D70

Villages of Lake Highlands

Grade D 70/100 composite score

For profit - Corporation

CMS Star Ratings

Overall
2/5
Health Insp.
1/5
Quality
5/5
Staffing
4/5
RN Staffing
Not rated

Certified Beds

126

Ownership

For profit - Corporation

Total Fines

$35,098

Last Survey

N/A

8615 Lullwater Dr, Dallas, TX 75238
2142210444

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.54h
LPN
1.73h
CNA
2.28h
Total
4.55h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

JSC LAKE HIGHLANDS I SENIOR LIVING, LP

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Apr 2010

100%

JAVELIN GROUP FUNDING I, LP

Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Apr 2020

EDEN, KEVIN

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Apr 2020

NAUL, ALAN

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Apr 2020

JAVELIN GROUP GEN PAR I, LLC

OrganizationGENERAL PARTNERSHIP INTERESTSince Apr 2010

CELEBRATION SENIOR CARE LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Apr 2019

EDEN, KEVIN

IndividualCORPORATE OFFICERSince Apr 2020

NAUL, ALAN

IndividualCORPORATE OFFICERSince Apr 2020

WOLFE, KELLY

IndividualW-2 MANAGING EMPLOYEESince Aug 2016

Penalties & Fines (3)

$35,098total fines
DateTypeDescriptionAmount
Aug 28, 2025Fine$17,955
Oct 24, 2024Fine$8,976
Apr 18, 2024Fine$8,167

Health Inspection Deficiencies (14)

December 1, 2025Health1 deficiency
0656DMinimal harm, Isolated

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

September 13, 2025Health2 deficiencies1 severe
0684JImmediate jeopardy, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

0842EMinimal harm, Pattern

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

August 28, 2025Health1 deficiency1 severe
0684KImmediate jeopardy, Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Aug 29, 2025
May 16, 2025Health3 deficiencies1 severe
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected May 20, 2025
0761EMinimal harm, Pattern

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

Corrected May 20, 2025
0695KImmediate jeopardy, Pattern

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected May 20, 2025
October 24, 2024Health1 deficiency1 severe
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Jul 2, 2024
August 20, 2024Health2 deficiencies
0656DMinimal harm, Isolated

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

Corrected Sep 25, 2024
0760DMinimal harm, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Aug 21, 2024
April 18, 2024Health2 deficiencies1 severe
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected May 22, 2024
0760JImmediate jeopardy, Isolated

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Feb 2, 2024
January 30, 2024Health1 deficiency
0880EMinimal harm, Pattern

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Feb 23, 2024
August 10, 2023Health1 deficiency
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Sep 4, 2023

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Frequently Asked Questions

What is the CareGrader rating for Villages of Lake Highlands?

Villages of Lake Highlands in Dallas, Texas has a CareGrader grade of D (Below Average), with a composite score of 69.5 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for Villages of Lake Highlands?

Villages of Lake Highlands has an overall CMS star rating of 2 out of 5, a health inspection rating of 1/5, and a staffing rating of 4/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does Villages of Lake Highlands have?

Villages of Lake Highlands has 14 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has Villages of Lake Highlands been fined?

Yes. Villages of Lake Highlands has $35,098 in total fines from CMS enforcement actions across 3 penalties.

How many beds does Villages of Lake Highlands have?

Villages of Lake Highlands has 126 certified beds with approximately 117 current residents (93% occupancy). The facility is located at 8615 Lullwater Dr, Dallas, Texas 75238. It is a for profit - corporation facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.