SNF | NOT APPLICABLE | — | — |
| Village Senior Care LLC Organization | ADP OF THE SNF | NOT APPLICABLE | — | — |
Ownership as reported to CMS/state. CMS ownership data has known gaps; merges between entities are published only after human review.
Cost context
County figures from public surveys. Not this facility’s price. Nursing-home rates are not published by CMS or Texas.
No county cost figures on file for Dallas.
Nearby nursing homes
| Facility | Distance | Last survey | Deficiencies · 3 yrs |
|---|---|---|---|
| Five Points at Lake Highlands Nursing and Rehab Dallas | 0.9 mi | 2026-05-26 | 0485 |
| C C Young Memorial Home Dallas | 1.8 mi | 2026-01-15 | 050 |
| Golden Acres Living and Rehabilitation Center Dallas | 2.6 mi | 2026-05-14 | 0220 |
| Pure Health Transitional Care At Texas Health Pres Dallas | 2.8 mi | 2025-07-02 | 030 |
| Avir at The Meadow Dallas | 3.5 mi | 2026-06-12 | 2365 |
Watch this facility
One email when a new survey, harm-class deficiency, penalty, Special Focus change or ownership change is recorded. Nothing else, ever.
Sources & provenance
| Section | Agency · dataset | Retrieved |
|---|---|---|
| Facility, ratings | CMS Provider Data · Nursing Home Provider Information | 2026-08-01 |
| Surveys | CMS · Survey Summary | 2026-08-01 |
| Deficiencies | CMS · Health Deficiencies (CMS-2567 findings via Care Compare) | 2026-08-01 |
| Penalties | CMS · Penalties | 2026-08-01 |
| Staffing | CMS · Payroll-Based Journal (PBJ, as published Aug 2026) | 2026-08-01 |
| Quality measures | CMS · MDS Quality Measures | 2026-08-01 |
| Ownership | CMS · Ownership | 2026-08-01 |