Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southlake Village Rehabilitation & Care Center during CMS and state inspections, most recent first.
A facility failed to ensure one nurse aide completed the required annual 12 hours of training, including abuse prevention and dementia care, and failed to ensure the aide received a performance review at least every 12 months. Records and staff interviews showed the aide had worked multiple floor shifts while lacking the required education, and the file did not contain a performance evaluation or PIP.
Failure to follow the standardized pureed diet recipe occurred when a PC prepared pureed Beef Stroganoff Casserole by adding cooked noodles, beef tips and gravy, and broth without using the measured scoop called for in the recipe. The RD confirmed the PC should have followed the recipe and used a scoop with measurements instead of a spatula.
A resident with severe cognitive impairment had no valid advance directive or medical/financial POA on file. Staff documented a call to the daughter, but no response was received, and later records still showed no POA on file. The only document obtained was a general POA from a prior facility that did not authorize medical or financial decision-making. The resident’s DNR form and clinical profile also reflected inconsistent documentation, with the daughter listed only as an emergency contact and responsible for trust, not as POA.
Hair not fully contained during meal prep. A Production Cook was observed multiple times preparing lunch and pureed food with bangs, ears, and hair at the neckline exposed while wearing a skull cap. A Culinary Chef was also observed with hair hanging from the ears, back of the neck, and forehead while handling delivered food. The Dietician confirmed the hair restraint was not completely covering the hair and that all hair should be covered.
Bathroom ventilation was not functional in multiple resident rooms, including rooms 302, 309, 312, 313, 316, and 418, during survey observations. Staff and maintenance confirmed the vents were not working when tested with one-ply tissue, and record review showed inspection logs were marked complete without documenting the status of the exhaust fans.
Missing Annual Nurse Aide Training and Performance Review
Penalty
Summary
The facility failed to ensure that 1 of 5 sampled nurse aides completed at least 12 hours of ongoing annual training, including abuse prevention and dementia management training, based on employment date as required. Record review showed NA-B was hired on 11/22/2022, and a review of the NetLearning transcript as of 9/2025 showed no course transcript for the last year. Staff interviews confirmed that NA-B had not had the required education for the past 2 years and had not completed abuse prevention or dementia management training last year. The staffing schedule showed NA-B worked multiple floor shifts between 8/24/25 and 9/21/25, and the staffing scheduler confirmed those shifts. The facility also failed to ensure that 1 of 5 sampled nurse aides had a performance review at least once every 12 months. The DON confirmed that she performs annual reviews for nursing staff and reviews NetLearning, but also confirmed that NA-B did not complete the paperwork or meet criteria for [DATE] and did not receive an evaluation. The personal file did not contain a performance improvement plan related to continuing education and did not contain a performance evaluation. The nurse aide/med aide competency check-off dated 7/22/25 showed skills reviewed, but it did not include a performance evaluation or continuing education. The Administrator confirmed that NA-B had not had a performance evaluation in over a year and that the last documented addressed concern was dated January 2024.
Failure to Follow Standardized Pureed Diet Recipe
Penalty
Summary
The facility failed to follow the menu when preparing food for residents on a pureed diet. The report states that six residents received pureed diets, and the facility census was 123. A review of the recipe for Pureed Beef Stroganoff Casserole showed that the standardized recipe called for beef stroganoff entree and beef broth to be placed in a food processor and blended until smooth, with a portion size of 2 #8 scoops. During an observation on 9/29/25 at 7:00 AM, the Production [NAME] was preparing pureed Beef Stroganoff Casserole. The PC was observed wearing a skull cap with hair exposed on the back of the neck, ears, and bangs. The PC placed a quart container of cooked noodles into the food processor, then added beef tips and gravy from a pan using a spatula instead of the measured scoop referenced in the recipe. The PC added beef broth a little at a time until the mixture reached an applesauce consistency, with about 1/2 cup of broth left unused. The pureed mixture was then placed into metal pans, covered, and put in the oven. The facility policy stated that standardized recipes are used when preparing menu items, and the Registered Dietician confirmed that the PC should have used a scoop with measurements and should have followed the recipe, but did not.
Missing valid POA and advance directive documentation
Penalty
Summary
The facility failed to ensure that valid and appropriate POA and advance directive documentation were maintained for a resident with severe cognitive impairment. Resident 9’s record showed a BIMS score of 2, indicating severe impairment, and the admission Social Services Review documented that no advance directives or POA were on file. The record also showed that staff called the daughter regarding POA, but no response was received, and the Quarterly Social Services Review later continued to document that no POA was on file and that staff had not received responses from the daughter regarding follow-up care needs. Progress notes through the review period contained no documentation that POA documentation had been obtained. The facility later produced a faxed copy of a General Power of Attorney from a prior facility, but it designated the daughter only as attorney-in-fact under a general POA and did not grant medical or financial authority. The resident’s DNR form contained two signatures, including the daughter’s name written with a forward slash beside it, and the Clinical Resident Profile listed the resident as DNR/Do Not Attempt Resuscitation while also documenting that POA was not invoked and that the daughter was only an emergency contact and responsible for trust, not medical or financial POA. The Social Services Coordinator confirmed that the only documented outreach was the call to the daughter and that the POA on file was general only.
Hair not fully contained during meal preparation
Penalty
Summary
The facility failed to contain hair while preparing meals for residents. During observations in the kitchen, the Production Cook was preparing lunch and was wearing a skull cap with bangs hanging out, hair hanging on both ears, and hair extending out of the skull cap down to the neckline. On another observation, the same Production Cook was again preparing lunch with bangs, ears, and hair at the neckline exposed while wearing a skull cap. On 9/29/25, the Production Cook was observed preparing pureed Beef Stroganoff Casserole while wearing a skull cap with hair exposed on the back of the neck, ears, and bangs. The Culinary Chef was also observed wearing a skull cap with hair hanging down on the ears, back of the neck, and forehead while putting away delivered food in the freezers. The Production Cook then combined cooked noodles, beef tips and gravy, and beef broth in a blender to puree the food, place it into metal pans, cover the pans, and put them in the oven. The policy review stated to clock in, place on hair covering, and wash hands, and the food code required hair restraints to effectively keep hair from contacting exposed food. The Dietician confirmed that the hair restraint was not completely covering the hair and that all hair should be covered.
Nonfunctional Bathroom Ventilation in Multiple Resident Rooms
Penalty
Summary
The facility failed to have functional bathroom ventilation in six resident rooms, including rooms 302, 309, 312, 313, 316, and 418, out of 30 rooms surveyed. During the initial tour on 9/24/2025, bathroom vents in those rooms were tested with one-ply tissue and were found not to be functioning. On 9/29/2025 at 7:23 AM, another observation found bathroom vents not functioning in rooms 302, 309, 312, 313, 316, 414, and 418 when tested the same way. During a tour with maintenance on 9/29/2025 at 7:46 AM, the bathroom vents in rooms 302, 309, 312, 313, 316, and 418 were again observed not functioning, and maintenance confirmed this during the tour. The facility stated preventative maintenance is performed quarterly and that filters were due to be changed soon, with possible dust buildup. Record review showed the facility’s vent fan inspection logbook required checking proper operation and cleanliness, but entries dated 6/19/2025, 7/16/2025, 8/1/2025, and 9/17/2025 were marked completed on time without documenting inspection status. A work history report showed exhaust fans were last documented as functional on 6/30/2025, while later monthly inspections were marked completed without indicating whether the fans were functioning.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Firethorn | 3.1 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing & Rehab Brookside Llc | 3.7 mi | ★★★★★ | 27 | 0 |
| Eventide Williamsburg | 4.4 mi | ★★★★★ | 10 | 0 |
| Holmes Lake Rehabilitation & Care Center | 4.6 mi | ★★★★★ | 10 | 0 |
| St. Jane De Chantal | 5 mi | ★★★★★ | 27 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.