For profit - Corporation · 126 certified beds · CMS number 676268
Villages of Lake Highlands, Dallas, TX
CMS records 13 health deficiencies at Villages of Lake Highlands in Dallas, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on May 16, 2025. The highest severity cited is K (immediate jeopardy to resident health or safety). 4 citations were at the immediate jeopardy level, 2 of them recorded as past non-compliance (fixed before the inspection). CMS lists 3 fines totaling $29,022 in the last three years.
- 13deficiencies, 3 cycles (TX median 25)
- 6in the latest cycle (TX median 8)
- Khighest severity · Immediate jeopardy
- $29,022fines, last 3 years
- 2CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Villages of Lake Highlands as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Villages of Lake Highlands may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (6 deficiencies)
Standard inspection May 16, 2025. CMS counts 6 health deficiencies and 3 fire safety deficiencies in this cycle.
Dec 1, 2025 · Complaint inspection
1 deficiency, highest D
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 5, 2025
Sep 13, 2025 · Complaint inspection
2 deficiencies, highest J
F842 · Complete, confidential medical records
Requirement cited (CMS): Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Past non-compliance (fixed before the inspection)
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection)
May 16, 2025 · Standard + complaint inspection
3 deficiencies, highest K
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 20, 2025
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 20, 2025
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date May 20, 2025
Previous cycle: 4 deficiencies (standard inspection Apr 18, 2024)
Standard inspection Apr 18, 2024. CMS counts 4 health deficiencies and 1 fire safety deficiency in this cycle.
Aug 28, 2025 · Complaint inspection
1 deficiency, highest K
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Aug 29, 2025
Oct 24, 2024 · Complaint inspection
1 deficiency, highest G
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- G Actual harm (not immediate jeopardy), isolated
- Status
- Past non-compliance (fixed before the inspection), Jul 2, 2024
Apr 18, 2024 · Standard + complaint inspection
2 deficiencies, highest J
F760 · No significant medication errors
Requirement cited (CMS): Ensure that residents are free from significant medication errors.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), Feb 2, 2024
F550 · Dignity and the right to exercise rights
Requirement cited (CMS): Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 22, 2024
Earlier cycle: 3 deficiencies (standard inspection Feb 9, 2023)
Standard inspection Feb 9, 2023. CMS counts 3 health deficiencies and 3 fire safety deficiencies in this cycle.
Aug 20, 2024 · Complaint inspection
2 deficiencies, highest D
F760 · No significant medication errors
Requirement cited (CMS): Ensure that residents are free from significant medication errors.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 21, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 25, 2024
Jan 30, 2024 · Complaint inspection
1 deficiency, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 23, 2024
- Found in
- infection control inspection
Tags cited in more than one inspection
4 tags cited on more than one inspection date at Villages of Lake Highlands; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F656 Comprehensive person-centered care plan | 2 | Dec 1, 2025; Aug 20, 2024 |
| F684 Quality of care | 2 | Sep 13, 2025 (PNC); Aug 28, 2025 |
| F760 No significant medication errors | 2 | Aug 20, 2024; Apr 18, 2024 (PNC) |
| F880 Infection prevention and control program | 2 | May 16, 2025; Jan 30, 2024 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Aug 28, 2025 | Fine | $11,879 |
| Oct 24, 2024 | Fine | $8,976 |
| Apr 18, 2024 | Fine | $8,167 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 4.48 h (above the Texas median of 3.27 h)
- RN hours per resident per day
- 0.52 h (above the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 4.05 h
- Nursing staff turnover
- 35.4% (Texas median 52.1%)
- Administrators who left
- 1
- CMS overall rating
- 2 of 5
- Health inspection rating
- 1 of 5
- Staffing rating
- 4 of 5
- Quality measure rating
- 5 of 5
CMS figures for Villages of Lake Highlands, copied as published; Texas medians are ours.
Facility details
- Address
- 8615 Lullwater Drive, Dallas, TX 75238
- Phone
- (214) 221-0444
- County
- Dallas
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Corporation
- Chain (CMS)
- Not part of a chain in CMS data
- Certified beds
- 126
- Average residents per day
- 111.1
- In Medicare/Medicaid since
- Nov 19, 2010
- Inside a hospital
- No
- Continuing care retirement community
- Yes
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How are a resident's goals and preferences written into the care plan? (F656, cited 2 times)
- How does the home make sure doctor's orders are followed consistently across shifts? (F684, cited 2 times)
- What happens when a medication error is discovered, and who is notified? (F760, cited 2 times)
- How do staff track and report infections among residents? (F880, cited 2 times)
Other nursing homes in Dallas
- South Dallas Nursing & Rehabilitation
Dallas · 62 deficiencies - Five Points at Lake Highlands Nursing and Rehab
Dallas · 53 deficiencies - Forest Park Nursing & Rehabilitation
Dallas · 51 deficiencies - Avir at The Meadow
Dallas · 44 deficiencies - Lakewest Rehabilitation and Skilled Care
Dallas · 44 deficiencies - The Hillcrest of North Dallas
Dallas · 44 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.