01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-06-04 | 4 | 2026-06-04 | 3 |
| Cycle 2 | 2025-04-11 | 3 | 2025-04-11 | 9 |
| Cycle 3 | 2024-03-14 | 8 | 2024-03-14 | 3 |
CMS CCN 6763512026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Discovery Village At Southlake
201 Watermere Drive · Southlake, TX 76092 · Tarrant County
Certified beds41CMS provider file
Recent citation rows30current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
30 rows in the current release
1 rows carry G–L scope/severity codes; 1 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-06-04 · FIREE0024Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish policies and procedures for volunteers.
Correction field: Deficient, Provider has date of correction · 2026-07-102026-06-04 · FIREE0026Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish roles under a Waiver declared by secretary.
Correction field: Deficient, Provider has date of correction · 2026-07-102026-06-04 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-07-102026-06-04 · HEALTHF0921Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2026-07-102026-06-04 · FIREK0372Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2026-07-102025-11-12 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-12-10 · complaint2025-11-12 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2025-12-10 · complaint2025-04-11 · FIREE0006Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · FIREE0009Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Include a process for Emergency Preparedness collaboration.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · FIREE0026Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish roles under a Waiver declared by secretary.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · HEALTHF0656Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · HEALTHF0700Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · HEALTHF0812Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · FIREK0343Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · FIREK0363Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2025-05-202025-04-11 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-05-202024-03-14 · FIREE0004Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2024-04-202024-03-14 · FIREE0006Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Conduct risk assessment and an All-Hazards approach.
Correction field: Deficient, Provider has date of correction · 2024-04-202024-03-14 · HEALTHF0583Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2024-04-202024-03-14 · HEALTHF0690Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Correction field: Deficient, Provider has date of correction · 2024-04-202024-03-14 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-04-2003 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2023-09-29 | Fine | $12,649 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- HCRI TUCSON PROPERTIES INCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST98% · since 04/01/2019
- DENOVELLIS, AARONIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 04/01/2019
- DUNCAN, LAWRENCEIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 04/01/2019
- HUTCHINSON, RICHARDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2019
- WIERZBICKI, STEVEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2019
- AMERICAN TRUST SENIOR CARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2019
- SMITH, RANDYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2019
- WIERZBICKI, STEVEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 04/01/2019
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.63per resident day
RN hours0.85per resident day
Weekend nurse hours3.31per resident day
Staff turnover43.2%CMS reported field
06 / LOCAL RECORDS
Open the Southlake ledger →