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Discovery Village at Southlake
201 Watermere Drive, Southlake, TX 76092 · CMS Certification Number (CCN) 676351
At a glance
- CMS overall rating
- ★★★★★ 5 of 5
- Health inspection citations
- 15 in the last 3 inspection cycles (1 immediate jeopardy, 0 actual harm, 3 from complaints)
- Fire safety citations
- 15
- Fines (last 3 years)
- 1 fine, total $12,649
- Payment denials
- 0
- Most recent standard inspection
- June 4, 2026
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★★★★★ 5 of 5 | 2.7 | 3 |
| Health inspections | ★★★★★ 5 of 5 | 2.8 | 2.8 |
| Staffing | ★★★★☆ 4 of 5 | 1.9 | 2.9 |
| Quality measures | ★★☆☆☆ 2 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
| Short-stay quality | ★★★★☆ 4 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | June 4, 2026 | 4 | 2 | 2 |
| Cycle 2 | April 11, 2025 | 4 | 3 | 1 |
CMS weighted health inspection score: 25 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
15 health citations across 5 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
June 4, 2026: 2 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 07/10/2026 |
November 12, 2025: 2 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/10/2025 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/10/2025 |
April 11, 2025: 3 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/20/2025 |
| E | F-0700 | 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. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/20/2025 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/20/2025 |
March 14, 2024: 7 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/20/2024 |
| F | F-0814 | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/20/2024 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/20/2024 |
| D | F-0700 | 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. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/20/2024 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/20/2024 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/20/2024 |
| E | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/20/2024 |
September 29, 2023: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Complaint | Past Non-Compliance Corrected 09/16/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
15 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 06/04/2026 | F | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/10/2026 |
| 06/04/2026 | F | E-0026 | Establish roles under a Waiver declared by secretary. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/10/2026 |
| 06/04/2026 | F | E-0024 | Establish policies and procedures for volunteers. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 07/10/2026 |
| 04/11/2025 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/20/2025 |
| 04/11/2025 | E | K-0363 | Install corridor and hallway doors that block smoke. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/20/2025 |
| 04/11/2025 | F | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/20/2025 |
| 04/11/2025 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/20/2025 |
| 04/11/2025 | F | K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/20/2025 |
| 04/11/2025 | E | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/20/2025 |
| 04/11/2025 | F | E-0026 | Establish roles under a Waiver declared by secretary. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 05/20/2025 |
| 04/11/2025 | F | E-0009 | Include a process for Emergency Preparedness collaboration. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 05/20/2025 |
| 04/11/2025 | F | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 05/20/2025 |
| 03/14/2024 | F | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 04/20/2024 |
| 03/14/2024 | F | E-0006 | Conduct risk assessment and an All-Hazards approach. Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 04/20/2024 |
| 03/14/2024 | F | E-0004 | Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies | Deficient, Provider has date of correction Corrected 04/20/2024 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| September 29, 2023 | Fine | $12,649 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.63 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.85 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.92 | Not published | Not published |
| Nurse aide hours per resident per day | 1.86 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.31 | Not published | Not published |
| RN hours per resident per day, weekends | 0.63 | Not published | Not published |
| Total nursing staff turnover (%) | 43.2 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 33.3 | Not published | Not published |
| Administrators who have left | Staffing data not submitted or invalid for calculating turnover. | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Dsl Tenant II, LLC
- Ownership type
- For profit - Corporation
- Chain
- Not published
- Ownership changed in last 12 months
- No
- Certified beds
- 41
- Average residents per day
- 39.6
- Participates in
- Medicare
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- January 22, 2014
- County/parish
- Tarrant
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
8 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| HCRI TUCSON PROPERTIES INC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 98% | undefined undefined, NaN |
| DENOVELLIS, AARON | CONTRACTED MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| DUNCAN, LAWRENCE | W-2 MANAGING EMPLOYEE | Individual | NOT APPLICABLE | undefined undefined, NaN |
| HUTCHINSON, RICHARD | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WIERZBICKI, STEVE | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| AMERICAN TRUST SENIOR CARE LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| SMITH, RANDY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WIERZBICKI, STEVE | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Discovery Village at Southlake. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.