Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pauls Valley Care Center during CMS and state inspections, most recent first.
A resident who was dependent on staff for transfers and required a mechanical lift sustained a femur fracture when the lift sling broke during a transfer. Two staff members were present and reported checking the sling, but there was no documented process for monitoring slings for wear or damage, leading to the use of a defective sling and resulting injury.
A resident on Medicaid was sent to the hospital for vomiting and chills, then was not allowed to return after IV antibiotics were completed. The hospital record stated the facility involuntarily discharged the resident without a 30-day notice, even though the resident wanted to return and contacted the ombudsman. The DON and administrator said the resident was discharged because they had been out of the facility for 30 days and later stated the facility could not meet the resident’s needs, including psychosocial needs, and had no documentation of alternate placement efforts.
Failure to Provide Bed-Hold and Discharge Notices: A resident with depression and anxiety was transferred to the hospital after vomiting and chills, but the facility had no documentation that a bed-hold policy was provided. The DON and administrator stated the resident was later discharged after being out of the facility for 30 days, and the facility did not provide a discharge notice to the ombudsman, who confirmed no notice was received.
A resident’s annual MDS assessment was not completed or transmitted within the required timeframe. The MDS coordinator stated the assessment was finished late, and the DON also signed it after the required 14-day window had passed.
A resident admitted with CKD and DM did not have a nutritional care plan included in the care plan initiated after admission. The MDS coordinator stated care plans were due within 21 days and updated quarterly, but also said it was difficult to keep up with care plans and MDS assessments and confirmed no nutritional care plan was present.
The facility failed to complete and submit quarterly reviews of the minimum data set (MDS) within the required timeframes for eight residents. The corporate regional director acknowledged the delay but had not completed/submitted all the delayed assessments.
The facility failed to develop comprehensive care plans for two residents, omitting critical information about smoking supervision and fall risks. One resident with paraplegia did not have their supervised smoking status included in their care plan, while another resident with hemiplegia and dementia had incidents related to smoking and falls that were not documented in their care plan.
An LPN failed to follow proper wound care protocols, including not sanitizing an overbed table, not changing gloves, and not sanitizing hands between tasks, which had the potential to introduce bacteria to a resident's wound bed. The DON confirmed the LPN was new and had not been observed performing wound care.
The facility failed to store hazardous chemicals securely, as required by their policy. Various hazardous chemicals were found in unsecured locations, posing a risk to residents, including one identified as wandering throughout the facility. Staff confirmed that these chemicals should have been locked up, but this was not the case during the inspection.
The facility failed to maintain sanitary conditions in the kitchen, with an active water leak from the three-compartment sink, standing water, and broken floor tiles. Staff confirmed the ongoing issue, and the administrator acknowledged the situation, noting the absence of a maintenance person.
The facility failed to include a resident's representative in discharge planning for a resident with heart failure, respiratory failure, and diabetes mellitus. The care plan was not signed or provided to the representative, who was only informed of the discharge date 48 hours before the resident's benefits expired. The administrator claimed the representative had not provided POA paperwork, but the medical record contained a signed durable power of attorney.
Failure to Monitor and Maintain Lift Equipment Results in Resident Injury
Penalty
Summary
A resident with morbid obesity, who was dependent on staff for all transfers and required a mechanical lift with two staff members for assistance, sustained a femur fracture during a transfer. The incident occurred when staff were transferring the resident post-shower using a Hoyer lift, and the lift sling broke while the resident was suspended, causing the resident to fall to the floor. The resident reported severe pain in the right leg, which was observed to be rotated inward and warm to the touch. Surgery was subsequently performed for the femur fracture. Review of facility records and staff interviews revealed that there was no documentation of routine monitoring or inspection of lift slings for signs of wear, such as frays or holes. Although staff reported that they always used two people for transfers and checked the slings, there was no formal process or documentation in place to ensure the slings were in good repair. The lack of documented monitoring contributed to the use of a defective sling, resulting in the resident's injury.
Involuntary discharge during hospitalization
Penalty
Summary
The facility failed to ensure that a resident was not involuntarily discharged during hospitalization. Resident #40 was a Medicaid resident who had been receiving long term care services and was sent to the hospital after vomiting, chills, and requesting transfer by EMS. The resident’s discharge return anticipated assessment showed the resident had recurrent unspecified major depressive disorder and anxiety, with memory documented as OK and independent cognitive skills for daily decision making. The facility’s Bed-Holds and Returns policy stated that a Medicaid resident exceeding the bed-hold period could return if the resident required facility services and remained eligible for Medicare skilled nursing services or Medicaid nursing services, and that if the resident exceeded 30 days out of the facility, the resident would be formally discharged. The hospital discharge summary showed the facility told the hospital the resident had been discharged from the facility, and the summary stated the resident had completed IV antibiotics and was ready to return to the facility. The summary also stated the facility involuntarily discharged the resident without a 30-day notice, and that the resident wanted to be transferred back and had contacted the ombudsman for legal assistance. During interviews, the DON and administrator stated the resident was discharged because they had been out of the facility for 30 days, and later stated the resident was not allowed to return after completion of IV antibiotics because the facility felt it could not meet the resident’s needs, including psychosocial needs. The DON also stated the facility could not locate documentation showing attempts to secure alternate placement for the resident.
Failure to Provide Bed-Hold and Discharge Notices
Penalty
Summary
The facility failed to provide a bed-hold policy upon transfer, failed to provide a discharge notice to the resident and/or representative, and failed to provide a copy of the discharge notice to the ombudsman for Resident #40. The resident’s discharge return anticipated resident assessment dated 09/30/25 showed an unplanned discharge to a short-term general hospital stay on 09/30/25. The assessment noted diagnoses including recurrent unspecified major depressive disorder and anxiety, and documented that the resident’s memory was OK and that the resident was independent in cognitive skills for daily decision making. A nursing note dated 09/30/25 stated the resident was vomiting and chilled and requested to go to the hospital, and an order was received to transfer the resident by emergency medical services. There was no documentation that a bed-hold policy was provided to the resident. The DON and administrator stated the resident was transferred to the hospital and later discharged from the facility after being out for 30 days per facility policy. The administrator stated the facility’s process was to mail discharge notices to the ombudsman, but the ombudsman stated they were not provided with a discharge notice for Resident #40.
Late Completion of Annual Resident Assessment
Penalty
Summary
The facility failed to ensure a comprehensive annual assessment was completed within 14 days for Resident #3. Record review showed Resident #3 was admitted on an unspecified date, and the annual assessment had an assessment reference date of 06/25/25. Although the MDS Coordinator #1 and the DON signed the assessment as completed on 08/05/25, MDS Coordinator #1 stated during interview on 12/18/25 at 3:37 p.m. that the annual assessment was not completed or transmitted until 08/05/25 and that it was not completed or transmitted timely. MDS Coordinator #1 also stated the assessment should have been completed by the 14th day after the assessment reference date.
Missing Nutrition Care Plan
Penalty
Summary
The facility failed to ensure the initiation of a comprehensive nutrition care plan for one resident. The resident was admitted with diagnoses including chronic kidney disease and diabetes mellitus. A care plan initiated on 07/16/25 did not show that the resident had a nutritional care plan. During interview, the MDS coordinator stated that care plans were to be completed within 21 days of admission and updated quarterly, and also stated that care plans were updated with different things such as falls and resident changes. The MDS coordinator further stated it was complicated to keep up with both care plans and MDS assessments and later stated they did not see a nutritional care plan for the resident.
Failure to Complete and Submit MDS Assessments Timely
Penalty
Summary
The facility failed to complete and submit quarterly reviews of the minimum data set (MDS) within the required timeframes for eight out of ten residents whose clinical records were reviewed. The facility's policy mandates that resident assessments be conducted and submitted in accordance with federal and state submission timeframes. However, the corporate regional director documented that several residents had not had a complete/submitted MDS assessment in the last 120 days. The regional director acknowledged the delay but had not completed/submitted all the delayed assessments.
Failure to Develop Comprehensive Care Plans for Smoking and Fall Risks
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in addressing their smoking and fall risks. Resident #1, diagnosed with paraplegia and neurological conditions, was assessed as a supervised smoker but did not have smoking included in their care plan. This oversight was confirmed by the Director of Nursing (DON) after the resident was observed smoking with staff supervision on two occasions. Resident #80, diagnosed with hemiplegia and dementia, was initially assessed as safe to smoke unsupervised. However, after an incident where the resident singed their hair while lighting a cigarette, the resident was reassessed and deemed unsafe to smoke unsupervised. Despite this, the resident's care plan did not reflect the updated smoking status. Additionally, Resident #80, who was at risk for falls and had a documented fall from their wheelchair, did not have fall risk included in their care plan. The DON acknowledged these omissions after the resident was observed using a rolling walker and requiring assistance with most activities of daily living.
Failure to Follow Proper Wound Care Protocols
Penalty
Summary
The facility failed to provide wound care in a manner that reduces the risk of infection or cross-contamination for one resident. During an observation, an LPN performed wound care without sanitizing an overbed table borrowed from the resident's roommate, and without changing gloves or sanitizing hands between tasks. The LPN handled the resident's soiled positioning pillow and performed the entire wound care procedure, including removing the old dressing, cleaning the wounds, and applying a new dressing, without changing gloves or sanitizing hands. This practice had the potential to introduce bacteria from the resident's intact skin and other surfaces to the wound bed. The LPN acknowledged the failure to follow proper hand hygiene and glove-changing protocols during the wound care procedure. The Director of Nursing (DON) confirmed that the LPN was new to the facility and had not yet been observed performing wound care. The DON stated that the LPN should have sanitized hands and changed gloves when moving from dirty tasks to clean tasks and when gloves were visibly soiled.
Failure to Secure Hazardous Chemicals
Penalty
Summary
The facility failed to store hazardous chemicals in a secure manner, as required by their policy. During an inspection, various hazardous chemicals were found in unsecured locations throughout the facility, including a bathroom, a shower room, and a hopper room. These chemicals included Bounce Back, Spraybuff, Soft Scrub with Bleach, Virex II 256, Good Sense, and Clorox Clean-Up with Bleach. The Material Safety Data Sheets (MSDS) for these chemicals indicated that they could cause serious harm if ingested, inhaled, or if they came into contact with skin or eyes. The facility's policy required these chemicals to be stored in locked areas, but this was not adhered to during the inspection. The director of nursing identified one wandering resident who ambulated throughout the facility, increasing the risk of exposure to these hazardous chemicals. Interviews with staff, including an LPN and the administrator, confirmed that the chemicals should have been locked up. The administrator acknowledged that the chemicals were supposed to be stored securely, either in locked cabinets or locked rooms, but this was not the case at the time of the inspection.
Sanitary Conditions Not Maintained in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed by surveyors. There was an active water leak from under the three-compartment sink, resulting in standing water on the kitchen floor. Several saturated bath sheets and towels were placed on the floor between the sink and the food prep table to manage the leak. Additionally, there were several missing, cracked, and broken floor tiles observed. The back door of the kitchen was also found to be open wide without a screen door present. These conditions were noted during observations on two separate occasions. Interviews with the kitchen staff and the dietary manager revealed that the leak had been ongoing for some time, and maintenance had been notified but no repairs had been made. The cook mentioned that they had to mop up the standing water every morning before starting their shift. The dietary manager confirmed the ongoing issue and stated that maintenance was aware. The administrator acknowledged the condition of the kitchen floor and mentioned that the facility was currently without a maintenance person, but there was a plan in place for repairs.
Failure to Include Resident's Representative in Discharge Planning
Penalty
Summary
The facility failed to ensure the resident's representative was included in discharge planning for a resident with diagnoses including heart failure, respiratory failure, and diabetes mellitus. The care plan, dated 08/25/23, documented that the resident, family, and staff were in agreement for discharge planning with a planned discharge date of 09/01/23. However, there was no evidence that the care plan had been signed or a copy given to the resident or the resident's representative. The resident's family member, who was the power of attorney (POA), reported not being included in the discharge care plan meeting and was only informed of the discharge date 48 hours before the resident's benefits ran out. The administrator reported that the family member who claimed to be the POA had not provided paperwork to verify this and that another family member, listed as a contact, was present for the care plan meeting. Despite this, the resident's medical record contained a signed durable power of attorney for the family member who reported not being included in the discharge planning. This oversight led to the family member being informed of the discharge plan only 48 hours before the resident's benefits expired, causing potential confusion and lack of preparation for the resident's discharge.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pauls Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Washita Valley Living Center | 1.2 mi | ★★★★★ | 0 | 0 |
| Burford Manor | 16.4 mi | ★★★★★ | 0 | 0 |
| Callaway Nursing Home | 18.3 mi | ★★★★★ | 1 | 0 |
| Artesian Home | 19.6 mi | ★★★★★ | 9 | 0 |
| Lexington Nursing Home, Inc. | 20.8 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.