CCN 676268
Villages of Lake Highlands
8615 Lullwater Drive, Dallas, TX 75238 · Dallas County
- Ownership
- For profit - Corporation
- Certified beds
- 126
- Residents per day
- 111.1
- Health citations
- 13
- Penalties
- 3
- Fines
- 3 · $29,022
Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Staffing hours
Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.
- Measure
- This home
- State
- U.S.
- Nurse aide
- 2.20
- 2.01
- 2.32
- LPN/LVN
- 1.76
- 0.95
- 0.86
- Registered nurse
- 0.52
- 0.43
- 0.69
- Total nurse staff
- 4.48
- 3.39
- 3.86
- Weekend total
- 4.05
- 2.98
- 3.42
- Weekend RN
- 0.42
- 0.34
- 0.48
Adjusted total nurse hours: 4.71. Adjusted RN hours: 0.54. Case-mix total: 3.65. Case-mix index: 1.333.
Total nursing staff turnover: 35.4%. RN turnover: 56.3%. Administrators who left: 1.
How to read staffing hours
Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Fines and penalties
CMS reports 3 fines totaling $29,022, and 0 payment denials.
| Date | Type | Amount or days |
|---|
| August 28, 2025 | Fine | $11,879 |
| October 24, 2024 | Fine | $8,976 |
| April 18, 2024 | Fine | $8,167 |
Cycle 1 standard survey: May 16, 2025. Health deficiencies counted in cycle 1: 6. Cycle 1 total health score: 169.
Cycle 2 standard survey: April 18, 2024. Cycle 2/3 health deficiencies: 7. Total weighted health survey score: 173.
Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections
Health inspection citations
The Health Deficiencies file lists 13 citations for this home, including 4 at immediate jeopardy and 1 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.
December 1, 2025
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · November 5, 2025 |
September 13, 2025
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1 | J: isolated, immediate jeopardy to resident health or safety | Past Non-Compliance |
| F842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Past Non-Compliance |
August 28, 2025
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | K: pattern, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · August 29, 2025 |
May 16, 2025
3 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Complaint survey · Standard survey · Cycle 1 | K: pattern, immediate jeopardy to resident health or safety | Deficient, Provider has date of correction · May 20, 2025 |
| F761 | 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. Pharmacy Service Deficiencies · Standard survey · Cycle 1 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 20, 2025 |
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 20, 2025 |
October 24, 2024
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2 | G: isolated, actual harm that is not immediate jeopardy | Past Non-Compliance · July 2, 2024 |
August 20, 2024
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · September 25, 2024 |
| F760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Complaint survey · Cycle 3 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · August 21, 2024 |
April 18, 2024
2 citations
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Complaint survey · Standard survey · Cycle 2 | J: isolated, immediate jeopardy to resident health or safety | Past Non-Compliance · February 2, 2024 |
| F550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Standard survey · Cycle 2 | D: isolated, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · May 22, 2024 |
January 30, 2024
1 citation
| Tag | What CMS cited | Scope and severity | Status |
|---|
| F880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Infection control survey · Cycle 3 | E: pattern, no actual harm, with potential for more than minimal harm | Deficient, Provider has date of correction · February 23, 2024 |
Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections