Discovery Village At Southlake

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 4 residents (Resident #40) reviewed for infection control.1.The facility failed to ensure CNA A performed hand hygiene in between glove changes while providing toileting care for Resident #40.2.The facility failed to ensure CNA A disinfected surfaces with acceptable disinfecting wipe. These failures could result in infection. Findings included:Record review of Resident #40's admission MDS assessment, dated 5/17/2026, revealed the resident was an [AGE] year-old female admitted on [DATE] with diagnoses of leg fracture, spine fracture, diabetes mellitus, and pain. The MDS also indicated the resident was dependent on toileting. Record review of Resident #40's care plan, dated 5/12/2026, revealed the resident was care planned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 (Resident #32) of 10 resident rooms reviewed for smoke detectors. The facility failed to ensure Resident #32 had a functional smoke detector installed in his room. This failure could result in an unsafe environment. Findings included:Findings included: Record review of Resident #32 face sheet dated 06/02/26 reflected a [AGE] year-old male admitted on [DATE]. During an interview and observation on 06/02/26 at 10:45 A.M., Resident #32's family member stated his smoke detector would not stop beeping last week and an unknown staff member took it down. Resident # 32's family member stated she had mentioned it to one of the nurses about the smoke detector missing. Observed that the smoke detector was missing from the room. Attempted interview on 06/02/26 at 11:10 A.M., revealed Resident# 32 was not interviewable. During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Disease process Colitis (this is inflammation of the colon which may cause abdominal pain, diarrhea and sometimes blood in stool)5. Use of high blood pressure medication Lisinopril6. Lower urinary tract symptoms due to benign prostatic hyperplasia (urinary difficulty due to enlarged prostate)7. Use of blood thinner Enoxaparin for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure accurately documented skilled nurse notes for Resident #1 on 10/16/25 when RN A documented Resident #1 was a female, he had a left hip fracture, was forgetful, had poor motor coordination, and had balance problems when standing. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the residents' care and place residents at risk for harm due to inaccurate records. Findings include: Record review of Resident #1's face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included high…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 4 of 7 residents (Resident #3, #5, #30, and Resident #34) reviewed for care plans in that: Residents #3, #5, #30, and Resident #34 use of bed rails/grab/transfer bars were not documented in their care plans. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care. Findings included: Resident #3 Record Review of Resident #'3s Face Sheet reflected an [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #3 had relevant diagnoses of Unspecified Atrial Fibrillation (a type of arrhythmia where the heart's upper chambers (atria) beat irregularly and out of sync with the lower chambers (ventricles), and the specific details about its behavior (how long it lasts, how…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to assess the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 4 of 7 residents (Resident #3, #5, #30, and Resident #34) rooms observed for bed rails/grab/transfer bars. The facility did not have informed consent and assessment of the residents for appropriateness or risk of entrapment for bed rails or grab/transfer bars for Residents #3, #5, #30, and Resident #34. This failure could place residents who used bed rails/grab/transfer bars at risk of injury or entrapment not being assessed for appropriateness for bed rails or grab bars, resident/responsible party not being aware of the risks posed by bed rails/grab/transfer bars, and informed consent for the potential dangers posed by grab/transfer bars or bed rails not being obtained from the resident or responsible party. Findings included: Resident #3 Record Review of Resident #'3s Face Sheet reflected an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for food safety. 1. The facility failed to remove five dented cans from the dry food storage area. 2. The facility failed to label a plastic container in the dry food storage area. The failures could place residents at risk for food-borne illness. Findings included: In an observation on 04/09/25 at 10:35 AM of the dry food storage area reflected one plastic container, with a white substance that was not labeled. In an observation on 04/09/25 at 10:42 AM of the dry food storage area reflected the following: *one dented can labeled black eyed peas on the third wired rack of the shelf, *one dented can labeled great northern beans on the second wired rack of the shelf, *two dented cans labeled green beans on the last wired rack of the shelf, and *one dented can labeled black beans on the fourth wired rack of the shelf. In an interview on 04/09/25 at 10:37 AM, the DS stated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. She said the built-in thermometer on the outside of the refrigerator read 37 degrees F. Observation on 03/13/2024 at 11:55 AM revealed a different thermometer inside the refrigerator that read 36 degrees F. Interview on 03/14/2024 at 11:47 AM the Dietary Manager stated she or the cook was responsible to verify the temperature was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. She stated the garbage can was supposed to have a lid for cross contamination. Interview on 03/14/2024 at approximately 11:47 am, the Dietary Manager stated she got three step trash cans with lids and placed them in the kitchen. Interview on 03/14/2024 at 5:42 PM, the Interim Administrator stated the reason for a step trash can was to ensure staff did not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. An interview with DON on 03/13/24 at 03:45 PM revealed that she was responsible for scheduling the nurses. She said that if there was no RN on duty for the day, she would come into work. DON provided RN hours on 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. She said that because she was a salaried employee,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 for 1 (back hallway) of 2 hallways reviewed for privacy and confidentiality. The facility failed to ensure private and confidential clinical records were not left in the back hallway unattended. This deficient practice could place residents at-risk for lack of privacy and confidentiality. The findings included: Continuous observation on 03/14/24 from 11:18 AM to 11:32 AM revealed 3 pages of clinical records titled Midnight Census Report dated 03/13/24. Noted on the printed documents were visible first and last names of residents, room numbers, care levels, and primary payer information. The documents were visible, face up, on a clip board, on top of a bedside table left in the open back hallway near resident's rooms. The bedside table contained menus as well. The documents appeared to have been left by someone who might have entered one of the residents' rooms in the back hallway. Upon entry into the residents' rooms…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections and restore as much bowel functions as possible for 1 of 1 (Resident #127) residents reviewed for bowel and blader incontinence. Facility failed to obtain physician orders for Resident #130's suprapubic indwelling catheter, catheter care, and maintenance (A suprapubic catheter is surgically implanted between the urinary bladder and the skin used to drain urine from the bladder). This failure could place residents at risk of infection. Findings included: Review of Resident #130's admission Records dated 03/13/24 revealed an [AGE] year-old female who admitted to facility on 03/01/24 with diagnoses including pressure ulcer (injury to skin and tissue due to pressure) of sacral region and paraplegia (paralysis in lower half of body). Review of Resident #130's order summary dated 03/13/24 did not reflect…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 2 residents (Resident #127) reviewed for respiratory care. Facility failed to obtain physician orders for Resident #127 to use, care, and maintain a CPAP machine. A CPAP machine is Continuous Positive Airways Pressure machine to keep breathing airways open while sleeping. These failures could place residents who receive respiratory care at risk of developing infections and a decreased quality of care. Findings Included: Review of Resident #127's admission Record dated 03/13/24 reflected an [AGE] year old female admitted to facility on 03/05/24 with diagnoses that included Asthma (a condition in which the airway becomes inflamed, narrowed and swells), chronic obstructive pulmonary disease/COPD (a group of lung disease that block airflow and make it difficult to breath), Sleep apnea ( a potentially serious…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for 1 of 3 residents (Resident 11) reviewed for bed rails. The facility failed to ensure physician orders were written for bed rail use for Resident #11. This failure could place residents at risk of injury. Findings Included: 1. Review of Resident #11's admission Records dated 03/13/24 revealed an [AGE] year-old female who admitted to facility on 03/15/23. Her diagnoses included senile degeneration of brain (a condition that causes a significant cognitive decline in abilities, memory, and language), muscle weakness, abnormalities of gait and mobility, repeated falls, depression, arthritis (a degenerative joint disease), difficulty in walking, high cholesterol, high blood pressure, altered mental status (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.