Discovery Village At Southlake

Penalties

• Sep 29, 2023 — Fine ($12,649)

Inspection findings

1. Jun 4, 2026 Fire Safety · 5 findings
   • Not serious Scope/severity F

     E0024 Emergency Preparedness Deficiencies

     Establish policies and procedures for volunteers.

     Corrected Jul 10, 2026 · CMS fire safety

   • Not serious Scope/severity F

     E0026 Emergency Preparedness Deficiencies

     Establish roles under a Waiver declared by secretary.

     Corrected Jul 10, 2026 · CMS fire safety

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0921 Environmental Deficiencies

     Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

     Corrected Jul 10, 2026 · CMS health inspection

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jul 10, 2026 · CMS fire safety

2. Nov 12, 2025 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0656 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.

     Corrected Dec 10, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0842 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.

     Corrected Dec 10, 2025 · CMS health inspection

3. Apr 11, 2025 Fire Safety · 12 findings
   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected May 20, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0009 Emergency Preparedness Deficiencies

     Include a process for Emergency Preparedness collaboration.

     Corrected May 20, 2025 · CMS fire safety

   • Not serious Scope/severity F

     E0026 Emergency Preparedness Deficiencies

     Establish roles under a Waiver declared by secretary.

     Corrected May 20, 2025 · CMS fire safety

   • Not serious Scope/severity E

     F0656 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.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0700 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.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected May 20, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0343 Smoke Deficiencies

     Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

     Corrected May 20, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected May 20, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected May 20, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0363 Smoke Deficiencies

     Install corridor and hallway doors that block smoke.

     Corrected May 20, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected May 20, 2025 · CMS fire safety

4. Mar 14, 2024 Fire Safety · 10 findings
   • Not serious Scope/severity F

     E0004 Emergency Preparedness Deficiencies

     Develop and maintain an Emergency Preparedness Program (EP).

     Corrected Apr 20, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0006 Emergency Preparedness Deficiencies

     Conduct risk assessment and an All-Hazards approach.

     Corrected Apr 20, 2024 · CMS fire safety

   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Apr 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0690 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.

     Corrected Apr 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Apr 20, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0700 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.

     Corrected Apr 20, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 20, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Apr 20, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     Corrected Apr 20, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0761 Miscellaneous Deficiencies

     To conduct inspection, testing and maintenance of fire doors by qualified individuals.

     Corrected Apr 20, 2024 · CMS fire safety

5. Sep 29, 2023 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Sep 16, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• DENOVELLIS, AARON — contracted managing employee, NOT APPLICABLE, since 04/01/2019
• DUNCAN, LAWRENCE — w-2 managing employee, NOT APPLICABLE, since 04/01/2019
• HUTCHINSON, RICHARD — corporate director, NOT APPLICABLE, since 04/01/2019
• SMITH, RANDY — operational/managerial control, NOT APPLICABLE, since 04/01/2019
• WIERZBICKI, STEVE — corporate director, NOT APPLICABLE, since 04/01/2019
• WIERZBICKI, STEVE — operational/managerial control, NOT APPLICABLE, since 04/01/2019
• AMERICAN TRUST SENIOR CARE LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2019
• HCRI TUCSON PROPERTIES INC — 5% or greater direct ownership interest, 98%, since 04/01/2019