All citations for Discovery Village at Southlake
State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.
Last standard health inspection on record
June 4, 2026
Showing 1 to 25 of 30 citations
Immediate jeopardy to resident health or safety
Ensure that residents are free from significant medication errors.
Past non-compliance: already corrected by the time of the inspection (September 16, 2023).
No harm, with potential for more than minimal harm
Establish policies and procedures for volunteers.
The home gave a date the problem would be corrected (July 10, 2026).
No harm, with potential for more than minimal harm
Establish roles under a Waiver declared by secretary.
The home gave a date the problem would be corrected (July 10, 2026).
No harm, with potential for more than minimal harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
The home gave a date the problem would be corrected (July 10, 2026).
No harm, with potential for more than minimal harm
Conduct risk assessment and an All-Hazards approach.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal harm
Include a process for Emergency Preparedness collaboration.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal harm
Establish roles under a Waiver declared by secretary.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal harm
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal harm
Have approved installation, maintenance and testing program for fire alarm systems.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal harm
Inspect, test, and maintain automatic sprinkler systems.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal harm
Have generator or other power source capable of supplying service within 10 seconds.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
The home gave a date the problem would be corrected (April 20, 2024).
No harm, with potential for more than minimal harm
Dispose of garbage and refuse properly.
The home gave a date the problem would be corrected (April 20, 2024).
No harm, with potential for more than minimal harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
The home gave a date the problem would be corrected (April 20, 2024).
No harm, with potential for more than minimal harm
Develop and maintain an Emergency Preparedness Program (EP).
The home gave a date the problem would be corrected (April 20, 2024).
No harm, with potential for more than minimal harm
Conduct risk assessment and an All-Hazards approach.
The home gave a date the problem would be corrected (April 20, 2024).
No harm, with potential for more than minimal harm
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
The home gave a date the problem would be corrected (April 20, 2024).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
The home gave a date the problem would be corrected (December 10, 2025).
No harm, with potential for more than minimal harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal 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.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal harm
Provide properly protected cooking facilities.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal harm
Install corridor and hallway doors that block smoke.
The home gave a date the problem would be corrected (May 20, 2025).
No harm, with potential for more than minimal harm
Keep residents' personal and medical records private and confidential.
The home gave a date the problem would be corrected (April 20, 2024).
No harm, with potential for more than minimal harm
Provide and implement an infection prevention and control program.
The home gave a date the problem would be corrected (July 10, 2026).
No harm, with potential for more than minimal harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
The home gave a date the problem would be corrected (July 10, 2026).
Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.