Cycle 1
Health 2025-04-11 · Fire 2025-04-11
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Southlake, TX
Discovery Village At Southlake
4-star overall rating with 4-star inspections with $12,649 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
201 Watermere Drive, Southlake, TX
(817) 482-1340
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
41
Certified beds
Average residents
39
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2014-01-22
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.61
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.47
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
3.99
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,834
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 24.86% · Performance 27.93% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.00% · Performance 8.39% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
3.05
Baseline 3.03 hours · Performance 3.95 hours · Measure score 3.05 · Achievement 3.05 · Improvement 2.84
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.43% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 260 · Observed rate 9.23% · Lower 95% interval 8.05% |
| Discharge to community | 65.65% |
50.57%
15.1 pts better
|
Better than the National Rate · Eligible stays 276 · Observed rate 60.87% · Lower 95% interval 60.83% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.3% |
95.27%
4 pts better
|
Numerator 142 · Denominator 143 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 143 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 52 · Denominator 91 |
| Discharge mobility score | 50.55% |
50.94%
0.4 pts worse
|
Numerator 46 · Denominator 91 |
| Pressure ulcers or injuries, new or worsened | 2.1% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 143 · Adjusted rate 2.05% |
| Healthcare-associated infections requiring hospitalization | 8.39% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 167 · Observed rate 8.38% · Lower 95% interval 5.87% |
| Staff COVID-19 vaccination coverage | 1.59% |
8.2%
6.6 pts worse
|
Numerator 1 · Denominator 63 |
| Staff flu vaccination coverage | 29.55% |
42%
12.4 pts worse
|
Numerator 26 · Denominator 88 |
| Discharge function score | 64.84% |
56.45%
8.4 pts better
|
Numerator 59 · Denominator 91 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 94 · Denominator 94 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 12.5% |
3.3%
9.2 pts worse
|
3.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
3.3%
0.3 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
18.9%
6.4 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
10.8%
1.3 pts worse
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
16.1%
5.5 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 12.7% |
0.5%
12.2 pts worse
|
1.0%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
0.8%
4.1 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
15.0%
3.4 pts worse
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
4.2%
2.6 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.6% |
89.7%
14.1 pts worse
|
81.7%
6.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 83.9% · Q2 71.4% · Q3 70.0% · Q4 76.2% · 4Q avg 75.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.0% |
12.0%
5 pts worse
|
12.0%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 16.2% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.3% |
88.0%
18.7 pts worse
|
79.7%
10.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 42.7% |
25.9%
16.8 pts worse
|
23.9%
18.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 42.7% · Observed 33.8% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2024-03-14
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2023-01-20 · Fire 2023-01-20
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-11
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-11
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-11
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-11
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-04-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-20
F · Potential for more than minimal harm
2024-03-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-03-14
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-03-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-12
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-10
D · Potential for more than minimal harm
2025-11-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-10
E · Potential for more than minimal harm
2025-04-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-20
E · Potential for more than minimal harm
2025-04-11
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-04-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-20
F · Potential for more than minimal harm
2024-03-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-03-14
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-04-20
F · Potential for more than minimal harm
2024-03-14
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-04-20
E · Potential for more than minimal harm
2024-03-14
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-03-14
F700 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-04-20
J · Immediate jeopardy
2023-09-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-16
E · Potential for more than minimal harm
2023-01-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-25
E · Potential for more than minimal harm
2023-01-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-25
D · Potential for more than minimal harm
2023-01-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-25
Penalties and ownership
What sits behind the stars
$12,649
2023-09-29
Fine
Fine · fine $12,649
Fine
Ownership
Hcri Tucson Properties Inc
5% Or Greater Direct Ownership Interest · Organization
American Trust Senior Care LLC
Operational/Managerial Control · Organization
Denovellis, Aaron
Contracted Managing Employee · Individual
Duncan, Lawrence
W-2 Managing Employee · Individual
Hutchinson, Richard
Corporate Director · Individual
Smith, Randy
Operational/Managerial Control · Individual
Welltower Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Trs Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Wierzbicki, Steve
Operational/Managerial Control · Individual
Wierzbicki, Steve
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Carlyle at Stonebridge Park
Southlake, TX
3-star overall rating with 2-star inspections with $125,895 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Keller Oaks Healthcare Center
Keller, TX
3-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Heritage House At Keller Rehab & Nursing
Keller, TX
5-star overall rating with 4-star inspections with $30,371 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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