A list of the most recent deficiencies for Discovery Village at Southlake. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| 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 |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-10 | 2021-12-24 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-10 | 2021-12-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-11-10 | 2021-12-15 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-11-10 | 2021-12-15 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-11-19 | 2020-01-03 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-11-19 | 2020-01-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-19 | 2020-01-03 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-19 | 2019-12-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-21 | 2019-12-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-21 | 2019-12-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-21 | 2019-12-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2019-11-19 | 2019-11-25 | N |
