Villages of Lake Highlands
8615 Lullwater Dr, Dallas, TX 75238 · Dallas County · 126 certified beds · avg 111 residents/day · certified since Nov 19, 2010
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Sep 13, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
▲ Immediate jeopardy, repeated · Aug 28, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Aug 29, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · May 16, 2025 · F-0695 · triggered by a complaint
The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Why it matters: Mistakes in breathing care can quickly become life-threatening for residents who depend on oxygen or equipment.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: May 20, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Apr 18, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 2, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Oct 24, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 2, 2024 (Past Non-Compliance)
All citations in the current public record (14)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 1, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Sep 13, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 13, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 28, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| May 16, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| May 16, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| May 16, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 24, 2024 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 20, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Aug 20, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 18, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 18, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jan 30, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Aug 10, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (2 → 3).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 6 | 2 | J ▲ |
| 2025 | 7 | 3 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $29,022.
| Date | Type | Amount / length |
|---|---|---|
| Aug 28, 2025 | Fine | $11,879 |
| Oct 24, 2024 | Fine | $8,976 |
| Apr 18, 2024 | Fine | $8,167 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.71 | 3.46 | 3.95 | top 5% in Texas; top 18% in the U.S. |
| Registered Nurse hours | 0.54 | 0.44 | 0.69 | top 22% in Texas; bottom 44% in the U.S. |
| Weekend total nurse staffing | 4.26 | 3.04 | 3.50 | top 5% in Texas; top 16% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.42 | 0.34 | 0.48 | top 22% in Texas; top 44% in the U.S. |
| Total nursing staff turnover (%) | 35.4 | 55.3 | 45.8 | top 12% in Texas; top 25% in the U.S. |
| RN turnover (%) | 56.3 | 54.6 | 42.9 | bottom 46% in Texas; bottom 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.48, RN 0.52, weekend 4.05. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Javelin Group Funding I, LP | Organization | 5% or Greater Indirect Ownership Interest | — | 09/01/2016 |
| JSC Lake Highlands I Senior Living, LP | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/15/2010 |
| JSC Lake Highlands I Senior Living, LP | Organization | 5% or Greater Indirect Ownership Interest | — | 03/25/2009 |
| Eden, Kevin | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2020 |
| Kamran, Mubashir | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2025 |
| Kamran, Mubashir | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2025 |
| Naul, Alan | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2020 |
| Village Senior Care LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/2016 |
| Village Senior Care LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/21/2026 |
| Wolfe, Kelly | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2016 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Five Points at Lake Highlands Nursing and Rehab | 0.9 mi | Dallas, TX | ★☆☆☆☆ | 1/5 | |
| C C Young Memorial Home | 1.8 mi | Dallas, TX | ★★★★★ | 5/5 | |
| Golden Acres Living and Rehabilitation Center | 2.6 mi | Dallas, TX | ★★★☆☆ | 3/5 | |
| Pure Health Transitional Care at Texas Health Pres | 2.8 mi | Dallas, TX | ★★★★★ | 5/5 | |
| Avir at the Meadow | 3.5 mi | Dallas, TX | ★☆☆☆☆ | 1/5 | |
| The Highlands Guest Care Center | 3.9 mi | Dallas, TX | ★☆☆☆☆ | 2/5 | |
| Presbyterian Village North Special Care Ctr | 4.0 mi | Dallas, TX | ★★★★☆ | 4/5 | |
| Avir at Garland | 4.0 mi | Garland, TX | ★☆☆☆☆ | 1/5 | abuse |
| The Legacy Midtown Park | 4.1 mi | Dallas, TX | ★★★★★ | 5/5 | |
| Le Reve Rehabilitation & Memory Care | 4.3 mi | Dallas, TX | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676268.