DISCOVERY VILLAGE AT SOUTHLAKE

201 WATERMERE DRIVE, SOUTHLAKE, TX 76092 (817) 482-1340
For profit - Corporation 41 Beds WELLTOWER, INC. Data: November 2025 1 Immediate Jeopardy citation
Trust Grade
51/100
#452 of 1168 in TX
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Last Inspection: March 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Discovery Village at Southlake has a Trust Grade of C, which means it is average and falls in the middle of the pack for nursing homes. In Texas, it ranks #452 out of 1168 facilities, placing it in the top half, and #18 out of 69 in Tarrant County, indicating that there are only a few better local options. Unfortunately, the trend is worsening, with reported issues increasing from 4 in 2023 to 7 in 2024. Staffing is a relative strength, with a 3 out of 5 rating and RN coverage that is better than 80% of Texas facilities, suggesting good oversight; however, the facility has a 60% turnover rate, which is concerning. Additionally, there were $12,649 in fines, reflecting average compliance issues, but a critical incident was noted where a resident received incorrect medications due to a transcription error, and there were also concerns about food safety and garbage disposal practices that could pose health risks to residents.

Trust Score
C
51/100
In Texas
#452/1168
Top 38%
Safety Record
High Risk
Review needed
Inspections
Getting Worse
4 → 7 violations
Staff Stability
⚠ Watch
60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
⚠ Watch
$12,649 in fines. Higher than 87% of Texas facilities, suggesting repeated compliance issues.
Skilled Nurses
○ Average
Each resident gets 34 minutes of Registered Nurse (RN) attention daily — about average for Texas. RNs are the most trained staff who monitor for health changes.
Violations
⚠ Watch
11 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 4 issues
2024: 7 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in fire safety.

The Bad

3-Star Overall Rating

Near Texas average (2.8)

Meets federal standards, typical of most facilities

Staff Turnover: 60%

14pts above Texas avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $12,649

Below median ($33,413)

Minor penalties assessed

Chain: WELLTOWER, INC.

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (60%)

12 points above Texas average of 48%

The Ugly 11 deficiencies on record

1 life-threatening
Mar 2024 7 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure residents who were incontinent of bowel and b...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: Review of Resident #130's admission Records dated 03/13/24 revealed an [AGE] year-old female who admitted to facility on 03/01/24 with diagnoses including pressure ulcer (injury to skin and tissue due to pressure) of sacral region and paraplegia (paralysis in lower half of body). Review of Resident #130's order summary dated 03/13/24 did not reflect physician orders for suprapubic indwelling catheter, catheter care, and maintenance. Observation and interview on 03/13/2024 at 09:40 AM, revealed Resident #130 had a suprapubic indwelling catheter, LVN C stated Resident #130 had home health and they were changing the catheter, and she could not remember the last time it was replaced. Interview on 03/13/2024 at 09:57 AM, the DON stated she would check with the nurse about the last time the foley was changed. She said there should be orders for the suprapubic indwelling catheter. DON did respond risk to resident for not having an order for care, maintenance of supra pubic catheter. Interview on 03/13/2024 at 10:00 AM, RN G stated the orders should come from urologist or the place of admission when the resident admits. She stated nursing should enter the orders. RN G stated she did catheter care which included assessing the color and amount and charted in the progress notes. Interview on 03/13/2024 at 11:31 AM, the DON stated she will change the catheter today, updated the care plan and inputting orders. She said Resident #130 should have orders and the admitting nurse should have put orders in. Interview on 03/13/2024 at 12:06 PM, the Attending Physician stated Resident #130 was her long-term patient and was aware she had a catheter. She stated the hospital should have given a date and home health would contact the office with the date of when it was changed. She said staff know they were supposed to look at the hospital records and should transcribe the orders. She said staff will review medications with the doctor, review records and talk to the family. She stated the DON and ADON double check orders. Interview on 03/14/2024 at 03:40 PM, the Administrator stated his expectation was every order to be put in and every nurse was trained to make sure that all physician orders go in. He stated the nurse was responsible and the DON should make sure all orders were in. He stated as the Administrator he was responsible to ensure that the policies were followed. The Administrator stated in IDT meetings, they go over orders including medications and diets. Interview on 03/14/2024 at 06:04 PM, the Interim Administrator stated his expectation was all residents should have orders. He stated physician orders drive care and instructs the care provider what to do. Record review of facility policy titled, Medication Orders revised 2014, reflected Supervision by a Physician 1. Each resident must be under the care of a Licensed Physician .2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order .6. Treatment orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are pr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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: Review of Resident #127's admission Record dated 03/13/24 reflected an [AGE] year old female admitted to facility on 03/05/24 with diagnoses that included Asthma (a condition in which the airway becomes inflamed, narrowed and swells), chronic obstructive pulmonary disease/COPD (a group of lung disease that block airflow and make it difficult to breath), Sleep apnea ( a potentially serious sleep disorder in which breathing repeatedly stops and starts), unilateral primary osteoarthritis of left knee (a chronic condition affecting the knee joint), and left artificial knee joint (total left knee replacement). Review of Resident #127's MDS assessment dated [DATE] did not reflect a BIMs score or CPAP oxygen use when sleeping. Review of Resident #127's hospital discharge date d 03/04/24 reflected reactive airway disease, sleep apnea, asthma and COPD were on Resident #127's problem list. It also reflected that Resident #127 was alert and oriented X 4, indicating she was cognitively intact and could understand others and others could understand her. Review of Resident #127's order summary dated 03/13/24 did not reflect physician orders for use of CPAP machine when asleep. Observation and interview with Resident #127 on 03/12/2024 at 10:12 AM revealed she admitted with a CPAP machine to the facility. She said that family had brought the water needed to use the machine. She said that she used the machine at home and had been using it at facility since admission [DATE]. Interview on 03/14/2024 at 04:54 PM, the DON stated she was not aware Resident #127 had a CPAP. She said nurses were in charge of doing admissions and the DON and IDT will follow up with medications, physician orders, immunization and consents. Interview on 03/14/2024 at 03:40 PM, the Administrator stated his expectation was every order to be put in and every nurse was trained to make sure that all physician orders go in. He stated the nurse was responsible and the DON should make sure all orders were in. He stated as the Administrator he was responsible to ensure that the policies were followed. The Administrator stated in IDT meetings, they go over orders including medications and diets. Interview on 03/14/2024 at 06:04 PM, the Interim Administrator stated his expectation was all residents should have orders. He stated physician orders drive care and instructs the care provider what to do. Record review of facility policy titled, Medication Orders revised 2014, reflected Supervision by a Physician 1. Each resident must be under the care of a Licensed Physician .2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order .6. Treatment orders - When recording treatment orders, specify the treatment, frequency and duration of the treatment .
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess the residents for risk of entrapment from bed ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Her diagnoses included senile degeneration of brain (a condition that causes a significant cognitive decline in abilities, memory, and language), muscle weakness, abnormalities of gait and mobility, repeated falls, depression, arthritis (a degenerative joint disease), difficulty in walking, high cholesterol, high blood pressure, altered mental status (a condition characterized by confusion, disorientation, and disorder) and lack of coordination. Review of Resident #11's MDS assessment dated [DATE] revealed a BIMS score of 1, indicating she had severe cognitive impairment and memory issues. Review of section P of MDS did not indicate bed rail use for Resident #11. Review of Resident #11's Care plan with an effective date of 03/11/24 reflected the following: Focus: My Bed Mobility Self Care Performance is independent. Goal: staff will assist me with my bed mobility on a daily basis over the next 90 days (Revision 8/15/23, target date 02/07/24). Interventions: I am independent with bed mobility. No revision date to indicate need for bed rail use. Care plan also reflected: o Focus: I have elected [hospice provider] hospice services r/t terminal diagnosis: Senile Degeneration of the brain Date Initiated: 01/25/2024. Goal: Dignity will be maintained, and the resident will be kept comfortable and pain free within one hour of intervention over the next 90 days. My comfort needs will be met over the next 90 days by adding hospice caregivers to my care. Date Initiated: 01/25/2024. Interventions: Administer comfort Medications as indicated by MD/Hospice, Administer Oxygen as indicated, Assist me with meals and hydration if I am unable to help myself, Assist with ADLs and provide comfort measures as needed, Delineation of Task for [hospice provider] Hospice Services to provide: Hospice will provide disease related medications according to POC as listed on hospice medication list, Hospice will assist with teaching facility staff, resident and family regarding death/dying, pain management, pain interventions/medications for symptom control. Hospice Pharmacy to review medications every 15 days and make recommendation based on the review as needed. Review of Resident #11's order summary dated 03/13/24 did not reflect physician orders for use of bed rail. Observation and interview on 03/14/2024 at 2:04 pm revealed Resident #11's left bed rail raised. CNA D stated she was told to only raise rail on one side of the bed; she stated the right rail was broken and hospice was aware. Interview and record review on 03/14/2024 at 10:59 AM, LVN B stated they usually raise the left bed rail to help Resident #11 not fall out of bed. She stated she did not know if the resident had orders for bed rails. LVN B looked in the MAR and hospice book and found no orders for bed rails. LVN B stated Resident #11 was on hospice and that was the bed hospice provided. She said she was not sure of the policy on using bed rails. LVN B stated having both rails up was a form of restraint if the resident could not get out of bed. Interview on 03/14/2024 at 11:27 AM, LVN B stated the MDS Coordinator said this was a restraint free facility and LVN B was asked to remove the rails from Resident #11's bed and she alert hospice. Interview on 03/14/2024 at 05:19 PM, the MDS Coordinator stated they were a restraint free facility and rails up would be a restraint. She stated she had no idea that Resident #11 had a bed with rails. Interview on 03/14/2024 at 03:40 PM, the Administrator stated his expectation was every order to be put in and every nurse was trained to make sure that all physician orders go in. He stated the nurse was responsible and the DON should make sure all orders were in. He stated as the Administrator he was responsible to ensure that the policies were followed. The Administrator stated in IDT meetings, they go over orders including medications and diets. Interview on 03/14/2024 at 06:04 PM, the Interim Administrator stated his expectation was all residents should have orders. He stated physician orders drive care and instructs the care provider what to do. Record review of facility policy titled, Bed Safety revised 2007, reflected .5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the president's request to increase the resident's sense of security. 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified .
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected multiple residents

Based 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 r...

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Based 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. The findings included: Continuous observation on 03/14/24 from 11:18 AM to 11:32 AM revealed 3 pages of clinical records titled Midnight Census Report dated 03/13/24. Noted on the printed documents were visible first and last names of residents, room numbers, care levels, and primary payer information. The documents were visible, face up, on a clip board, on top of a bedside table left in the open back hallway near resident's rooms. The bedside table contained menus as well. The documents appeared to have been left by someone who might have entered one of the residents' rooms in the back hallway. Upon entry into the residents' rooms close to where the documents were left, it was revealed no staff member was there. At 11:32 AM the interim Administrator, the DON, and LVN C came to the back hallway and said they were there to remove the unattended visible residents' documents. DON said CNA E might have left the documents there. Interview with CNA E on 03/14/24 at 11:38 AM revealed she was gone for about 10 to 15 minutes and was not aware that she had left resident's information face up. She said she had gone to answer a resident's call light. She said she was making rounds to help residents complete meal choices for Friday, Saturday, and Sunday. She said that she used the midnight census to assist residents fill their meal tickets then she would cross their names off the list. CNA E said she usually took the documents with her if she had to step away, but this time, she rushed to assist a resident. She said that she was trained in protecting residents' information and HIPAA. She said the risk of not securing clinical records was violation of residents' rights. Interview with DON on 03/14/24 at 04: 51 PM reveled that She had been trained on HIPAA to protect resident information and privacy. She said every staff member is trained on HIPAA. She said she expected CNA E to flip over the clip board with pieces of paper with residents' information or best practice to take document with her. She said she expected everyone to protect resident's records. DON said that she would start in-services immediately. Interview with interim administrator on 03/14/24 at 05:32 PM, revealed he expected all staff to handle clinical records with confidentiality. He said he expected staff to close, turn off, or lock computer screens when not in use. He said all staff are taught to protect resident information when they are hired. He said if a document/s are on paper he expected staff to take it with them and to secure it. He said it was the staff's responsibility to make sure documents are secure. Risk of not securing clinical documents was Breach of resident's privacy. Review of the facility's policy titled Confidentiality of Information and Personal Privacy revised April 2017 revealed: .the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based 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 kitche...

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Based 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. Findings included: Observation and interview on 03/12/2024 at 8:59 AM revealed the thermometer hanging on one of the shelves inside of the refrigerator read 50 degrees F. The Assistant Dietary Manager read the thermometer at 50 degrees F and stated she could put another thermometer inside. She said the temperature should be 41 degrees or below. She said the built-in thermometer on the outside of the refrigerator read 37 degrees F. Observation on 03/13/2024 at 11:55 AM revealed a different thermometer inside the refrigerator that read 36 degrees F. Interview on 03/14/2024 at 11:47 AM the Dietary Manager stated she or the cook was responsible to verify the temperature was correct. She stated the thermometer inside was just a backup and she did not think she would have a thermometer inside the fridge after this. Interview on 03/14/2024 at 3:56 PM, the Administrator stated his expectation was for food to be kept at the proper temperature. He stated they go by the thermometer that was inbuilt and that was the accurate one. Record review of facility policy titled, Refrigerators and Freezers revised December 2014, revealed: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation .
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Garbage Disposal (Tag F0814)

Could have caused harm · This affected most or all residents

Based 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 ha...

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Based 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. Findings included: Observation and interview on 03/12/2024 at 8:59 AM, revealed there was no trash can with a lid near the handwashing sink. The Assistant Dietary Manager stated they had a step trash can, but it was broken, and another one was supposed to be in today. She moved a garbage can without a lid (that was not in use) from the food prep area and put it near the sink. She stated the garbage can was supposed to have a lid for cross contamination. Interview on 03/14/2024 at approximately 11:47 am, the Dietary Manager stated she got three step trash cans with lids and placed them in the kitchen. Interview on 03/14/2024 at 5:42 PM, the Interim Administrator stated the reason for a step trash can was to ensure staff did not touch anything. He stated the garbage cans should have lids so that anything in the air will not be circulating. The facility did not provide a policy on garbage and refuse in the kitchen. Record review of the US FDA Food Code, dated 2022, reflected: 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnables shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT .
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Staffing Data (Tag F0851)

Could have caused harm · This affected most or all residents

Based 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 (O...

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Based 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. Findings included: Review of the CMS PBJ report for Fiscal Year Quarter 1 of 2024 (October 1- December 31, 2023) reflected No RN Hours was triggered, for lack of RN coverage on 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. Review of RN time stamp detail sheets for DON and direct care schedules for 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23 reflected sufficient RN coverage on those dates. An interview with DON on 03/13/24 at 03:45 PM revealed that she was responsible for scheduling the nurses. She said that if there was no RN on duty for the day, she would come into work. DON provided RN hours on 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. She said that because she was a salaried employee, it was not possible to clock in and clock out therefore, she wrote the time and date on the schedule, signed it, and turned them in to the Administer. An interview with interim Administrator on 03/13/24 at 04:06 PM revealed DON is mandated to work 8 hours if there was no nurse on the schedule. He said she does not clock in using a tracking tool. She writes her ins and outs with signature. An interview with the Administrator on 03/14/24 at 04:06 PM revealed that because his parent company was not a typical nursing home company, all department heads were salaried employees. He said his system was not set up to report DON hours worked for 11/12/23, 12/02/23, 12/03/23, 12/17/23, 12/24/23, and 12/30/23. He said that he used a third-party HR vendor payroll company that sent him a document with all hours of employees that clock in and clock out. He said he was unable to edit the information to add the missing RN hours because it altered the format of the document and PBJ website would not accept the altered file. He said that he had reached out to PBJ website, but they told him They could not help him. Facility did not provide policy for PBJ staffing data reporting at exit 03/14/24 at 06:50 PM. Review of CMS undated policy PROCEDURE AND GUIDANCE §483.35(b) reflected The facility is responsible for submitting staffing data through the PBJ (Refer to, §483.70(q)).
Sept 2023 1 deficiency 1 IJ
CRITICAL (J) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0760 (Tag F0760)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The facility provided sufficient evidence that all alleged violations were investigated, corrected, further medication errors prevented, and was in substantial compliance after the exit date of the last standard recertification and before the abbreviated survey began. This deficient practice could affect residents who received medication by not receiving the correct medication and dose, putting resident at risk for the potential for severe side effects. Findings included: Review of the facility's Provider Investigation Report, dated 09/17/23, revealed, On 9/14/2023, [Resident #1] admitted to the facility from [Hospital]. The facility received the patient's medication list which included medication list for another patient at the hospital. The admitting nurse, [LVN A] proceeded to enter the medication orders on the medication list she received from the hospital not realizing that the medication list she received included medication list for another patient on the same hospital unit who was also scheduled to transfer to a different unit at the facility. The pharmacy filled the order without identifying the error. Resident #1 was administered the medication on the list received from the hospital. On 9/16/2023, the facility discovered that the resident's medication list received from the hospital included pages of medication lists belonging to another male patient. The facility immediately notified the physician, who gave an order to send the resident to the hospital for observation and evaluation. The family was notified. The facility Ombudsman was notified. On 9/17/2023, the Resident #1's family member reported to the DON, [DON], RN that her mom was doing better but was diagnosed with Pneumonia. In addition, the facility immediately started education and in-services on admission Process- Hospital report paper must be used for every admission, two Nurses must verify the medication and sign on admission medication list provided, admission check-off must be completed by admitting Nurse and return to ADON within 24 hours of admission, staple discharge orders to it, reconcile medication with family or resident upon admission during baseline care plan. Medication should be read out to the Doctor for verification/reconciliation. Review of Resident #1's face sheet, dated 09/28/2023 revealed the resident was an [AGE] year-old female admitted on [DATE] with the following diagnoses of dementia, hyperlipidemia, atherosclerotic heart disease, and cognitive communication deficit. Review of Resident #1's physician orders for 09/14/2023 revealed the resident was originally ordered to receive the following medications: - Acetaminophen 650 mg tab. Take 1 Tablet (650mg total) by mouth every 6 (six) hours as needed for pain. - Calcium Carbonate-Vitamin D3 250 mg - 3.125 mcg (125 unit) Tab. Take 1 tablet by mouth daily with meal. Start taking on: September 15, 2023. - Enoxaparin 40 mg/0.4 ml Syringe. Commonly known as: Lovenox. Inject 0.4 mls (40 mg total) under the skin daily for 14 days. Indications: deep vein thrombosis prevention in hip surgery. - Hydrocodone-acetaminophen 5-325 mg per tablet. Commonly known as: Norco. Take 1 tablet by mouth every 6 (six) hours as needed (severe pain not responding to Tylenol). Indications: acute pain. - Aspirin 81 MG EC tablet - Hydralazine 25 mg tablet. Commonly known as: Aspresoline. Take 1 tablet (25 mg total) by mouth every 8-hour as needed (for BP 170/90 or higher) - Melatonin 5 mg Chew - Metoprolol 5 mg tablet. Commonly known as: Lopressor. Take ½ tab by mouth BID. Hold for SBP less than 100) Review of Resident #1's MAR for September 14, 2023, revealed Resident #1 was administered the following medications that were not originally ordered by the physician. These medications were listed on the hospital discharge paperwork for Resident #2: - Enoxaparin Sodium Injection Prefilled Syringe Kit 40 MG/0.4ML (Enoxaparin Sodium) Inject 1 vial subcutaneously one time a day for Blood Thinner for 14 Days. Given at 0800 - 08/15/23, 08/16/23. (This medication was on Resident #1's Hospital MAR). - Acetaminophen ER Oral Tablet Extended Release 650 mg (Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain. May give two every 8 hours as needed for pain. May give two 325 tabs to equal 650mg. - Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for Blood Thinner. Given at 0800 - 08/15/23, 08/16/23; Given at 1700 - 08/14/23, 08/15/23, 08/16/23. - Bactroban External Cream 2 % (Mupirocin Calcium (Topical)) Apply to affected area topically two times a day for infection. Given at 0800 - 08/15/23, 08/16/23; Given at 1700 - 08/14/23, 08/15/23, 08/16/23. - Abiraterone Acetate Oral Tablet 250 MG (Abiraterone Acetate) Give 4 tablet by mouth at bedtime for Hormone-Start Date: 09/14/2023 - Given at 2000. Given 09/14/23, 09/15/23, 09/16/23. - Ascorbic Acid Oral Tablet 500 MG (Ascorbic Acid) Give 1 tablet by mouth one time a day for SUPPLEMENT-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Aspirin Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for blood thinner-Start Date: 09/15/2023 at 0800 - Given 09/15/23. - Calcium Carbonate-Vit D-Min Oral Tablet (Calcium Carbonate-Vitamin D w/ Minerals) Give 1 tablet by mouth one time a day for Deficiency-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Cholecalciferol Oral Tablet 125 MCG (5000 UT) (Cholecalciferol) Give 1 tablet by mouth one time a day for Deficiency-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Colchicine Oral Tablet 0.6 MG (Colchicine) Give 1 tablet by mouth one time a day for Gout-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for edema-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Miralax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for Constipation-Start Date:09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Montelukast Sodium Oral Tablet 10 MG (Montelukast Sodium) Give 1 tablet by mouth one time a day for inflammatory/allergy-Start Date: 09/15/2023 at 0800 - - Given 09/15/23, 09/16/23. - Multivitamin Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day for SUPPLEMENT-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth in the morning for Ulcer-Start Date: 09/15/2023 at 0600 - Given 09/15/23, 09/16/23. - Prednisone Oral Tablet 5 MG (Prednisone) Give 1 tablet by mouth at bedtime for Inflammation (take at night along with Zytiga)-Start Date: 09/14/2023 at 2000 - Given 09/15/23, 09/16/23. - Probiotic Oral Capsule (Saccharomyces Boulardii) Give 1 capsule by mouth one time a day for SUPPLEMENT-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Rosuvastatin Calcium Oral Tablet 40 MG (Rosuvastatin Calcium) Give 1 tablet by mouth at bedtime for Cholesterol-Start Date: 09/14/2023 at 2000 - Given only 09/14/23. - Senna-Docusate Sodium Oral Tablet 8.650 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth one time a day for Constipation-Start Date: 09/16/2023 at 0800 - Given only 09/16/23. - Tolterodine Tartrate ER Oral Capsule Extended Release 24 Hour 4 MG (Tolterodine Tartrate) Give 1 capsule by mouth one time a day for UTI-Start Date: 09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Duloxetine HCl Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl) Give 1 capsule by mouth two times a day for Depression-Start Date: 09/14/2023 at 1700/0800 - Given at 0800 - 09/15/23, 09/16/23 and 1700 - 09/15/14, 09/15/23, 09/16/23. - Hydralazine HCl Oral Tablet 25 MG (Hydralazine HCl) Give 1 tablet by mouth two times a day for Hypertension (Hold IF SBP<110 OR DBP<60)-Start Date: 09/14/2023 at 1700/ 0800 - 09/15/23 (BP - 115/82, Pulse - 103), 0800 - 09/16/23 (BP-140/94, Pulse-72), 1700 - 09/14/23 (BP-114/64, Pulse-73), 09/15/23- (BP-100/66, P-73), 09/16/23 (no BP or P documented). - Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for Hypertension (Hold IF SBP<110 OR DBP<60)-Start Date: 09/15/2023 at 0800 /1700- 09/15/23 - (BP - 115/82, P-103), 09/16/23 (BP-140/64, P-72) 1700- 09/15/23 (BP-100/66, P-73), 09/16/23 (No BP 0r P documented) - Potassium Chloride ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride) Give 1 tablet by mouth two times a day for Low potassium-Start Date: 09/15/2023 0800/1700 - Given both days at each time 09/15/23, 09/16/23. - Pregabalin Oral Capsule 225 MG (Pregabalin) Give 1 capsule by mouth two times a day for Nerve pain-Start Date: 09/15/2023 at 0800/1700 - Given both days at each time 09/15/23, 09/16/23. - Keflex Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth four times a day for skin infection for 4 Days-Start Date: 09/14/2023 - Given at 2000 on 09/14/23. Given at 0800, 1200, 1600, 2000 on 09/15/23 and 09/16/2023. - Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 1 tablet by mouth four times a day for pain-Start Date: 09/15/2023. Given 09/15/23 at 1600, 2000; 09/16/23 at 0800, 1200, 1600, 2000. Review of Resident #1's head-to-toe assessment, dated 09/16/2023, revealed RN completed the assessment and indicated the resident did not experience adverse side effects. Interview on 09/29/2023 at 11:02 AM with Resident #2 revealed he was discharged from hospital on [DATE] and admitted to this facility the same day as Resident #1. Resident #2 stated he received medications as ordered per his physician orders and did not experience adverse effects from his medication. Review of Resident # 2's physician orders and MAR from resent hospital discharge to facility revealed: - Acetaminophen ER Oral Tablet Extended Release 650 mg (Acetaminophen) Give 1 tablet by mouth every 8 hours as needed for pain. May give two every 8 hours as needed for pain. May give two 325 tabs to equal 650mg. Order Date: 09/14/2023 Start Date: 09/14/2023. - Eliquis Oral Tablet 5 mg (Apixaban) Give 1 tablet by mouth two times a day related to Unspecified Diastolic (Congestive) Health Failure (150/30) Order Date: 09/14/2023 Start Date: 09/15/2023. - Atorvastin Calcium Oral Tablet 40 mg (Atorvastin Calcium) Give 1 tablet by mouth in the evening for hyperlipidemia. Order Date: 09/14/2023 Start Date: 09/15/2023. - Zytiga Oral Tablet 250 MG (Abiraterone Acetate) Give 4 tablet by mouth at bedtime related to Personal History of Malignant Neoplasm of Malignant Prostate - Order Date: 09/14/2023. Start Date: 09/14/2023. - Vitamin C Oral Tablet 500 MG (Ascorbic Acid) Give 1 tablet by mouth one time a day for SUPPLEMENT- Order Date: 09/14/2023. Start Date: 09/15/23. - Aspirin Oral Tablet Delayed Release 81 MG (Aspirin) Give 1 tablet by mouth one time a day for blood thinner-Order Date: 09/14/2023 Start Date: 09/15/2023. - Cholecalciferol Oral Tablet 125 MCG (5000 UT) (Cholecalciferol) Give 1 tablet by mouth one time a day for Deficiency-Order Date: 09/14/2023 Start Date: 09/15/2023. - Colchicine Oral Tablet 0.6 MG (Colchicine) Give 1 tablet by mouth one time a day for Gout-Order Date: 09/19/2023 Start Date: 09/29/2023. - Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for edema-Order Date: 09/14/2023 Start Date: 09/15/2023. - Miralax Oral Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 1 scoop by mouth one time a day for Constipation-Start Date:09/15/2023 at 0800 - Given 09/15/23, 09/16/23. - Montelukast Sodium Oral Tablet 10 MG (Montelukast Sodium) Give 1 tablet by mouth one time a day for inflammatory/allergy-Order Date: 09/14/2023 Start Date: 09/15/2023. - Multivitamin Oral Tablet (Multiple Vitamin) Give 1 tablet by mouth one time a day for SUPPLEMENT-Order Date: 09/15/2023 Start Date: 09/14/23. - Protonix Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 1 tablet by mouth in the morning for GERD-Order Date: 09/14/2023. Start Date: 09/15/23. - Prednisone Oral Tablet 5 MG (Prednisone) Give 1 tablet by mouth at bedtime for Inflammation (take at night along with Zytiga)-Order Date: 09/14/2023 Start Date: 09/15/2023. - Probiotic Oral Capsule (Saccharomyces Boulardii) Give 1 capsule by mouth one time a day for SUPPLEMENT- Order Date: 09/14/2023 Start Date: 09/15/23. - Senna-Docusate Sodium Oral Tablet 8.650 MG (Sennosides-Docusate Sodium) Give 1 tablet by mouth one time a day for Constipation-Order Date: 09/14/2023 Start Date: 09/15/2023. - Tolterodine Tartrate ER Oral Capsule Extended Release 24 Hour 4 MG (Tolterodine Tartrate) Give 1 capsule by mouth one time a day for UTI-order Date: 09/14/2023 Start Date: 09/15/2023. - Duloxetine HCl Oral Capsule Delayed Release Particles 60 MG (Duloxetine HCl) Give 1 capsule by mouth two times a day for Depression-Order Date: 09/14/2023 Start Date: 09/15/2023. - Hydralazine HCl Oral Tablet 25 MG (Hydralazine HCl) Give 1 tablet by mouth two times a day for Hypertension (Hold IF SBP<110 OR DBP<60)-Order Date: 09/15/2023 Start Date: 09/16/2023. - Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 1 tablet by mouth two times a day for Hypertension (Hold IF SBP<110 OR DBP<60)-Order Date: 09/14/2023. Start Date: 09/15/2023. - Potassium Chloride ER Oral Tablet Extended Release 10 MEQ (Potassium Chloride) Give 1 tablet by mouth two times a day for Low Potassium-Order Date: 09/14/2023 Start Date: 09/15/2023. - Pregabalin Oral Capsule 225 MG (Pregabalin) Give 1 capsule by mouth two times a day for Nerve pain-Order Date: 09/14/2023 Start Date: 09/15/2023. Interview on 09/29/2023 at 10:21 AM with LVN A revealed that medication error occurred after LVN A was given the discharge papers from the paramedics. Paramedics arrived with Resident #1 on 09/14/2023 at 6:27 PM. Paramedics provided discharge papers from [Hospital]. LVN A stated the discharge summary had Resident #1's name at the top of the page and Resident # 2's at the bottom and did not notice this on the hospital MAR. She stated the medications listed were for Resident #2, not Resident #1, which she ended up transcribing. Wrong medications were ordered as a result. Resident #1 and Resident #2 both admitted on [DATE] back to the facility and it was the hospital that sent the wrong documentation. When LVN A sent the orders to be sent to the pharmacy to be filled, the pharmacy also did not catch the mistake. LVN A was suspended on 09/18/2023 for medication error and in-service and training was provided to prevent reoccurrence. LVN A revealed that she was unable to comment on if the resident suffered adverse effect but Resident # 1 was sent out to hospital for breathing difficulties. LVN A revealed the in-service was held on 09/16/2023. She stated when new patients arrive from the hospital, nurses were to verify every page of medications with resident/family. She stated she was to contact the Physician with information concerning medications and to have another nurse to check as well. The DON/ADON were to check medications after her and orders were to be texted to the Physician. Orders had to be written out by the nurse receiving the order on Telephone order. Reviewed LVN A's employee file on 09/29/2023, revealed there are no disciplinary actions in file. Reviewed the EMR/NAR with no findings. LVN license was current with no disciplinary actions against license. Interview on 09/29/2023 at 10:44 AM with the Physician (who was Resident #1's primary physician) revealed that Resident #1 did not suffer any adverse reaction from the medication error(s). Physician revealed on 09/16/2023 Resident #1 was having breathing difficulty because of pneumonia unrelated to the medications. Resident #1 transferred to the hospital for evaluation and treatment after being administered the incorrect medications. Resident #1 is now in another SNF/NF and was at her baseline. Physician revealed that the hospital mixed up the physician orders before they sent them to the facility. Both residents (Resident #1 and Resident #2) were being transferred to the facility at the same time after hospitalization. Physician stated would speak to the head of the department to discuss how the orders were easily mixed up and could cause issues at the facility level. Physician revealed that Resident #1 and Resident #2 were on the same floor at the hospital, so the physician discharge orders were mixed up before sent with paramedics. Interview on 09/29/2023 at 11:18 AM with LVN C revealed the process to follow receiving hospital discharge papers for new admission included the charge nurse receiving the new resident would sign off on paper packet, speak with the family, review and verify medication list with resident/family, reconcile and inform physician of any discrepancies , put medications into the system, get consent for medications that would require consent, complete assessments, and chart. LVN C revealed it was the nurse on shift that was responsible for inputting the correct data into the system and the ADON was to come behind and ensure it was correct. For any medication administration error found, the nurse was to immediately notify the physician and DON/Administrator. A head-to-toe assessment would be completed which included checking for cognitive orientation, neuro status, vitals, check lungs, speaking to physician if blood work was needed and asking how the resident was feeling. LVN C revealed nursing staff were in-serviced on medication error by the DON. Facility staff were in-serviced on the following: right name, right order, right patient, right route, and how it was given. LVN C stated nursing staff were to check for any recent changes to medications and dosages. If any discrepancies, the nurse was to contact the physician, the family, the DON and monitor the resident for adverse reactions. The DON conducted the in-service for facility nurses. When pharmacy delivers medications, to prevent medication error, nurses were to compare the list received with the medications. Nurses were to check the MAR when administering. LVN C was unaware of any adverse effects Resident #1 experienced. Interview on 09/29/2023 at 11:34 AM with DON revealed after auditing the medications on 09/16/23, there were no additional medication errors found. Resident #1 was the only one affected. The DON stated since the incident, the facility changed admission tasks and required receiving nurse to check medications immediately and have at least two nurses verified. The family, DON, ADON would need to be notified. All nursing staff were in-serviced by the DON and it was held on 09/19/2023. The DON stated she was unaware of any side effects Resident #1 experienced. Interview on 09/29/2023 at 11:45 AM with Administrator revealed after auditing, no other residents were affected. The only incident that happened was related to Resident #1. The Administrator stated the interventions made after the incident was the facility now required two nurses to review the admission paperwork as well as the DON and ADON. The resident and/or family would be notified to verify medications and care plan. All nursing staff were in-serviced on 09/16/2023 by the DON. Administrator revealed that he was not a clinician, so he spoke with [physician] on 09/16/23 and there was informed no side effects from medications. Interview on 10/06/2023 at 12:14 PM with RN B revealed he was called to Resident # 1's room by Activity Staff due to Resident # 1 was complaining of breathing difficulties on 09/16/23. RN B checked oxygen stats and placed oxygen on Resident # 1 to make her comfortable. RN contacted Physician. Family member revealed to RN B that Resident #1 had told her that she was given medication tablets she was not familiar with. Family member had a list and provided it. RN compared the list daughter had with the Physician Orders in Resident's chart and noted that there were medications that did not belong to Resident #1. RN B immediately called the DON and Physician. Physician arrived at facility and assessed resident. Resident tested for Covid-19 and test was negative. Physician ordered resident to be sent to hospital 911. Review of the facility's in-service by the DON, dated 09/16/23, revealed facility nurses (including LVNs/RNs) were trained on two nurses to verify medication and name on every page during admission. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on all orders text by the [physician] must be written out by the nurse receiving the order. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on discontinuing resident medication list, immediately after discharge. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on verifying medication with the family and upon admission, to verify medication and skin issues with family. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on medication to be called out to physician upon admission as well as no two anticoagulant drugs to be administered without verifying with physician. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on discontinuing medication list 24-hours after discharge to hospital. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on paying attention to safe medication practices - the right patient, the right drug, the right time, the right dose, and the right route. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on hospital paperwork to be used during report. Review of the facility's in-service by the DON, dated 09/16/23, revealed nurses (including LVNs/RNs) were trained on admission check-off. Review of facility's policy on Medication-Administration, revised 06/2020, revealed, .Compare the Licensed Practitioner's prescription/order with the MAR (first check) Verify the resident's identify before administering the medication . Review of the facility's policy on admission and Orientation of Residents, dated 06/2020, revealed, .will provide the following information to the Admissions Office: .C. Medication orders, including a medical condition or problem associated with each medication .
Jan 2023 3 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, 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 two of four residents (Resident #34 and Resident #166) reviewed for care plans. The facility failed to ensure Resident #34 and Resident #166 had a comprehensive person-centered care plan that included care for respiratory services. This failure could place residents at risk for their needs not being met and not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being. Finding included: 1. Record review of Resident #34's face sheet, dated 01/19/23, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #34 had diagnoses which included leg fracture, dementia, heart disease, kidney disease, anxiety, and falls. Record review of Resident #34's MDS, dated [DATE], revealed she was moderately cognitively impaired with a BIMS score of 9. She required extensive assistance of two staff members with bed mobility, extensive assistance of one staff member for toileting, and the supervision of one staff member for personal hygiene. Record review of Resident #34's physician orders revealed: Continuous oxygen at 2-5L per min via NC every shift dated to start 05/11/22. Record review of Resident #34's Comprehensive Care Plan, dated 01/18/23, revealed no documentation of care interventions for oxygen delivery care provided. In observation of Resident #34 on 01/18/23 at 10:58 AM revealed the resident was in her wheelchair in her room. Resident #34's nasal cannula was in her nostrils and concentrator turned on. In observation of Resident #34 on 01/19/23 at 10:29 AM revealed the resident in her bed. The resident's nasal cannula was in her nostrils and the concentrator was turned on. 2. Record review of Resident #166's face sheet, dated 01/20/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #166 had diagnoses which included respiratory failure, hypertension (high blood pressure), inflammation of the lower extremity blood vessels, obstruction of lung disease, kidney disease, and mobility abnormalities. Record review of Resident #166's MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She was totally dependent on staff with bed mobility, extensive assistance with toileting and personal hygiene. Record review of Resident #166's physician orders revealed: oxygen at 2l/nc continually every shift dated to start 01/08/23. Record review of Resident #166's Comprehensive Care Plan, dated 01/08/23, revealed no documentation of care interventions for oxygen delivery care provided. In observation of Resident #166 on 01/19/23 at 1:51 PM revealed the resident was in her recliner resting. The nasal cannula was positioned in the resident's nostrils and the concentrator was turned on. In interview with the DON on 01/20/23 at 11:51 AM, she stated Comprehensive Care Plans were initiated by the Social Worker and organized by the leadership team. She stated the MDS Coordinator updated care plans and ensured accuracy. She stated respiratory services should have been captured on the care plans for Resident #34 and Resident #166. She stated it was not a harm to the resident if the care plan is being carried out but she stated it was the facility's policy to ensure any type of treatment, intervention, and care to meet the patient's needs, especially oxygen therapy, to be reflected on the care plan. An attempt was made to interview MDS Coordinator on 01/20/23 at 12:00 PM, but the MDS Coordinator was not available for interview. Record review of the facility policy, Care Planning - Interdisciplinary Team, revised September 2013, reflected: Policy Statement, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Record review of the facility policy, Care Plans, Comprehensive Person-Centered, revised December 2016, reflected: Policy Statement, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implements for each resident. Policy Interpretation and Implementation, 1. The Interdisciplinary Team (IDT) .develops and implements a comprehensive, person-centered care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 8. The comprehensive, person-centered care plan will .l. Identify the professional services that are responsible for each element of care .o. Reflect currently recognized standards of practice for problem areas and conditions.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed ensure residents who needed respiratory care were provided...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 of 4 residents (Resident #25, Resident #34, Resident #166 and Resident #170) reviewed for respiratory care. 1. The facility failed to ensure Resident #34 and Resident #166 had oxygen concentrator filters free of sediment and debris. 2. The facility failed to ensure Resident #25, Resident #34, Resident #166, and Resident #170 had oxygen tubing that was not on the floor. These failures could place residents at risk of not receiving proper delivery of oxygen, cross contamination, respiratory compromise and/or infection and residents not having their respiratory needs met. Finding included: 1. Record review of Resident #25's face sheet, dated 01/20/23, revealed an [AGE] year-old female who was re-admitted to the facility on [DATE] on hospice. Resident #25 had diagnoses which included fracture of the back, back pain, brain hemorrhage, mobility abnormalities, falls, and cognitive deficits. Record review of Resident #25's MDS, dated [DATE], stated she was moderately cognitively impaired with a BIMS score of 10. She required extensive assistance of one staff with bed mobility, toileting, and limited assistance of one staff with personal hygiene. Record review of Resident #25's physician orders revealed: Continuous oxygen at 2L per NC prn every 8 hours as needed dated to start 10/22/2022. Record review of Resident #25's Comprehensive Care Plan, dated 01/18/22, revealed Resident #25 had an altered cardiovascular status with an intervention as give oxygen as ordered by the physician. In observation of Resident #25 on 01/18/23 at 10:50 AM revealed the resident was resting in her bed in her room. Resident #25's nasal cannula was in her nostrils and the concentrator was on. The resident's nasal cannula tubing was observed on the floor to the right side of her bed. 2. Record review of Resident #34's face sheet, dated 01/19/23, revealed a [AGE] year-old female who was re-admitted to the facility on [DATE]. Resident #34 had diagnoses which included leg fracture, dementia, heart disease, kidney disease, anxiety, and falls. Record review of Resident #34's MDS, dated [DATE], revealed she was moderately cognitively impaired with a BIMS score of 9. She required extensive assistance of two staff members with bed mobility, extensive assistance of one staff member for toileting, and the supervision of one staff member for personal hygiene. Record review of Resident #34's physician orders revealed: Continuous oxygen at 2-5L per min via NC every shift dated to start 05/11/22. In observation of Resident #34 on 01/18/23 at 10:58 AM revealed the resident was in her wheelchair in her room. Resident #34's nasal cannula was in her nostrils and the concentrator was turned on. The resident's nasal cannula tubing was on the floor to the left side of her bed. Resident #34's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present. In observation of Resident #34 on 01/19/23 at 10:29 AM revealed the resident in her bed. Resident #34's nasal cannula was in her nostrils and the concentrator was turned on. The resident's nasal cannula tubing was on the floor to the left side of her bed. Resident #34's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present. 3. Record review of Resident #166's face sheet, dated 01/20/22, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #166 had diagnoses which included respiratory failure, hypertension, inflammation of the lower extremity blood vessels, obstruction of lung disease, kidney disease, and mobility abnormalities. Record review of Resident #166's MDS, dated [DATE], revealed she was cognitively intact with a BIMS score of 15. She was totally dependent on staff with bed mobility, extensive assistance with toileting and personal hygiene. Record review of Resident #166's physician orders revealed: oxygen at 2l/nc continually every shift dated to start 01/08/23. In observation of Resident #166 on 01/19/23 at 1:51 PM revealed resident in her recliner resting. Nasal cannula positioned in resident's nostrils and concentrator turned on. Resident's nasal cannula tubing on the floor to the right side of her bed. Resident #166's oxygen concentrator filter was observed to have significant brown, black, and grey debris sediment accumulation present. 4. Record review of Resident #170's face sheet, dated 01/20/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #170 had diagnoses which included respiratory failure, depression, heart failure, obstruction of lung disease, mobility abnormalities, and Type 2 diabetes. Record review of Resident #170's MDS, dated [DATE], revealed she was moderately cognitively impaired with a BIMS score of 8. She required extensive assistance of 2 staff for bed mobility and assistance of one staff for transfers. Record review of Resident #170's physician orders revealed: Continuous oxygen at 2L per NC every shift dated to start 01/06/23. In observation of Resident #170 on 01/19/23 at 2:04 PM, the resident was in her bed resting. The nasal cannula was positioned in the resident's nostrils and the concentrator was turned on. The resident's nasal cannula tubing was observed on the floor. In interview on 01/19/23 at 1:40 PM with LVN M, she stated Resident #34's filter was dirty. She stated she was not sure when the oxygen concentrator's filter was cleaned. She stated the nasal cannula tubing was on the floor for Resident #25, Resident #34, Resident #166, and Resident #170 was not a concern. She stated it was ultimately the nurse's responsibility to ensure the oxygen concentrator and tubing was functioning and kept clean, but she never received instructions to keep the nasal cannula tubing off the floor nor how or when to clean the oxygen concentrator filter. She stated if the oxygen concentrator filter was dirty, it could cause respiratory compromise, as the resident could inhale foreign particulates. In observation and interview with LVN J on 01/19/23 at 1:51 PM, she stated Resident #166's filter was dirty. She stated nasal cannula tubing should not be on the floor for Resident #25, Resident #34, Resident #166, and Resident #170. She stated she should roll up any excess nasal cannula tubing up to prevent it from being on the floor. She stated she was not sure when the oxygen concentrator filter was cleaned for Resident #166. She stated it was ultimately the nurse's responsibility to ensure the oxygen tubing was off the ground and the filter was clean. She stated there was currently no system in place to inspect and/or clean the oxygen concentrator filter. She stated if the oxygen concentrator filter was dirty, it could cause the concentrator to not work properly causing respiratory compromise. She stated if the tubing was on the floor, it could be an infection control risk. In interview with DON on 01/20/23 at 11:51 AM, she stated there was not a policy, protocol, or procedure on oxygen concentrator filter inspection and/or cleaning. She stated it was best practice to clean the filter weekly and she was in the process of implementing interventions to ensure this was completed by the nursing staff. She stated if the oxygen concentrator filter was dirty, it could result in possible respiratory issues from the accumulation of particles and infection control concerns. She stated she did not consider the nasal cannula tubing on the floor for Resident #25, Resident #34, Resident #166, and Resident #170 as a concern. She stated there was not a policy for the facility to ensure the nasal cannula tubing remained off the floor. An attempt was made to interview MDS Coordinator on 01/20/23 at 12:00 PM, but the MDS Coordinator was not available for interview. Record review of the facility policy, Oxygen Administration, revised October 2010, reflected: Purpose, The purpose of this procedure is to provide guidelines for safe oxygen administration .Preparation .2. Review the resident's care plan .Steps in Procedure .12. Check the .tank . to be sure they are in good working order
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based 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 in the facility's ...

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Based 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 in the facility's only kitchen. 1. The facility failed to ensure all foods stored in the refrigerator, freezer, and dry food storage areas were dated with a use by or expiration date. 2. The facility failed to ensure expired foods were discarded upon the use by or expiration date. This failure could place residents at risk of food-borne illnesses. Findings included: Observation on 01/18/23 at 8:45 AM of the kitchen revealed the following: • Four 6-pound cans of Tapioca Pudding revelaed no date of when the products were received and stored by the facility • Twenty-seven Loaves of wheat bread revelaed no date of when the products were received and stored by the facility • Twelve 12 loaves of hamburger buns revelaed no date of when the products were received and stored by the facility. • Observation of the facility's walk-in refrigerator revealed one gallon container of opened cocktail sauce with a use by date of 07/08/22. • One whole strawberry cream pie revelaed no date of when the products were received and stored by the facility Interview with [NAME] A on 01/18/23 at 8:50 AM revealed she was one of the cooks at the facility and had been there for 2 years. She stated everyone was supposed to know how to date and label products that were delivered. She stated they did have a Dietary Aide, not at work today, putting away delivered products, and label and date them accordingly. She stated they had a shipment that came in the morning of 01/17/23, and the dietary aide failed to label and date some products. She stated the loaves of bread and cans of pudding had arrived in that shipment. She stated the risks to residents if food items were not properly labeled and dated was they could be served expired food and become sick. Interview with the Dietary Manager (DM) on 01/19/23 at 09:40 AM revealed she had been the DM for 2 years. She stated she was advised by the [NAME] of the concerns identified and had corrected them. She stated food items were to be dated and labeled prior to being stored. She stated her dietary aide, who was not at work that day, and was assigned to date and label items that were delivered, prior to it being stored. She stated the food had arrived this past Tuesday, 01/17/23. She stated dietary aides were assigned to checking for expired foods in the pantry, refrigerator, and freezer. She stated the risk to residents if food was not properly dated and labeled was that residents could get ill from eating expired foods. Interview with the Administrator on 01/20/2023 at 12:30 PM revealed he was the Executive Director of the entire facility and has been at the facility over two years. He stated he was advised by his Dietary Manager of the findings, and he knew the Dietary Manager had completed In-service on storing food items. The Administrator stated they had just received a shipment the morning of 01/17/23 and the dietary aide that was working, failed to properly date and label all of the inventory that came in because he had gotten distracted attempting to assist a resident. The Administrator stated the requirements for labeling and dating inventory was that it must be done immediately before storing the items. He stated the risk to not properly dating and labeling food was the resident was at risk of eating expired food and could get ill. Record review of the facility's policy on Food Receiving and Storage, dated July 2014, revealed all foods should be labeled and dated use by date.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "What changes have you made since the serious inspection findings?"
  • "Why is there high staff turnover? How do you retain staff?"
  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • Licensed and certified facility. Meets minimum state requirements.
Concerns
  • • Multiple safety concerns identified: 1 life-threatening violation(s). Review inspection reports carefully.
  • • 11 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
  • • $12,649 in fines. Above average for Texas. Some compliance problems on record.
  • • Grade C (51/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 51/100. Visit in person and ask pointed questions.

About This Facility

What is Discovery Village At Southlake's CMS Rating?

CMS assigns DISCOVERY VILLAGE AT SOUTHLAKE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Discovery Village At Southlake Staffed?

CMS rates DISCOVERY VILLAGE AT SOUTHLAKE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Texas average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Discovery Village At Southlake?

State health inspectors documented 11 deficiencies at DISCOVERY VILLAGE AT SOUTHLAKE during 2023 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 10 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Discovery Village At Southlake?

DISCOVERY VILLAGE AT SOUTHLAKE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by WELLTOWER, INC., a chain that manages multiple nursing homes. With 41 certified beds and approximately 37 residents (about 90% occupancy), it is a smaller facility located in SOUTHLAKE, Texas.

How Does Discovery Village At Southlake Compare to Other Texas Nursing Homes?

Compared to the 100 nursing homes in Texas, DISCOVERY VILLAGE AT SOUTHLAKE's overall rating (3 stars) is above the state average of 2.8, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Discovery Village At Southlake?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the facility's high staff turnover rate.

Is Discovery Village At Southlake Safe?

Based on CMS inspection data, DISCOVERY VILLAGE AT SOUTHLAKE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Discovery Village At Southlake Stick Around?

Staff turnover at DISCOVERY VILLAGE AT SOUTHLAKE is high. At 60%, the facility is 14 percentage points above the Texas average of 46%. Registered Nurse turnover is particularly concerning at 60%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Discovery Village At Southlake Ever Fined?

DISCOVERY VILLAGE AT SOUTHLAKE has been fined $12,649 across 1 penalty action. This is below the Texas average of $33,205. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Discovery Village At Southlake on Any Federal Watch List?

DISCOVERY VILLAGE AT SOUTHLAKE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

DISCOVERY VILLAGE AT SOUTHLAKE

201 WATERMERE DRIVE, SOUTHLAKE, TX 76092 | (817) 482-1340

C
Trust Grade (51/100)
3.0
CMS Rating
11
Deficiencies

Strengths

  • Licensed facility

Concerns

  • 1 Immediate Jeopardy citation

Ask about: Inspection Response, Staff Retention, Rn Coverage

nursinghomedata.org | Data: CMS November 2025