Villages of Lake Highlands

8615 Lullwater Dr, Dallas, TX 75238

Independent ratings: No payments from facilities
B

Near federal staffing minimum — above average inspection record.

Quality Breakdown

RN Staffing
Registered nurse time each resident receives daily. Federal minimum: 0.55 hrs.
0.52 ✗ Below federal minimum (0.55)
Health Deficiencies
Violations found during federal inspections over the last 3 years.
7
CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
Quality: ★★★★★ (5/5)
Staffing: ★★★★☆ (4/5)
NursingHomeGrade Score
73/100

Data last updated: April 12, 2026

Inspection Deficiencies

Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).

Most recent inspection (May 16, 2025)

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025

E Potential harm — pattern F0761 Status: Corrected

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 — Deficient, Provider has date of correction, corrected May 20, 2025

J Immediate jeopardy — isolated F0684 Status: Outstanding

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

Quality of Life and Care Deficiencies — Past Non-Compliance

K Immediate jeopardy — pattern F0684 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected August 29, 2025

K Immediate jeopardy — pattern F0695 Status: Corrected

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

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 20, 2025

D Potential harm — isolated F0656 Status: Corrected

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 — Deficient, Provider has date of correction, corrected November 5, 2025

E Potential harm — pattern F0842 Status: Outstanding

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 — Past Non-Compliance

Inspection cycle 2 (August 20, 2024)

D Potential harm — isolated F0760 Status: Corrected

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected August 21, 2024

J Immediate jeopardy — isolated F0760 Status: Corrected

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Past Non-Compliance, corrected February 2, 2024

G Actual harm — isolated F0689 Status: Corrected

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

Quality of Life and Care Deficiencies — Past Non-Compliance, corrected July 2, 2024

D Potential harm — isolated F0656 Status: Corrected

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 — Deficient, Provider has date of correction, corrected September 25, 2024

D Potential harm — isolated F0550 Status: Corrected

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

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 22, 2024

Inspection cycle 3 (January 30, 2024)

E Potential harm — pattern F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 23, 2024

D Potential harm — isolated F0880 Status: Corrected

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected September 4, 2023

Quality Assurance & Integrity

NursingHomeGrade is strictly independent. We do not accept payments from facilities. Our grades are calculated solely from federal CMS datasets.

Learn about our data methodology →

Nearby facilities in Dallas

Compare local nursing homes using the same CMS-backed grading method.

Compare nearby →
D

AVIR AT DALLAS

4200 Live Oak St, Dallas, TX 75204

45/100 score 0.23 hrs RN staffing 10 deficiencies

Need help choosing a facility?

Get free guidance from senior living advisors. We may earn a referral fee from comparison services, but never from nursing facilities and never in ways that affect grades.

Compare nearby options → Get free help →

Get score alerts for this facility

We'll email you when Villages of Lake Highlands's staffing score changes.