Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Discovery Village At Southlake during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including a pressure ulcer, edema, colitis, and recent surgery, did not have a comprehensive care plan addressing all identified needs. Although physician orders and treatments were in place, the care plan only focused on fall risk, omitting interventions for other significant health issues. Staff interviews revealed confusion over care planning responsibilities, and family concerns raised during meetings were not incorporated into the plan.
A resident's medical record contained inaccurate documentation by an RN, including incorrect gender, diagnosis, and care needs, which was discovered when the family requested records at discharge. Staff interviews indicated the error may have resulted from confusion during charting, and facility leadership was unaware of the issue until notified.
Four residents with significant mobility and cognitive impairments were using bed rails or grab/transfer bars, but their care plans did not document or address the use of these devices. Staff interviews revealed uncertainty about policy, assessment, and consent requirements for grab/transfer bars, and the facility's own policy requiring comprehensive, individualized care planning was not followed.
Several residents with significant mobility and cognitive impairments had grab/transfer bars installed on their beds without documented assessment for safety risks or informed consent. Care plans did not mention these devices, and staff interviews revealed confusion about facility policy and requirements. The facility's policy required assessment and consent for bed rails, including grab/assist bars, but these steps were not completed or documented.
Surveyors found that the facility failed to remove five dented cans from dry storage and did not label a plastic container containing a white substance, contrary to facility policy requiring all food items to be labeled and dated. Staff interviews confirmed these lapses and acknowledged that dented cans were not placed in the designated area for return, and that the unlabeled container could lead to ingredient mix-ups.
The facility failed to maintain accurate refrigerator temperatures, with an internal thermometer reading 50 degrees F, above the recommended 41 degrees F or below. The built-in thermometer read 37 degrees F, and the facility relied on this for accuracy. The Dietary Manager and Administrator acknowledged the discrepancy.
The facility failed to dispose of garbage and refuse properly in the kitchen. There was no trash can with a lid near the handwashing sink, and the available garbage can did not have a lid. The Assistant Dietary Manager acknowledged the issue, and the Dietary Manager later confirmed that three step trash cans with lids were placed in the kitchen. The Interim Administrator explained the necessity of step trash cans with lids to prevent contamination. The facility did not provide a policy on garbage and refuse in the kitchen.
The facility failed to submit accurate RN staffing data to CMS for several dates in Fiscal Year Quarter 1 of 2024. Despite having sufficient RN coverage, the hours were not recorded due to the DON being a salaried employee who did not clock in and out, and system limitations prevented the inclusion of manually recorded hours.
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records when a CNA left clinical documents unattended in a hallway. The documents contained sensitive information and were visible to anyone passing by. Both the DON and the interim Administrator confirmed that staff are trained on HIPAA and are expected to secure residents' information.
The facility failed to document physician orders for a resident's suprapubic indwelling catheter care and maintenance, placing the resident at risk of infection. Staff were unaware of the last catheter replacement, and the facility's policy on maintaining current orders was not followed.
The facility failed to obtain physician orders for a resident's CPAP machine, despite the resident's history of asthma, COPD, and sleep apnea. The oversight was discovered through observation, interview, and record review, revealing a lack of awareness and oversight by the DON and Administrator.
The facility failed to assess a resident for bed rail entrapment risk, review risks and benefits, and obtain informed consent before installing bed rails. The resident's care plan did not indicate the need for bed rails, and there were no physician orders for their use. Staff were unaware of the policy, and the facility's failure to follow procedures placed residents at risk of injury.
Failure to Develop and Implement Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical needs. Despite the resident having a range of diagnoses including hypertension, colitis, pressure ulcers, edema, and recent orthopedic surgery, the care plan only addressed fall risk and did not include measurable objectives or interventions for other significant health issues. Physician orders and medication administration records indicated active treatment for these conditions, but these were not reflected in the resident's care plan. Interviews with facility staff revealed a lack of clarity and communication regarding responsibility for care plan development. The MDS nurse, who was responsible for initiating care plans, did not complete sections related to skin and pressure ulcers, citing remote work and lack of direct resident contact. The ADON, who conducted wound rounds, did not contribute to the care plan, believing it was outside her scope. The DON, who was on vacation during the resident's stay, stated that care plan completion was a shared responsibility but was not informed of the missing care plan sections. Other staff, including the admissions nurse and social worker, described their roles as limited to data collection or room preparation, not care plan development. Family interviews indicated that concerns raised during a care plan meeting, such as the resident's pressure wound, diarrhea, and need for specific interventions, were not addressed in the care plan or acted upon before discharge. The lack of a comprehensive care plan resulted in the resident's needs not being fully identified or met, as evidenced by ongoing issues with wound care, bowel management, and medication administration. Facility policy required comprehensive care plans with measurable, time-limited goals, but this was not followed in the resident's case.
Inaccurate Medical Record Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, a skilled nurse note documented by an RN incorrectly identified the resident's gender, medical history, and care needs, including stating the resident had a left hip fracture and was recovering from a left hemiarthroplasty, when in fact the resident did not have this diagnosis. The note also included inaccurate information about the resident's cognitive and physical status. This documentation error was discovered when the resident's family requested records upon discharge and noticed the discrepancies. Interviews with facility staff revealed that the RN responsible for the documentation could not explain why the incorrect information was entered, attributing it to high resident turnover and possibly confusing residents while charting. The Director of Nursing and the Administrator were not aware of the inaccurate record until it was brought to their attention. Review of the facility's documentation policy confirmed the requirement for accurate and complete records to ensure proper communication and care.
Failure to Include Bed Rail/Grab Bar Use in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for four residents who were observed to use bed rails or grab/transfer bars. Despite the presence of these devices on the residents' beds, their use was not documented in the care plans as either an intervention or a focus area. This omission was identified through observations, interviews, and record reviews, which showed that the care plans did not specify the use of grab/transfer bars or bed rails, nor did they address the need for assessment, consent, or individualized interventions related to these devices. The residents involved had significant medical histories and functional limitations. For example, one resident had diagnoses including atrial fibrillation, aphasia, dementia, and required substantial assistance with mobility and self-care. Another resident had a history of fractures, reduced mobility, repeated falls, and required assistance with transfers and ambulation. Despite these complex needs and the use of assistive devices such as grab/transfer bars, the care plans only included general interventions related to mobility, therapy, and fall risk, without specific mention or planning for the use of bed rails or grab/transfer bars. Staff interviews revealed a lack of awareness regarding facility policy on the use of grab/transfer bars, with uncertainty about whether assessments or consents were required and whether these devices should be included in care plans. The Director of Nursing and Administrator both indicated that grab/transfer bars were standard on most beds and did not consider them a safety risk or restraint, and therefore did not see the need for assessment or care planning. However, the facility's own policy required comprehensive, person-centered care plans that address all resident needs, including measurable objectives and interventions derived from thorough assessment, which was not followed in these cases.
Failure to Assess and Obtain Consent for Bed Rails and Grab/Transfer Bars
Penalty
Summary
The facility failed to assess the risks and benefits of bed rails or grab/transfer bars and did not obtain informed consent prior to their installation for four residents. For each of these residents, there was no documentation in the care plans or electronic health records indicating that an assessment for the appropriateness or risk of entrapment had been completed, nor was there evidence of informed consent from the residents or their representatives. Observations confirmed that grab/transfer bars were present and raised on both sides of the beds for these residents, and interviews with staff revealed uncertainty about the facility's policy and requirements regarding the use of such devices. The residents involved had significant medical histories, including conditions such as atrial fibrillation, dementia, Alzheimer's disease, lower extremity weakness, recent fractures, and severe cognitive impairment. Their care plans addressed issues such as impaired mobility, unsteady gait, fall risk, and the need for assistance with activities of daily living, but did not mention the use of bed rails or grab/transfer bars as interventions. In some cases, residents were unable to be interviewed due to cognitive decline, while one resident expressed concern about the placement of the rails near her head. Staff interviews indicated a lack of knowledge about the facility's policy on bed rails and grab/transfer bars, with some staff believing that assessments and consents were unnecessary for these devices. The administrator stated that the beds were received with grab/assist bars already installed and that they were not considered a risk or restraint, and therefore did not require assessment or consent. The facility's own policy, however, defined grab/assist bars as bed rails and required assessment, attempts at alternatives, interdisciplinary evaluation, and informed consent prior to use, none of which were documented for the affected residents.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to adhere to professional standards for food safety in its kitchen. Specifically, five dented cans containing various food items were found stored on different racks in the dry food storage area. Additionally, a plastic container holding a white substance, possibly cornmeal or flour, was not labeled. Staff interviews confirmed that all food items are required by facility policy to be labeled and dated, and that dented cans should be removed or returned to the vendor. However, these procedures were not followed, and the reasons for these lapses were not clearly explained by staff. The facility's own policy mandates that all food items must be labeled with the product name, date opened, and use-by date, and that storage areas should be regularly inspected to ensure compliance. Despite this, the observed deficiencies included both the presence of unlabeled food and the improper storage of dented cans, which were not placed in the designated area for return. These failures were acknowledged by dietary staff and management during interviews, who recognized the risks associated with such practices.
Failure to Maintain Accurate Refrigerator Temperature
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the thermometer inside the refrigerator read 50 degrees F, which is above the recommended temperature of 41 degrees F or below. The Assistant Dietary Manager acknowledged the discrepancy and suggested placing another thermometer inside. The built-in thermometer on the outside of the refrigerator read 37 degrees F. A subsequent observation showed a different thermometer inside the refrigerator reading 36 degrees F. The Dietary Manager stated that either she or the cook was responsible for verifying the temperature and considered the internal thermometer as a backup. The Administrator confirmed that the facility relied on the built-in thermometer for accuracy. The facility's policy on refrigerator and freezer maintenance, revised in December 2014, was reviewed and indicated the need for safe temperature maintenance and sanitation.
Improper Disposal of Garbage and Refuse in Kitchen
Penalty
Summary
The facility failed to dispose of garbage and refuse properly in the kitchen. Specifically, there was no trash can with a lid near the handwashing sink, and the available garbage can did not have a lid. The Assistant Dietary Manager acknowledged that the step trash can was broken and another one was expected to arrive. She moved an unused garbage can without a lid from the food prep area to the sink. The Dietary Manager later confirmed that three step trash cans with lids were placed in the kitchen. The Interim Administrator explained that step trash cans with lids are necessary to prevent staff from touching anything and to avoid airborne contamination. The facility did not provide a policy on garbage and refuse in the kitchen. The US FDA Food Code requires receptacles containing food residue to be covered with tight-fitting lids or doors when not in continuous use or after they are filled.
Failure to Submit Accurate RN Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for Fiscal Year Quarter 1 of 2024. Specifically, the facility did not report RN staff hours for several dates, including 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. Despite having sufficient RN coverage on these dates, as evidenced by RN time stamp detail sheets and direct care schedules, the hours were not recorded in the payroll system because the Director of Nursing (DON), a salaried employee, did not clock in and out. Instead, the DON manually recorded her hours, which were not included in the electronic submission to CMS due to system limitations and the inability to edit the payroll document provided by a third-party HR vendor without altering its format, which the PBJ website would not accept. Interviews with the DON, interim Administrator, and Administrator revealed that the facility's system was not set up to report the DON's hours worked on the specified dates. The Administrator mentioned that the parent company was not a typical nursing home company, and all department heads were salaried employees. The facility did not provide a policy for PBJ staffing data reporting at the time of the survey exit. The CMS policy requires facilities to submit staffing data through the PBJ system, which the facility failed to comply with due to the aforementioned issues.
Failure to Ensure Confidentiality of Resident Records
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records. Continuous observation revealed that three pages of clinical records titled Midnight Census Report were left unattended in the back hallway. These documents, which contained residents' first and last names, room numbers, care levels, and primary payer information, were visible on a clipboard on top of a bedside table. The documents appeared to have been left by a staff member who had entered one of the residents' rooms nearby. No staff member was present in the vicinity when the documents were found. The interim Administrator, the DON, and an LVN later arrived to remove the unattended documents. Interview with the CNA responsible for the documents revealed that she had left them unattended for about 10 to 15 minutes while answering a resident's call light. She admitted to usually taking the documents with her but had rushed to assist a resident this time. Both the DON and the interim Administrator confirmed that all staff are trained on HIPAA and are expected to secure residents' information. The facility's policy on confidentiality and personal privacy, revised in April 2017, mandates safeguarding the personal privacy and confidentiality of all resident records.
Failure to Document Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with a suprapubic indwelling catheter received appropriate treatment and services. The resident, who was admitted with a suprapubic catheter, did not have physician orders for catheter care and maintenance documented in their records. Observations and interviews revealed that the nursing staff were unaware of the last time the catheter was replaced, and the Director of Nursing (DON) acknowledged that there should have been orders for the catheter. The attending physician confirmed that the hospital should have provided a date for catheter replacement and that the facility staff were responsible for transcribing these orders into the resident's records. Additionally, the facility's policy on medication orders requires that each resident must be under the care of a licensed physician and that a current list of orders must be maintained in the clinical record. The policy also specifies that treatment orders should include the treatment, frequency, and duration. Interviews with the DON, RN, and administrators highlighted that the admitting nurse should have entered the orders, and the DON and Assistant Director of Nursing (ADON) were responsible for double-checking these orders. The failure to obtain and document physician orders for the resident's catheter care placed the resident at risk of infection.
Failure to Obtain Physician Orders for CPAP Machine
Penalty
Summary
The facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practice. Specifically, the facility did not obtain physician orders for a resident to use, care, and maintain a CPAP machine. The resident, who was admitted with a CPAP machine and had a history of asthma, COPD, and sleep apnea, had been using the machine since admission without proper physician orders. This oversight was discovered through observation, interview, and record review, revealing that the resident's medical records did not reflect the necessary physician orders for the CPAP machine. Interviews with the Director of Nursing (DON) and the Administrator indicated a lack of awareness and oversight regarding the resident's use of the CPAP machine. The DON stated that nurses were responsible for admissions and obtaining physician orders, while the Administrator emphasized that all orders should be entered and verified. The facility's policy on medication orders requires that each resident be under the care of a licensed physician and that a current list of orders be maintained in the clinical record. The failure to obtain and document physician orders for the CPAP machine could place residents at risk of developing infections and receiving decreased quality of care.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to assess residents for the risk of entrapment from bed rails prior to their installation, review the risks and benefits with the resident or their representative, and obtain informed consent before installing bed rails for one of the three residents reviewed. Specifically, Resident #11, who had severe cognitive impairment and multiple health issues, was found to have a bed rail installed without a proper assessment, informed consent, or physician orders. The resident's care plan did not indicate the need for bed rails, and there were no physician orders for their use in the resident's records. Additionally, the facility's policy on bed safety was not followed, as there was no interdisciplinary assessment or consultation with the attending physician, and no consent was obtained from the resident or their legal representative. During observations and interviews, it was revealed that the left bed rail was raised for Resident #11, while the right rail was broken. Staff members, including a CNA and an LVN, were unaware of the policy on bed rail use and did not know if there were any orders for the bed rails. The MDS Coordinator and the Administrator confirmed that the facility was supposed to be restraint-free and that bed rails should not have been used without proper orders and assessments. The facility's failure to follow its own policies and procedures regarding bed rail use placed residents at risk of injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,143 citations issued within 25 miles in the last 12 months — including the 43 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Southlake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Carlyle At Stonebridge Park | 0.5 mi | ★★★★★ | 14 | 1 |
| Keller Oaks Healthcare Center | 1.5 mi | ★★★★★ | 2 | 0 |
| Heritage House At Keller Rehab & Nursing | 3.7 mi | ★★★★★ | 7 | 1 |
| Bear Creek Nursing And Rehabilitation | 4.2 mi | ★★★★★ | 14 | 2 |
| Oakmont Guest Care Center | 4.7 mi | ★★★★★ | 2 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Discovery Village At Southlake.
100% money-back within 48 hours.
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.