Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
DISCOVERY VILLAGE AT SOUTHLAKE
SOUTHLAKE, TX · 41 certified beds · Last Life Safety survey June 4, 2026
CMS Certification Number 676351 · first certified January 2014
Also on this campus
The same campus holds a state-licensed assisted living facility, with its own state record on the Assisted Living Index: Discovery Village at Southlake (201 Watermere Drive). Matched by the telephone number the two records share. The records are separate and are never added together.
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
- Ownership changed April 1, 2019 (change of ownership)from NORTH TOWER CARE GROUP, LP
Position within TX
15 citations — more than 86% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens July 2027 — about 9 months from now. This facility’s last Life Safety survey was June 2026. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Emergency preparedness
7 of the 15 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| March 14, 2024 | 3 |
| April 11, 2025 | 9 |
| June 4, 2026 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | 2 | 2026-06-04 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 2 | 2025-04-11 |
| E-0024 | Establish policies and procedures for volunteers. | 1 | 2026-06-04 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2024-03-14 |
| E-0009 | Include a process for Emergency Preparedness collaboration. | 1 | 2025-04-11 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2024-03-14 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2025-04-11 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2026-06-04 |
What the citations cover
- Emergency Preparedness Deficiencies 7
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 1
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 7 |
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 4, 2026 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (July 10, 2026) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (July 10, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 10, 2026) |
April 11, 2025 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (May 20, 2025) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (May 20, 2025) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (May 20, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 20, 2025) |
| K-0343 | Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Deficient, Provider has date of correction (May 20, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 20, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (May 20, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 20, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (May 20, 2025) |
March 14, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 20, 2024) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (April 20, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (April 20, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.