01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-16 | 7 | 2025-05-16 | 3 |
| Cycle 2 | 2024-04-18 | 5 | 2024-04-18 | 1 |
| Cycle 3 | 2023-02-09 | 2 | 2023-02-09 | 3 |
CMS CCN 6762682026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Villages Of Lake Highlands
8615 Lullwater Dr · Dallas, TX 75238 · Dallas County
Certified beds126CMS provider file
Recent citation rows21current CMS citation release
Penalty rows3current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
21 rows in the current release
5 rows carry G–L scope/severity codes; 4 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-01 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-11-05 · complaint2025-09-13 · HEALTHF0684Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Past Non-Compliance · complaint2025-09-13 · HEALTHF0842Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Past Non-Compliance · complaint2025-08-28 · HEALTHF0684Severity K · pattern of immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-08-29 · complaint2025-05-16 · HEALTHF0695Severity K · pattern of immediate jeopardy
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-05-20 · complaint2025-05-16 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-05-16 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-05-16 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-06-042025-05-16 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-05-162025-05-16 · FIREK0923Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2025-06-042024-10-24 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2024-07-02 · complaint2024-08-20 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2024-09-25 · complaint2024-08-20 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-08-21 · complaint2024-04-18 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-05-222024-04-18 · HEALTHF0760Severity J · isolated immediate jeopardy
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Past Non-Compliance · 2024-02-02 · complaint2024-04-18 · FIREK0324Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-04-232024-01-30 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-02-23 · complaint · infection control2023-08-10 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2023-09-04 · complaint2023-02-09 · FIREK0347Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Properly provide smoke detection systems in areas open to corridors.
Correction field: Deficient, Provider has date of correction · 2023-03-012023-02-09 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2023-03-012023-02-09 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2023-03-0103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-08-28 | Fine | $11,879 | 0 |
| 2024-10-24 | Fine | $8,976 | 0 |
| 2024-04-18 | Fine | $8,167 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- JSC LAKE HIGHLANDS I SENIOR LIVING, LPOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/15/2010
- JAVELIN GROUP FUNDING I, LPOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 09/01/2016
- JSC LAKE HIGHLANDS I SENIOR LIVING, LPOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDED · since 03/25/2009
- VILLAGE SENIOR CARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2016
- KAMRAN, MUBASHIRIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2025
- WOLFE, KELLYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2016
- VILLAGE SENIOR CARE LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 01/21/2026
- EDEN, KEVINIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/01/2020
- KAMRAN, MUBASHIRIndividual · ADP OF THE SNFNOT APPLICABLE · since 09/01/2025
- NAUL, ALANIndividual · ADP OF THE SNFNOT APPLICABLE · since 05/01/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.48per resident day
RN hours0.52per resident day
Weekend nurse hours4.05per resident day
Staff turnover35.4%CMS reported field
06 / LOCAL RECORDS
Open the Dallas ledger →Other published facilities nearby
Avir At Dallas136 beds · CMS overall 1/549 citation rowsAvir At The Meadow184 beds · CMS overall 1/568 citation rowsBrentwood Place Four90 beds · CMS overall 3/530 citation rowsBrentwood Place One120 beds · CMS overall 5/517 citation rowsBrentwood Place Three120 beds · CMS overall 1/529 citation rowsBrentwood Place Two120 beds · CMS overall 3/536 citation rowsC C Young Memorial Home129 beds · CMS overall 5/513 citation rowsContinuing Care At Highland Springs44 beds · CMS overall 3/524 citation rows