Discovery Village at Southlake
Southlake, Texas · CCN 676351
11 surveys since 2015, 9 of them producing a finding at harm level or worse.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
- Citations on record
- 59
- Surveys
- 11
- Harm or worse
- 9
- Immediate jeopardyall corrected before survey
- 5
Findings at the most serious level CMS records. All were recorded as past non-compliance — corrected before the survey.
Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.
The facility
- Certified beds
- 41
- Ownership
- For profit - Corporation
- Chain
- Independent
- County
- Tarrant
- Medicare-certified since
- 2014
CMS ratings
- Overall
- 5
- Health inspection
- 5
- Staffing
- 4
- Quality measures
- 2
CMS’s own Five-Star ratings.
Compared with similar facilities
Not shown for this facility: too few citations in window (n=18, floor 20).
Last survey on record
Jun 4, 2026
158 days ago.
Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.
Staffing
| Measure | This facility | Peer median |
|---|---|---|
| Nurse hours per resident day | 3.63 | 3.40 |
| Registered-nurse hours per resident day | 0.85 | — |
| Annual nurse turnover | 43.2% | 50.0% |
As reported by the facility to CMS, beside the peer-group median.
Enforcement
- Fines
- $12,649 across 1 penalty
Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.
Severity of recent findings
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J15.6% | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D844.4% | E633.3% | F316.7% |
| No harm, potential for minimal | A— | B— | C— |
Most frequently cited here
In CMS’s current monthly file.
- F6563×
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- F8123×
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- F6952×
Provide safe and appropriate respiratory care for a resident when needed.
- F7002×
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
- F5831×
Keep residents' personal and medical records private and confidential.
In the surveyor’s words
From the most serious findings on record at Discovery Village at Southlake, in the surveyor’s own words.
- Immediate jeopardy, isolatedF760Sep 29, 2023
Based on, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of two residents reviewed for medication administration. LVN A failed to transcribe the correction medication list when Resident #1 was discharged from the hospital back to the facility, which led to Resident #1 being administered incorrect medications from 09/14/23 to 09/16/23 which were originally for Resident #2. The IJ (Immediate Jeopardy) was identified as past noncompliance (PNC) on 09/14/23 and ended on 09/16/23. […]
- No harm, potential for more than minimal, widespreadF812Mar 14, 2024
Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation and storage. The facility failed to ensure the thermometer used in the refrigerator read the accurate temperature. This failure could place residents at risk of foodborne illness. Findings included: Observation and interview on 03/12/2024 at 8:59 AM revealed the thermometer hanging on one of the shelves inside of the refrigerator read 50 degrees F. The Assistant Dietary Manager read the thermometer at 50 degrees F and stated she could put another thermometer inside. She said the temperature should be 41 degrees or below. […]
- No harm, potential for more than minimal, widespreadF814Mar 14, 2024
Based on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 out of 1 kitchen observed. The facility failed to have a garbage can near the handwashing sink. The facility failed to ensure garbage cans with lids were used in the kitchen. This failure could place residents at risk for foodborne illness. Findings included: Observation and interview on 03/12/2024 at 8:59 AM, revealed there was no trash can with a lid near the handwashing sink. The Assistant Dietary Manager stated they had a step trash can, but it was broken, and another one was supposed to be in today. She moved a garbage can without a lid (that was not in use) from the food prep area and put it near the sink. […]
- No harm, potential for more than minimal, widespreadF851Mar 14, 2024
Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for quarter review for Fiscal year Quarter 1 of 2024 (October 1- December 31, 2023). The facility failed to submit RN staff hours for 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. Findings included: Review of the CMS PBJ report for Fiscal Year Quarter 1 of 2024 (October 1- December 31, 2023) reflected No RN Hours was triggered, for lack of RN coverage on 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. Review of RN time stamp detail sheets for DON and direct care schedules for 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23 reflected sufficient RN coverage on those dates. […]
- No harm, potential for more than minimal, patternF656Nov 12, 2025
Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop a care plan to address Resident #1's needs as follows:1. Stage 2 wound on his bottom (pressure ulcer)2. Right heel edema (leg swelling)3. Bowl movement changes due to ileus (this is temporary slowing or cessation of intestinal movement)4. […]
Read 28 findings in full →The most serious and the most recent: 28 of 59 on record.
Every survey on record
FindingsAt actual harm or above
- Jun 4, 2026Standard2 findings
- Nov 12, 2025Complaint2 findings
- Apr 11, 2025Standard3 findings
- Mar 14, 2024Standard7 findings
- Sep 29, 2023Complaint1 finding · 1 harm
- Jan 20, 2023Standard3 findings
- Nov 21, 2019Standard3 findings
- Jan 8, 2019Standard16 findings · 1 harm
Show the 3 earlier surveys
- Jan 13, 2017Standard and complaint10 findings
- Nov 18, 2015Standard2 findings · 1 harm
- Jan 31, 2015Standard and complaint10 findings · 6 harm
Surveys that found no deficiencies are not in CMS’s files and do not appear here.
Comparable facilities
The nearest facilities to this one in the same peer group, by weighted findings.
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