Discovery Village at Southlake

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 of 4 residents (Resident #40) reviewed for infection control.1. The facility failed to ensure CNA A performed hand hygiene in between glove changes while providing toileting care for Resident #40.2. The facility failed to ensure CNA A disinfected surfaces with acceptable disinfecting wipe. These failures could result in infection.

Inspectors wroteBased on observation, interview, and record review, the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 (Resident #32) of 10 resident rooms reviewed for smoke detectors. The facility failed to ensure Resident #32 had a functional smoke detector installed in his room. This failure could result in an unsafe environment.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop a care plan to address Resident #1's needs as follows:1. Stage 2 wound on his bottom (pressure ulcer)2. Right heel edema (leg swelling)3. Bowl movement changes due to ileus (this is temporary slowing or cessation of intestinal movement)4. Disease process Colitis (this is inflammation of the colon which may cause abdominal pain, diarrhea and sometimes blood in stool)5. Use of high blood pressure medication Lisinopril6. [...]

Inspectors wroteBased on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accurate medical records. The facility failed to ensure accurately documented skilled nurse notes for Resident #1 on 10/16/25 when RN A documented Resident #1 was a female, he had a left hip fracture, was forgetful, had poor motor coordination, and had balance problems when standing. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information and could cause confusion about the residents' care and place residents at risk for harm due to inaccurate records.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 4 of 7 residents (Resident #3, #5, #30, and Resident #34) reviewed for care plans in that: Residents #3, #5, #30, and Resident #34 use of bed rails/grab/transfer bars were not documented in their care plans. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to assess the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 4 of 7 residents (Resident #3, #5, #30, and Resident #34) rooms observed for bed rails/grab/transfer bars. The facility did not have informed consent and assessment of the residents for appropriateness or risk of entrapment for bed rails or grab/transfer bars for Residents #3, #5, #30, and Resident #34. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety in the facility's only kitchen observed for food safety. 1. The facility failed to remove five dented cans from the dry food storage area. 2. The facility failed to label a plastic container in the dry food storage area. The failures could place residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation and storage. The facility failed to ensure the thermometer used in the refrigerator read the accurate temperature. This failure could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 out of 1 kitchen observed. The facility failed to have a garbage can near the handwashing sink. The facility failed to ensure garbage cans with lids were used in the kitchen. This failure could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for quarter review for Fiscal year Quarter 1 of 2024 (October 1- December 31, 2023). The facility failed to submit RN staff hours for 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had a right to secure and confidential personal and medical records for 1 (back hallway) of 2 hallways reviewed for privacy and confidentiality. The facility failed to ensure private and confidential clinical records were not left in the back hallway unattended. This deficient practice could place residents at-risk for lack of privacy and confidentiality.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections and restore as much bowel functions as possible for 1 of 1 (Resident #127) residents reviewed for bowel and blader incontinence. Facility failed to obtain physician orders for Resident #130's suprapubic indwelling catheter, catheter care, and maintenance (A suprapubic catheter is surgically implanted between the urinary bladder and the skin used to drain urine from the bladder). This failure could place residents at risk of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 2 residents (Resident #127) reviewed for respiratory care. Facility failed to obtain physician orders for Resident #127 to use, care, and maintain a CPAP machine. A CPAP machine is Continuous Positive Airways Pressure machine to keep breathing airways open while sleeping. These failures could place residents who receive respiratory care at risk of developing infections and a decreased quality of care. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the residents for risk of entrapment from bed rails prior to installation, review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of bed rails for 1 of 3 residents (Resident 11) reviewed for bed rails. The facility failed to ensure physician orders were written for bed rail use for Resident #11. This failure could place residents at risk of injury. Findings Included: 1. Review of Resident #11's admission Records dated 03/13/24 revealed an [AGE] year-old female who admitted to facility on 03/15/23. [...]

Inspectors wroteBased on, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of two residents reviewed for medication administration. LVN A failed to transcribe the correction medication list when Resident #1 was discharged from the hospital back to the facility, which led to Resident #1 being administered incorrect medications from 09/14/23 to 09/16/23 which were originally for Resident #2. The IJ (Immediate Jeopardy) was identified as past noncompliance (PNC) on 09/14/23 and ended on 09/16/23. [...]