Cycle 1
Health 2025-05-16 · Fire 2025-05-16
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Dallas, TX
Villages of Lake Highlands
2-star overall rating with 1-star inspections with $28,814 in total fines with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
8615 Lullwater Dr, Dallas, TX
(214) 221-0444
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
126
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-11-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.67
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.39
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.19
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.79
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
4.55
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,940
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.04
Composite VBP score used to determine payment impact.
Payment multiplier
0.9912
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.29
Baseline 19.48% · Performance 20.37% · Measure score 2.29 · Achievement 2.29 · Improvement 0
Healthcare-associated infections
5.80
Baseline 4.79% · Performance 6.10% · Measure score 5.80 · Achievement 5.80 · Improvement 0
Total nurse turnover
3.44
Baseline 45.54% · Performance 49.61% · Measure score 3.44 · Achievement 3.44 · Improvement 0
Adjusted total nurse staffing
3.68
Baseline 3.94 hours · Performance 4.13 hours · Measure score 3.68 · Achievement 3.68 · Improvement 0.52
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 383 · Observed rate 10.44% · Lower 95% interval 7.92% |
| Discharge to community | 58.71% |
50.57%
8.1 pts better
|
Better than the National Rate · Eligible stays 354 · Observed rate 52.26% · Lower 95% interval 53.16% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 264 · Denominator 264 |
| Falls with major injury | 0.38% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 264 |
| Discharge self-care score | 62.22% |
53.69%
8.5 pts better
|
Numerator 112 · Denominator 180 |
| Discharge mobility score | 68.33% |
50.94%
17.4 pts better
|
Numerator 123 · Denominator 180 |
| Pressure ulcers or injuries, new or worsened | 0.76% |
2.29%
1.5 pts better
|
Numerator 2 · Denominator 264 · Adjusted rate 0.74% |
| Healthcare-associated infections requiring hospitalization | 6.1% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 212 · Observed rate 5.66% · Lower 95% interval 4.13% |
| Staff COVID-19 vaccination coverage | 10.78% |
8.2%
2.6 pts better
|
Numerator 18 · Denominator 167 |
| Staff flu vaccination coverage | 67.07% |
42%
25.1 pts better
|
Numerator 112 · Denominator 167 |
| Discharge function score | 73.33% |
56.45%
16.9 pts better
|
Numerator 132 · Denominator 180 |
| Transfer of health information to provider | 97.14% |
95.95%
1.2 pts better
|
Numerator 136 · Denominator 140 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 106 · Denominator 106 |
| Resident COVID-19 vaccinations up to date | 25.19% |
25.2%
About the same
|
Numerator 33 · Denominator 131 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
97.1%
3.5 pts worse
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.4% · Q2 89.4% · Q3 100.0% · Q4 96.9% · 4Q avg 93.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
97.9%
0.7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.3%
0.8 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.5% · Q3 4.5% · Q4 4.6% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.0% |
2.7%
5.3 pts worse
|
11.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 11.6% · Q3 7.3% · Q4 7.7% · 4Q avg 8.0% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
3.3%
1.8 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.5% · Q3 4.8% · Q4 0.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
18.9%
2.6 pts better
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 15.6% · Q3 11.4% · Q4 10.9% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.5% |
10.8%
5.3 pts better
|
16.7%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 6.1% · Q3 5.4% · Q4 2.7% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.5% |
16.1%
1.4 pts worse
|
14.9%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 19.0% · Q3 15.4% · Q4 16.7% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.5%
0.5 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 0.9% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.2% |
15.0%
2.2 pts worse
|
19.8%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 14.1% · Q3 18.6% · Q4 17.0% · 4Q avg 17.2% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
4.2%
2.7 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 5.7% · Q3 5.1% · Q4 5.2% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 46.3% |
89.7%
43.4 pts worse
|
81.7%
35.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 42.3% · Q3 61.4% · Q4 55.6% · 4Q avg 46.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
12.0%
5.1 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 7.7% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.8% · Q4 0.4% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 45.4% |
88.0%
42.6 pts worse
|
79.7%
34.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 45.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
25.9%
2.5 pts better
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 24.7% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-18 · Fire 2024-04-18
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-02-09 · Fire 2023-02-09
2 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-05-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-05-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-04
C · Minimal harm
2024-04-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-23
E · Potential for more than minimal harm
2023-02-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-02-09
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-03-01
D · Potential for more than minimal harm
2023-02-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-11-05
J · Immediate jeopardy
2025-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
E · Potential for more than minimal harm
2025-09-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Not marked corrected
K · Immediate jeopardy
2025-08-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-29
K · Immediate jeopardy
2025-05-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-05-16
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-20
G · Actual harm
2024-10-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-08-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-21
J · Immediate jeopardy
2024-04-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-02
D · Potential for more than minimal harm
2024-04-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-05-22
E · Potential for more than minimal harm
2024-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-08-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-04
Penalties and ownership
What sits behind the stars
$11,671
2025-08-28
Fine
Fine · fine $11,671
Fine
$8,976
2024-10-24
Fine
Fine · fine $8,976
Fine
$8,167
2024-04-18
Fine
Fine · fine $8,167
Fine
Ownership
Jsc Lake Highlands I Senior Living, LP
5% Or Greater Direct Ownership Interest · Organization
Eden, Kevin
5% Or Greater Indirect Ownership Interest · Individual
Eden, Kevin
Corporate Officer · Individual
Javelin Group Funding I, LP
5% Or Greater Indirect Ownership Interest · Organization
Javelin Group Gen Par I, LLC
General Partnership Interest · Organization
Naul, Alan
5% Or Greater Indirect Ownership Interest · Individual
Naul, Alan
Corporate Officer · Individual
Village Senior Care LLC
Operational/Managerial Control · Organization
Wolfe, Kelly
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Five Points at Lake Highlands Nursing and Rehab
Dallas, TX
1-star overall rating with 1-star inspections with $72,182 in total fines with 24 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
C C Young Memorial Home
Dallas, TX
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Golden Acres Living And Rehabilitation Center
Dallas, TX
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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