Public Record
Discovery Village at Southlake
From CMS
Facility profile
- CMS overall rating
- 4 / 5
- Certified beds
- 41
- Avg. residents per day
- 42
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Health citations
- 16
- Fire safety findings
- 12
- Inspections on file
- 7
- Last inspection
- 2025-11-12
*CMS
*CMS
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*CMS
Citations
16 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0700Generalpotential for harm
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.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0851Generalpotential for harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0583Generalpotential for harm
Keep residents' personal and medical records private and confidential.
- 0700Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0814Generalpotential for harm
Dispose of garbage and refuse properly.
- 0760Seriousimmediate jeopardy
Ensure that residents are free from significant medication errors.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- Inspection2 deficiencies
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based…
Read full statement of deficiencies - View inspection reportInspectionFire Safety9 deficiencies
- Inspection3 deficiencies
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based…
Read full statement of deficiencies - Inspection7 deficiencies
F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure each resident had a right to secure and confidential personal and medical records…
Read full statement of deficiencies - View inspection reportInspectionFire Safety3 deficiencies
- Inspection1 deficiency
F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to provide pharmaceutical…
Read full statement of deficiencies - Inspection3 deficiencies
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based…
Read full statement of deficiencies
FAQ
Questions and answers
- What is Discovery Village at Southlake?
- Discovery Village at Southlake is a Medicare- and Medicaid-certified nursing home in Southlake, TX, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 676351.
- What is the CMS rating for Discovery Village at Southlake?
- Discovery Village at Southlake has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Discovery Village at Southlake have?
- Discovery Village at Southlake is certified for 41 beds. It serves an average of 42 residents per day.
- How many citations does Discovery Village at Southlake have?
- Discovery Village at Southlake has 16 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Discovery Village at Southlake last inspected?
- Discovery Village at Southlake was last inspected on November 12, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/676351-discovery-village-at-southlake