Discovery Village At Southlake is an average performer in CMS ratings, earning a C grade with a score of 67/100. Located in Southlake, Texas, the facility meets baseline standards across most quality metrics.
Staffing at Discovery Village At Southlake is near the national average, with 3.61 total nursing hours per resident per day (national average: 3.8 hours).
Recent CMS inspections identified 16 deficiencies at Discovery Village At Southlake, including 1 classified as serious — among the most concerning citation levels. The most notable finding involved: develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured..
Score Breakdown
🏥 Staffing Details
| Staff Type | Hours/Resident/Day | National Avg | Comparison |
|---|---|---|---|
| Total Nursing | 3.61 | 3.8 | Average |
| Registered Nurses (RN) | 0.69 | 0.7 | Average |
| Licensed Practical Nurses (LPN) | 0.87 | 0.7 | Above Average |
| Certified Nursing Assistants (CNA) | 2.05 | 2.4 | Below Average |
| Weekend Total Nursing | 3.47 | 3.8 | Average |
| Weekend RN Hours | 0.37 | 0.7 | Below Average |
🔍 Inspection & Deficiency History
View recent deficiencies (5 shown)
- Tag 0656 Severity EDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Nov 11, 2025 · Resident Assessment and Care Planning Deficiencies
- Tag 0842 Severity DSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standarNov 11, 2025 · Resident Assessment and Care Planning Deficiencies
- Tag 0656 Severity EDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Apr 10, 2025 · Resident Assessment and Care Planning Deficiencies
- Tag 0700 Severity ETry 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 theseApr 10, 2025 · Quality of Life and Care Deficiencies
- Tag 0812 Severity DProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Apr 10, 2025 · Nutrition and Dietary Deficiencies
📊 Resident Outcome Measures
Based on CMS quality measure data. Lower percentages are better for most metrics.
| Measure | This Facility | Nat'l Avg | |
|---|---|---|---|
| Residents with pressure ulcers | 6.8% | 4.5% | Worse |
| Falls with major injury | 12.5% | 3.0% | Worse |
| On antipsychotic medication | 12.1% | 14.5% | Better |
| Urinary tract infections | 4.9% | 2.5% | Worse |
| ADL decline (daily activities) | 21.6% | 14.0% | Worse |
| Excessive weight loss | 3.0% | 7.5% | Better |
| New/worsened incontinence | 18.4% | 45.0% | Better |
⚠️ Penalties & Fines
1 penalty recorded by CMS
Total fines: $12,649
How This Grade Was Calculated
This facility's grade of C is based on a score of 67 out of 100, calculated from official CMS Nursing Home Compare data:
- Overall CMS Rating: 4★ → 32 pts (max 40)
- Health Inspection Rating: 4★ → 20 pts (max 25)
- Staffing Rating: 3★ → 12 pts (max 20)
- Quality Measures Rating: 3★ → 9 pts (max 15)
- Penalty deductions: -5 pts
- Fine deductions: -1 pts
Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40
Facility Details
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