Discovery Village At Southlake
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
facility. He said normally the expectation was he was present during the care plan meetings. He said the MDS nurse should have completed the comprehensive care plan. He said the care plan was in place so treatments were done. He said the expectation was the baseline care plans were completed first and then comprehensively thereafter. He said the ADON should have completed the pressure ulcer section because
she did the skin assessments, or she should have given the information to the MDS nurse to complete the care plan for skin integrity. He said it was everyone's [DON, ADON, and MDS nurse's] responsibility to make sure care plans were made. He said this information was not communicated with him and he was not aware of missing care plans. He said the risk was not having direction of care. Attempted interview with the DOR by phone on 11/12/25 at 3:32 PM, was unsuccessful. The DOR did not answer or call back. In an
interview with the ADM on 11/12/25 at 5:50 PM, he stated the expectation was each resident had both baseline and comprehensive care completed in a timely manner. He said he was not sure how this care plan got missed. He said the expectation was the MDS nurse initiated the care plans and the DON supervised it was done. He said moving forward he would have checks in place and have the DON complete care plan audits. He said care plans are important to direct care for the residents. Record review of the facility's policy titled Care Plan-Resident, dated 12/2016, reflected staff must develop a comprehensive care plan to meet the needs of the residents with measurable and time limited goals.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
11/12/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Discovery Village at Southlake
201 Watermere Drive Southlake, TX 76092
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0842
Federal health inspectors cited DISCOVERY VILLAGE AT SOUTHLAKE in SOUTHLAKE, TX for a deficiency under regulatory tag F-F0842 during a complaint investigation conducted on 2025-11-12.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 2 deficiencies cited during this inspection of DISCOVERY VILLAGE AT SOUTHLAKE.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-12-10.
DISCOVERY VILLAGE AT SOUTHLAKE in SOUTHLAKE, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SOUTHLAKE, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from DISCOVERY VILLAGE AT SOUTHLAKE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.