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Complaint Investigation

Villages Of Lake Highlands

September 13, 2025 · Dallas, TX · 8615 Lullwater Dr
Citations 2
CMS Rating 2/5
Beds 126
Provider ID 676268
Healthcare Facility
Villages Of Lake Highlands
Dallas, TX  ·  View full profile →
Inspection Summary

Villages of Lake Highlands in Dallas, TX — inspection on September 13, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0684
Quality of Life and Care Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

property without consent.4.

All staff considered mandatory reporters of abuse, neglect and misappropriation5. If you witness or suspect abuse, neglect, or misappropriation, your first responsibility is to:-I have attended training on abuse, neglect, and misappropriation-I understand the definitions, signs, and reporting requirements-I understand that I am a mandatory reporter and must immediately report any suspected or witnessed abuse, neglect, or misappropriation.-I understand that failure to follow reporting procedures may result in disciplinary action, up tp and including termination, and potential legal consequences.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/13/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Villages of Lake Highlands

8615 Lullwater Dr Dallas, TX 75238

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited Villages of Lake Highlands in Dallas, TX for a deficiency under regulatory tag F-F0842 during a complaint investigation conducted on 2025-09-13.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 2 deficiencies cited during this inspection of Villages of Lake Highlands.

Correction Status: Past Non-Compliance.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Dallas, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Villages of Lake Highlands or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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