SNF
Villages of Lake Highlands
CCN: 676268 · Dallas, TX 75238 · Dallas County
CCRC
Overview
- Address
- 8615 Lullwater Dr, Dallas, TX 75238
- Phone
- 2142210444
- Certified beds
- 126
- Avg daily residents
- 118 (93% of beds filled)
- Ownership
- For-profit corporation
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 2010-11-19
- Setting
- Urban
2 /5
★★★★★
CMS Overall Rating
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 4.39 | 3.72 | 4.55 | ≥ 3.48 | |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.52 | 0.65 | 0.54 | ≥ 0.55 | Below floor |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 1.67 | 0.83 | 1.73 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 2.20 | 2.25 | 2.28 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 2.19 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.17 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Total nurse (weekend)
3.79
hrs / resident / day
RN (weekend)
0.48
hrs / resident / day
Total nurse (adjusted, weekend)
3.93
hrs / resident / day
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Total nursing staff turnover
43.3%
annual
RN turnover
47.1%
annual
Administrators departed
0
last 12 months
Resident acuity
Nursing Case-Mix Index
1.32
higher acuity than avg
Case-Mix Index Ratio
0.96
facility / state ratio
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-05-16 | 7 | 3 | 5 | 294 | 1 | 294 |
| Cycle 2/3 (prior) | 2024-04-18 | 7 | 2 | 6 | 64 | 1 | 64 |
Total weighted health score
236.5
lower is better
Infection-control citations
1
last cycle
Deficiencies (14)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
9 D/E/F Actual harm — potential for minor
1 G/H/I Actual harm
4 J/K/L Immediate jeopardy
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2025-12-01 | 2025-11-05 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J | 2025-09-13 | — |
| 0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | E | 2025-09-13 | — |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | K | 2025-08-28 | 2025-08-29 |
| 0761 | 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. | E | 2025-05-16 | 2025-05-20 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2025-05-16 | 2025-05-20 |
| 0695 | Provide safe and appropriate respiratory care for a resident when needed. | K | 2025-05-16 | 2025-05-20 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G | 2024-10-24 | 2024-07-02 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2024-08-20 | 2024-09-25 |
| 0760 | Ensure that residents are free from significant medication errors. | D | 2024-08-20 | 2024-08-21 |
| 0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D | 2024-04-18 | 2024-05-22 |
| 0760 | Ensure that residents are free from significant medication errors. | J | 2024-04-18 | 2024-02-02 |
| 0880 | Provide and implement an infection prevention and control program. | E | 2024-01-30 | 2024-02-23 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2023-08-10 | 2023-09-04 |
Penalties (3)
Fines issued
3
last 3 years
Total fines
$28,814
| Date | Type | Fine amount |
|---|---|---|
| 2024-04-18 | Fine | $8,167 |
| 2024-10-24 | Fine | $8,976 |
| 2025-08-28 | Fine | $11,671 |
Source: CMS Nursing Home Penalties.
Financial Health (FY 2023)
Payer mix (share of resident days)
Medicare 20.1% Medicaid 18.8% Other 61.1%
Operating performance
Operating Margin
-0.5%
Total Margin
0.3%
Occupancy Rate
89.6%
Cost per Resident Day
$70
Revenue & costs
Net Patient Revenue
$15.4M
Total Costs
$2.9M
Net Income
$53K
Balance sheet
Total Assets
$1.8M
Total Liabilities
$768K
Fund Balance
$1.0M
Current Ratio
2.23
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Owner / manager organizations (4)
| Organization | Role | Association |
|---|---|---|
| JSC LAKE HIGHLANDS I SENIOR LIVING, LP | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 04/15/2010 |
| JAVELIN GROUP FUNDING I, LP | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 04/17/2020 |
| JAVELIN GROUP GEN PAR I, LLC | GENERAL PARTNERSHIP INTEREST | since 04/15/2010 |
| VILLAGE SENIOR CARE LLC | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2019 |
Owner / manager individuals (5)
| Name | Role | Association |
|---|---|---|
| EDEN, KEVIN | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 04/17/2020 |
| NAUL, ALAN | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | since 04/17/2020 |
| EDEN, KEVIN | CORPORATE OFFICER | since 04/17/2020 |
| NAUL, ALAN | CORPORATE OFFICER | since 04/17/2020 |
| WOLFE, KELLY | W-2 MANAGING EMPLOYEE | since 08/01/2016 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- Yes
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- No
Methodology & sources
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Penalties (
nh-penalties), vintage 2026, downloaded 2026-04-14 , 16,915 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 113 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $70 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 2.23 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 18.8% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 20.1% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $52,981 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $15,448,610 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 89.6% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | -0.5% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $1,789,529 | metrics.total_assets |
| Cost Report | Total Costs ($) | $2,874,874 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $1,021,315 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $768,214 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | 0.3% | metrics.total_margin |
| Provider Information | Abuse Icon | N | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 1.73229 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 2.28226 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.53676 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 4.55131 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 3.92671 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 117.6 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.82639 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.24595 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.65138 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.72372 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.28206 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | — | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | — | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | — | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | — | Chain Average Staffing Rating |
| Provider Information | Chain ID | — | Chain ID |
| Provider Information | Chain Name | — | Chain Name |
| Provider Information | City/Town | Dallas | City/Town |
| Provider Information | CMS Certification Number (CCN) | 676268 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | Y | Continuing Care Retirement Community |
| Provider Information | County/Parish | Dallas | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 2010-11-19 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 1 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 32.8667 | Latitude |
| Provider Information | Legal Business Name | JSC LAKE HIGHLANDS OPERATIONS, LP | Legal Business Name |
| Provider Information | Location | 8615 Lullwater Dr,Dallas,TX,75238 | Location |
| Provider Information | Long-Stay QM Rating | 5 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -96.704 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 0 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 126 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | 1 | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | — | Number of Facilities in Chain |
| Provider Information | Number of Fines | 3 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.31915 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.95754 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 2 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | For profit - Corporation | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 8615 Lullwater Dr | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | Villages of Lake Highlands | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 390 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 5 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 294 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 5 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 1 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 3 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-05-16 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 294 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 7 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 2 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2024-04-18 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 64 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 6 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 64 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 7 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.48003 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 47.1 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 2.18841 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 1.67073 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 2.20116 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.16632 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.51768 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 4.38957 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 5 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 4 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | TX | State |
| Provider Information | Telephone Number | 2142210444 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 28814.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 3.78716 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 3 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 43.3 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 236.500 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 75238 | ZIP Code |