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Deficiency Records for Discovery Village at Southlake

View the most recent health deficiencies and inspection results for Discovery Village at Southlake. Stay informed about quality of care issues.

View the most recent health deficiencies and inspection results for Discovery Village at Southlake. Stay informed about quality of care issues.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2025-11-12 2025-12-10 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-11-12 2025-12-10 Y
Include a process for Emergency Preparedness collaboration. Fire Safety 2025-04-11 2025-05-20 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2025-04-11 2025-05-20 N
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. Health 2025-04-11 2025-05-20 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2025-04-11 2025-05-20 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2025-04-11 2025-05-20 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2025-04-11 2025-05-20 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2025-04-11 2025-05-20 N
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Fire Safety 2025-04-11 2025-05-20 N
Provide properly protected cooking facilities. Fire Safety 2025-04-11 2025-05-20 N
Establish roles under a Waiver declared by secretary. Fire Safety 2025-04-11 2025-05-20 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2025-04-11 2025-05-20 N
Install corridor and hallway doors that block smoke. Fire Safety 2025-04-11 2025-05-20 N
Keep residents' personal and medical records private and confidential. Health 2024-03-14 2024-04-20 N
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Health 2024-03-14 2024-04-20 N
Dispose of garbage and refuse properly. Health 2024-03-14 2024-04-20 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2024-03-14 2024-04-20 N
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. Health 2024-03-14 2024-04-20 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2024-03-14 2024-04-20 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2024-03-14 2024-04-20 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2024-03-14 2024-04-20 N
Conduct risk assessment and an All-Hazards approach. Fire Safety 2024-03-14 2024-04-20 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2024-03-14 2024-04-20 N
Ensure that residents are free from significant medication errors. Health 2023-09-29 2023-09-16 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-01-20 2023-02-25 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-01-20 2023-02-25 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-01-20 2023-02-25 N

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