A+
98/100DISCOVERY VILLAGE AT SOUTHLAKE Inspection Report, Violations & Safety Grade (SOUTHLAKE, Texas)
201 WATERMERE DRIVE, SOUTHLAKE, Texas 76092
Phone: 8174821340
CMS Overall:5/5
Overview & Bed Count
Certified Beds
41
Avg Residents/Day
41
Ownership
For profit - Corporation
Provider Type
Medicare
County
Tarrant
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall5/5
Health5/5
Staffing5/5
Quality2/5
Nurse Staffing Check
| Metric | This Facility | Texas Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.98 | 0.44 | +0.53 |
| Total Nurse Hours per Resident per Day | 3.85 | 3.42 | +0.44 |
| CMS Staffing Rating | 5/5 | 1.9/5 | - |
| Nursing Staff Turnover | 23.7% | 50.8% | - |
Health Citation History
14 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-04 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2026-06-04 | Environmental Deficiencies | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D – Moderate Harm Potential |
| 2025-11-12 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2025-11-12 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2025-04-11 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | E – Moderate Harm Potential |
| 2025-04-11 | Quality of Life and Care Deficiencies | 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. | E – Moderate Harm Potential |
| 2025-04-11 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | D – Moderate Harm Potential |
| 2024-03-14 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-03-14 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | F – Moderate Harm Potential |
| 2024-03-14 | Administration Deficiencies | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F – Moderate Harm Potential |
| 2024-03-14 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | E – Moderate Harm Potential |
| 2024-03-14 | Quality of Life and Care Deficiencies | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | D – Moderate Harm Potential |
| 2024-03-14 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-03-14 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
Fire Safety Citation History
15 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-06-04 | Emergency Preparedness Deficiencies | Establish policies and procedures for volunteers. | F – Moderate Harm Potential |
| 2026-06-04 | Emergency Preparedness Deficiencies | Establish roles under a Waiver declared by secretary. | F – Moderate Harm Potential |
| 2026-06-04 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | F – Moderate Harm Potential |
| 2025-04-11 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2025-04-11 | Emergency Preparedness Deficiencies | Include a process for Emergency Preparedness collaboration. | F – Moderate Harm Potential |
| 2025-04-11 | Emergency Preparedness Deficiencies | Establish roles under a Waiver declared by secretary. | F – Moderate Harm Potential |
| 2025-04-11 | Smoke Deficiencies | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | F – Moderate Harm Potential |
| 2025-04-11 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2025-04-11 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2025-04-11 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2025-04-11 | Smoke Deficiencies | Provide properly protected cooking facilities. | E – Moderate Harm Potential |
| 2025-04-11 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2024-03-14 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2024-03-14 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2024-03-14 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
Total Penalties & Fines
$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties
No penalty records found.
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the SOUTHLAKE area at no cost.
Find Safe, Vetted Facilities Near SOUTHLAKE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.