Villages of Lake Highlands: Data Analysis and Ratings
CMS Five Star Rating(5 out of 5):
8615 LULLWATER DR DALLAS, TX 75238
214-221-0444
Data date: April 01, 2023
The Most Important Data about Villages of Lake Highlands
We've looked at a lot of nursing homes, this is what we think you need to see first and if you don't want to spend a lot of time. (It's the tl;dr section.)
There is no indication of abuse occuring at Villages of Lake Highlands. (CMS flags facilities where abuse has either happened or is very likely.)
CMS 5-Star Overall Rating:
(5 out of 5):
(The national average overall star rating is 3 stars.)
Current Trend: Improving
Total Nursing Hours Spent Per Resident Per Day: 4.22
(The national average is 3.74 )
According to our analysis, Villages of Lake Highlands is ranked #4 out of 149 skilled nursing homes within a 25 mile radius. See detailed information from recent inspection reports, nursing hours analysis, surverys, and information on owners and operators. Click here to view the ranked list of nursing homes near Villages of Lake Highlands.
What is this page all about?
Below is everything shred of information that we can find about Villages of Lake Highlands, along with our best effort to make sense of the data. Our purpose here is to help you to make good decisions when picking a nursing home and to keep you informed once you have chosen a home. We know from personal experience that choosing a nursing home is not something you do once and then you forget about it. In fact, it gets worse. Once you select a nursing home and get through the initial steps of figuring out how to pay for it, then the real worries start. Are they taking good care of me or my loved one? This is the question that will keep you up at night: Can I really trust these people? We wish we could answer this question, we can't. What he can do is churn through the tons of data and try and help you to make sense of it. We hope it helps.
General Data Card
These are the basic data points for the facility.
Data date: April 01, 2023
Address: 8615 LULLWATER DR
DALLAS, TX 75238
Phone: 214-221-0444
Ranking: Villages of Lake Highlands is ranked #2 out of 59 facilities within a 10 mile radius and #4 out of 149 facilities within a 25 mile radius.
Medicare Provider Number: 676268
Participating in Medicare Since: November 19, 2010
No. of Certified Beds: 131
No. of Residents: 117
Occupancy: 89.31 % (as of 04/30/2023 )
Amount fined in recent period: $650.00
Complaints filed: 2
Ratings History for Villages of Lake Highlands
Review of Villages of Lake Highlands Ratings and Inspection Scores
CMS regularly inspects every skilled nursing facility. (The timing is supposed to be annually, but since the beginning of the Covid pandemic, these inspections have not occured as frequently.) The results of the multi-day inspection is reduced to a series of scores which are then translated into the star ratings. The health inspection scores are an absolute value, so you can compare one facility's score directly to another. The Overall Star rating is based on the facility's performance as compared to other facilities in the same state, so you cannot easily compare one facility's Overall star rating to a facility in another state.
Ratings
| Overall Rating | 5: |
| Health Inspection Rating | 5: |
| Quality Rating | 4: |
| Staffing Rating | 4: |
Inspection Scores
| Cycle 1 Score | NA |
| Cycle 2 Score (as of October 21, 2021) | 12 |
| Cycle 3 Score (as of November 08, 2019) | 8 |
| Weighted All Cycles Score | 5 |
It has been 1 months since the most recent inspection.
What Goes Into the Nursing Home's 5-Star Rating
CMS has put a lot of effort into creating its very elaborate 5-Star Quality Rating System specifically to provide a quick way for residents and family members to easily understand how well a nursing home is performing and to make comparing nursing homes easier. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and best performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.
The rating system has five separate ratings including:
- Overall rating
- Health Inspection rating
- Staff rating
- RN Staffing rating
- Quality Measures rating
Nursing homes are rated from 1-star to 5-stars with 1-star being the best rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS. See the latest cut rates on this table.
Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :
- Begin with the Health Inspection Rating
- Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
- Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
- Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
- Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.
Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)
Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.
Most Recent Nursing Home Inspections
CMS is required to inspect each senior nursing facility at least annually. These inspections take several days. Additional follow-up inspections as conducted as needed or for certain purposes. Inspections stopped for more than seven months in 2020 due to the Covid pandemic. That stoppage has caused all inspections to be delayed as the inspectors continue to deal with a backlog. The table below shows the latest inspections for Villages of Lake Highlands including health, fire, and inspection control inspections:
| Inspection Type | Inspection Date |
|---|---|
| Fire Safety Standard | February 08, 2023 |
| Fire Safety Standard | October 19, 2021 |
| Fire Safety Standard | November 07, 2019 |
| Health Complaint | October 06, 2021 |
| Health Standard | February 09, 2023 |
| Health Standard | October 21, 2021 |
| Health Standard | November 08, 2019 |
| Infection Control | January 05, 2023 |
| Infection Control | November 01, 2022 |
| Infection Control | August 16, 2022 |
| Infection Control | May 04, 2022 |
| Infection Control | March 07, 2022 |
| Infection Control | January 31, 2022 |
| Infection Control | October 06, 2021 |
| Infection Control | September 21, 2021 |
| Infection Control | March 17, 2021 |
| Infection Control | February 05, 2021 |
| Infection Control | November 10, 2020 |
| Infection Control | October 22, 2020 |
| Infection Control | August 25, 2020 |
| Infection Control | July 28, 2020 |
| Infection Control | April 08, 2020 |
Owner and Operator Information for Villages of Lake Highlands
Our database of owners and operators shows all direct owners of the nursing nurse, any managers and directors, and the most adjacent indirect owners of the facility (that is, if the direct owner is company, then the owners of that company.) Lists of nursing home owners are available and you can search for nursing home owners and operators on our site.
Business Entity Name:
JSC LAKE HIGHLANDS OPERATIONS, LP
Owners:
- KEVIN EDEN (INDIRECT)
- JAVELIN GROUP FUNDING I LP (INDIRECT)
- JSC LAKE HIGHLANDS I SENIOR LIVING LP (DIRECT- 100%)
- ALAN NAUL (INDIRECT)
Managers and Directors:
- CELEBRATION SENIOR CARE LLC (OPERATIONAL/MANAGERIAL CONTROL)
- KEVIN EDEN (OFFICER)
- ALAN NAUL (OFFICER)
- KELLY WOLFE (MANAGING EMPLOYEE)
Analysis of Nursing Hours Spent Per Patient
CMS provides detailed information about how long nursing staff spends with residents. This data includes nursing subcategories of Registered Nurse, Licensed Practical Nurse, and non-nursing Certified Nursing Assistants. More hours spend per patient should can indicate a better facility or it could indicate more complicated situations.
The nursing staff of Villages of Lake Highlands spends MORE time on average with its residents than the state average for total nursing homes spent per resident and MORE time than the national average for total nursing homes spent per resident.
| Type | Facility | State / National Avg |
|---|---|---|
| Registered Nurse (RN) | ||
| Hours | 0.60 | 0.36 / 0.65 |
| Case Mix | 0.32 | 0.42 / 0.39 |
| Adjusted | 0.74 | NA / NA |
| Licensed Practical Nurse (LPN) | ||
| Hours | 1.37 | 1.02 / 0.88 |
| Case Mix | 0.69 | NA / NA |
| Adjusted | 1.45 | NA / NA |
| Certified Nursing Assistants (CNA) | ||
| Hours | 2.25 | 1.93 / 2.21 |
| Case Mix | 2.05 | NA / NA |
| Adjusted | 2.23 | NA / NA |
| Total Licensed Staff | ||
| Hours | 1.97 | 1.38 / 1.53 |
| Physical Therapist (PT) | ||
| Hours | 0.17 | 0.06 / 0.07 |
| Total Nursing Homes Spent per Resident on Average | ||
| Hours | 4.22 | 3.30 / 3.74 |
| Case Mix | 3.06 | 3.22 / 3.16 |
| Adjusted | 4.35 | NA / NA |
Quality Measures
Quality measures are based both on patient survey information and on the results of actual claims that are filed with CMS. It is not clear what period is covered in the measures.
| Desc. | Perc. | State Avg. / Comparison |
|---|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursing home admission (qm521) | 23.7% |
24.5% Better |
| Percentage of short-stay residents who had an outpatient emergency department visit (qm522) | 7.2% |
12.2% Better |
| Number of hospitalizations per 1000 long-stay resident days (qm551) | 0.8% |
1.9% Better |
| Number of outpatient emergency department visits per 1000 long-stay resident days (qm552) | 0.5% |
1.2% Better |
| Percentage of long-stay residents whose need for help with daily activities has increased (qm401) | 26.3% |
17.2% Worse |
| Percentage of long-stay residents who lose too much weight (qm404) | 1.0% |
4.9% Better |
| Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) | 50.0% |
52.3% Better |
| Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) | 2.1% |
1.5% Worse |
| Percentage of long-stay residents with a urinary tract infection (qm407) | 2.3% |
1.4% Worse |
| Percentage of long-stay residents who have depressive symptoms (qm408) | 4.0% |
5.3% Better |
| Percentage of long-stay residents who were physically restrained (qm409) | 0.0% |
0.0% Better |
| Percentage of long-stay residents experiencing one or more falls with major injury (qm410) | 4.4% |
3.4% Worse |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) | 96.7% |
95.6% Better |
| Percentage of long-stay residents who received an antipsychotic medication (qm419) | 5.1% |
10.1% Better |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) | 60.3% |
83.9% Worse |
| Percentage of short-stay residents who newly received an antipsychotic medication (qm434) | 0.4% |
1.8% Better |
| Percentage of long-stay residents whose ability to move independently worsened (qm451) | 31.6% |
13.4% Worse |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) | 12.8% |
22.1% Better |
| Percentage of high risk long-stay residents with pressure ulcers (qm453) | 8.0% |
7.3% Worse |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm454) | 96.1% |
96.1% Better |
| Percentage of short-stay residents who made improvements in function (qm471) | 67.9% |
66.6% Better |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm472) | 78.6% |
77.8% Better |
Villages of Lake Highlands Violations, Complaints and Fines
These are complaints and fines that are reported by CMS. Some of the data is not very recent, but we have decided to include it here so that you have as much information as possible.
Amount fined in recent period: $650.00, Complaints filed: 2
| Deficiency | Deficiency Date / Date Corrected |
|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. (Fire Safety) | 11-07-2019 / 11-25-2019 |
| Have an alternate power supply for its alarm system. (Fire Safety) | 11-07-2019 / 12-10-2019 |
| Inspect, test, and maintain automatic sprinkler systems. (Fire Safety) | 11-07-2019 / 11-21-2019 |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. (Fire Safety) | 11-07-2019 / 12-10-2019 |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. (Fire Safety) | 11-07-2019 / 11-21-2019 |
| Have properly installed electrical wiring and gas equipment. (Fire Safety) | 11-07-2019 / 11-22-2019 |
| PASARR screening for Mental disorders or Intellectual Disabilities (Health) | 11-08-2019 / 11-22-2019 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Health) | 11-08-2019 / 12-01-2019 |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. (Health) | 11-08-2019 / 11-11-2019 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Health) | 11-08-2019 / 12-09-2019 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Health) | 11-08-2019 / 12-01-2019 |
| Ensure that residents are fully informed and understand their health status, care and treatments. (Health) | 10-06-2021 / 11-15-2021 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Health) | 10-06-2021 / 11-15-2021 |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (Health) | 10-06-2021 / 11-15-2021 |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. (Fire Safety) | 10-19-2021 / 10-20-2021 |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. (Fire Safety) | 10-19-2021 / 10-20-2021 |
| Have properly installed electrical wiring and gas equipment. (Fire Safety) | 10-19-2021 / 10-20-2021 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Health) | 10-21-2021 / 12-01-2021 |
| Properly provide smoke detection systems in areas open to corridors. (Fire Safety) | 02-08-2023 / 03-01-2023 |
| Install corridor and hallway doors that block smoke. (Fire Safety) | 02-08-2023 / 03-01-2023 |
| Have properly installed electrical wiring and gas equipment. (Fire Safety) | 02-08-2023 / 03-01-2023 |
Hospitals Near Villages of Lake Highlands
Quite often skilled nursing facilities and hospitals work closely together to help patients recover or manage a terminal illness. Hospitals deals with acute care while nursing homes treat patients for a longer period of time. New residents at skilled nursing homes typically come from a hospital and nursing home residents may be readmitted to a hospital if their recovery does not proceed well. (Hospital readmission rates are closely monitored by CMS.) Consequently it is important that you consider which hospitals are near a nursing home which choosing one. Below is a list of hospitals near Villages of Lake Highlands.
This information is based on the most recent Hospital data. Historical data is not available.
| Hospital | 5-Star Overall Rating |
|---|---|
|
MEDICAL CITY ARLINGTON 3301 MATLOCK ROAD ARLINGTON, TX 76015 |
2 |
|
MEDICAL CITY PLANO 3901 W 15TH ST PLANO, TX 75075 |
2 |
|
PARKLAND HEALTH & HOSPITAL SYSTEM 5200 HARRY HINES BLVD DALLAS, TX 75235 |
2 |
|
METHODIST RICHARDSON MEDICAL CENTER 2831 E PRESIDENT GEORGE BUSH HIGHWAY RICHARDSON, TX 75082 |
2 |
|
METHODIST CHARLTON MEDICAL CENTER 3500 W WHEATLAND ROAD DALLAS, TX 75237 |
2 |
|
BAYLOR SCOTT & WHITE MEDICAL CENTER-WHITE ROCK 9440 POPPY DR DALLAS, TX 75218 |
2 |
|
BAYLOR SCOTT AND WHITE MEDICAL CENTER SUNNYVALE 231 SOUTH COLLINS ROAD SUNNYVALE, TX 75182 |
2 |
|
TEXAS HEALTH ARLINGTON MEMORIAL HOSPITAL 800 W RANDOL MILL RD ARLINGTON, TX 76012 |
2 |
|
MEDICAL CITY LAS COLINAS 6800 N MACARTHUR BLVD IRVING, TX 75039 |
3 |
|
U S M D HOSPITAL AT ARLINGTON L P 801 W INTERSTATE 20 ARLINGTON, TX 76017 |
3 |
|
METHODIST DALLAS MEDICAL CENTER 1441 NORTH BECKLEY AVENUE DALLAS, TX 75203 |
3 |
|
TEXAS HEALTH PRESBYTERIAN HOSPITAL ALLEN 1105 CENTRAL EXPRESSWAY NORTH ALLEN, TX 75013 |
3 |
|
TEXAS HEALTH PRESBYTERIAN HOSPITAL DALLAS 8200 WALNUT HILL LANE DALLAS, TX 75231 |
3 |
|
BAYLOR SCOTT & WHITE MEDICAL CENTER PLANO 4700 ALLIANCE BOULEVARD PLANO, TX 75093 |
3 |
|
TEXAS HEALTH PRESBYTERIAN HOSPITAL PLANO 6200 W PARKER RD PLANO, TX 75093 |
3 |
|
BAYLOR UNIVERSITY MEDICAL CENTER 3500 GASTON AVE DALLAS, TX 75246 |
3 |
|
SANA HEALTHCARE CARROLLTON D/B/A CARROLLTON REGIONAL MEDICAL CENTER 4343 NORTH JOSEY LANE CARROLLTON, TX 75010 |
3 |
|
METHODIST MANSFIELD MEDICAL CENTER 2700 E BROAD STREET MANSFIELD, TX 76063 |
3 |
|
BAYLOR SCOTT AND WHITE MEDICAL CENTER LAKE POINTE 6800 SCENIC DR ROWLETT, TX 75088 |
3 |
|
MEDICAL CITY DENTON 3535 SOUTH I35 EAST DENTON, TX 76210 |
3 |
Medical Professionals Associated with Villages of Lake Highlands
These are the doctors who are affiliated with Villages of Lake Highlands. The data is from the most recent period. Historical data is not available.
- SHAHINA SUMAN ( INTERNAL MEDICINE - TEXAS HEALTH PHYSICIANS GROUP )
- PHUONG TRINH ( INTERNAL MEDICINE - COGENT HEALTHCARE OF TEXAS PA )
- ANKIT PUNATAR ( INTERNAL MEDICINE - MERIDIAN HEALTH PARTNERS PLLC )
Detailed Analysis Pages:
Depending on the nursing home, this page can get really long. So, we have also broken up the data onto separate pages to allow you to find what you want more easily. We will keep adding to these pages as we continue to analyze the nursing home database.
CMS Five Star Ratings and Quality Measures for Villages of Lake Highlands
Five different rating results plus detailed inspection numbers and quality measures for Villages of Lake Highlands.
Covid Infections at Villages of Lake Highlands
This report is updated weekly and shows new and historical infection levels.
Nursing Hours Analysis for Villages of Lake Highlands
How long a nurse spends with a resident can be an important factor in their recovery. This page shows the average nursing hours spent per resident for RNs, LPNs, CNAs, PTs and all licensed staff.
Ownership Details for Villages of Lake Highlands
A list of all of the registered owners for Villages of Lake Highlands. This includes direct and indirect owners and managers.
Noted Deficiencies for Villages of Lake Highlands
A list of all of the deficiencies for the facility. This includes a description, type of deficiency, incident date and when the facility reports that the incident was corrected.
Comparison Ranking of Nearby Skilled Nursing Facilities
How does Villages of Lake Highlands compare to other skilled nursing facilities? This list shows the competitive set within a 25 mile radius.
Best Nursing Homes in DALLAS, TX
Homes that you should consider. A list ranking the best skilled nursing facilities in DALLAS based on their weighted inspection score as of April 01, 2023.
Worst Nursing Homes in DALLAS, TX
Homes that you avoid if possible. A list ranking the worst skilled nursing facilities in DALLAS based on their weighted inspection score as of April 01, 2023.
Other Data Periods:
Data on Villages of Lake Highlands is available for the following periods:
