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
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing
LPN hours / resident day
0.87
Licensed practical nurse staffing
Aide hours / resident day
2.05
Nurse aide staffing
Weekend hours
3.47
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
59%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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