Discovery Village At Southlake
DISCOVERY VILLAGE AT SOUTHLAKE in SOUTHLAKE, TX — inspection on November 12, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/12/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Discovery Village at Southlake
201 Watermere Drive Southlake, TX 76092
SUMMARY STATEMENT OF DEFICIENCIES
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.