Villages of Lake Highlands
8615 Lullwater Drive, Dallas, TX 75238
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Follow this homeVillages of Lake Highlands is a nursing home in Dallas, Texas. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating3 of 5
- Last standard health inspectionJuly 23, 2026 (3 months ago)
- Health citations since January 30, 202425 (Texas average 28)
- Fines in the past three years3, $29,022 in total
- CMS flagsNone listed by CMS
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CMS flags
CMS does not list this home as a Special Focus Facility or a candidate. CMS does not show an abuse icon for it. CMS lists no change of ownership in the past 12 months.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 1 of 5 to 2 of 5.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Health inspection on July 23, 2026
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation F0641. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on August 28, 2026.
Citation F0655. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on August 28, 2026.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on August 28, 2026.
CMS has cited this home for F0656 3 times since 2024.
Citation F0689. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 28, 2026.
CMS has cited this home for F0689 2 times since 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on August 28, 2026.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 28, 2026.
CMS has cited this home for F0880 3 times since 2024.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on August 28, 2026.
Citation F0693. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS lists it as corrected on August 28, 2026.
Citation F0695. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on August 28, 2026.
CMS has cited this home for F0695 2 times since 2025.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on August 28, 2026.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on August 28, 2026.
CMS has cited this home for F0761 2 times since 2025.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on August 28, 2026.
Fire safety inspection on July 23, 2026
4 citationsCMS lists this as a standard inspection.
Show the 4 citations
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on August 21, 2026.
CMS has cited this home for K0321 2 times since 2025.
Citation K0324. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on August 21, 2026.
CMS has cited this home for K0324 2 times since 2024.
Citation K0344. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have an alternate power supply for its alarm system.
CMS lists it as corrected on August 21, 2026.
Citation K0511. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on August 21, 2026.
CMS update of May 27, 2026
Fine
CMS changed the fine from August 28, 2025 from $11,671 to $11,879.
CMS update of April 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
CMS update of February 25, 2026
Fine
CMS changed the fine from August 28, 2025 from $17,955 to $11,671.
CMS update of January 14, 2026
Health citation
CMS removed citation F0689 from the health inspection on September 13, 2025.
CMS update of December 15, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
Health inspection on December 1, 2025
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on November 5, 2025.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on September 13, 2025
2 citationsCMS lists this as a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.
Show the 2 citations
Citation F0684. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS has cited this home for F0684 2 times since 2025.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Health inspection on August 28, 2025
1 citationCMS lists this as a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.
CMS fine of $11,879 on August 28, 2025.
Show the 1 citation
Citation F0684. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on August 29, 2025.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of May 28, 2025
Fine
CMS changed the fine from October 24, 2024 from $8,824 to $8,976.
Health inspection on May 16, 2025
3 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.
Show the 3 citations
Citation F0695. Severity K: immediate jeopardy, pattern.
The rule CMS cited:
Provide safe and appropriate respiratory care for a resident when needed.
CMS lists it as corrected on May 20, 2025.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on May 20, 2025.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on May 20, 2025.
Fire safety inspection on May 16, 2025
3 citationsCMS lists this as a standard inspection.
Show the 3 citations
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on May 16, 2025.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on June 4, 2025.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on June 4, 2025.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Staffing
Total nurse staffing reported to CMS went from 4.4 to 3.9 hours per resident per day.
CMS update of March 26, 2025
Fine
CMS changed the fine from October 24, 2024 from $13,575 to $8,824.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
Fine
CMS changed the fine from April 18, 2024 from $8,021 to $8,167.
CMS update of December 20, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 5 of 5 to 4 of 5.
Fine
CMS changed the fine from April 18, 2024 from $12,340 to $8,021.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 4 of 5.
Health inspection on October 24, 2024
1 citationCMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
143 of 1,177 Texas homes (12%) got a citation at the actual harm level in 2024.
CMS fine of $8,976 on October 24, 2024.
Show the 1 citation
Citation F0689. Severity G: actual harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on July 2, 2024.
CMS update of September 26, 2024
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 5 of 5.
Health inspection on August 20, 2024
2 citationsCMS lists this as a complaint inspection.
Show the 2 citations
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on September 25, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on August 21, 2024.
CMS has cited this home for F0760 2 times since 2024.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS health inspection star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Health inspection on April 18, 2024
2 citationsCMS lists this as a standard inspection and a complaint inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
411 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2024.
CMS fine of $8,167 on April 18, 2024.
Show the 2 citations
Citation F0760. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on February 2, 2024.
Citation F0550. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on May 22, 2024.
Fire safety inspection on April 18, 2024
1 citationCMS lists this as a standard inspection.
Show the 1 citation
Citation K0324. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 23, 2024.
Health inspection on January 30, 2024
1 citationCMS lists this as a complaint inspection.
Show the 1 citation
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 23, 2024.
CMS star ratings
- 3 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (214) 221-0444
- Last standard health inspection
- July 23, 2026 (3 months ago)
- Certified beds
- 126
- Residents per day, on average
- 100.3
- Ownership type
- For profit - Partnership
- Legal business name
- Jsc Lake Highlands Operations, LP
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Texas average (25 vs 28).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- JSC LAKE HIGHLANDS I SENIOR LIVING, LP5% or greater direct ownership interest · 100% · since 04/15/2010
- JAVELIN GROUP FUNDING I, LP5% or greater indirect ownership interest · no percentage provided · since 09/01/2016
- JSC LAKE HIGHLANDS I SENIOR LIVING, LP5% or greater indirect ownership interest · no percentage provided · since 03/25/2009
- VILLAGE SENIOR CARE LLCOperational/managerial control · not applicable · since 09/01/2016
- KAMRAN, MUBASHIROperational/managerial control · not applicable · since 09/01/2025
Show 1 more
- WOLFE, KELLYOperational/managerial control · not applicable · since 09/01/2016
Questions
When was Villages of Lake Highlands last inspected?
CMS lists July 23, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Villages of Lake Highlands have?
CMS lists 25 health citations since January 30, 2024. CMS also calls these deficiencies.
Has Villages of Lake Highlands been fined?
CMS lists 3 fines in the past three years, $29,022 in total.
What is the CMS star rating of Villages of Lake Highlands?
Its CMS overall star rating is 3 of 5.
Is Villages of Lake Highlands a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.