Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Parkview Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, mobility limitations, and a history of falls eloped through an unsecured delayed-egress door after power flickers caused door locks to disengage and one egress door was not properly reset. In the days prior, staff documented increased confusion and wandering, including roaming halls and attempting to use the same egress door at night. On the day of the event, the resident was left finishing dinner alone in the dining room while CNAs, aware of her tendency to wander, became occupied on another hall and did not promptly return. The unsecured door between the dining room and the resident’s room allowed her to self-propel outside, where she was later found on a side road next to an overturned wheelchair and returned by a passerby, revealing that the door had remained disengaged and not latching.
Two residents with cognitive impairment and behavioral issues were involved in an altercation after one wandered into the other's room, despite prior staff awareness of threats and behavioral risks. The assaulted resident sustained a head injury requiring hospital care, and staff failed to implement effective interventions to prevent the incident.
A resident with dementia and a history of wandering and aggressive behaviors was not adequately supervised or monitored, leading to an incident where the resident entered another resident's room and was physically assaulted, resulting in a head injury. The care plan did not fully reflect the resident's behaviors, and staff were unclear about monitoring responsibilities and documentation, contributing to the deficiency.
Unlabeled and Undated Food in Kitchen Storage Areas: Surveyors found multiple food items in a refrigerator and freezers that were undated and unlabeled, including cut sandwiches, yogurts of unknown origin, pie crusts, and open sliced green peppers. Staff, including the Dietary Supervisor, cook, RD, and ADMIN, stated that all food must be labeled and dated and that any unlabeled or undated items should be discarded, yet the items were still present during the kitchen observations.
Incomplete Care Plan for Left Hand and Wrist Contracture: A resident with DM, hemiplegia/hemiparesis following CVA, and mild cognitive impairment had a care plan for impaired physical functioning, but it did not address a left hand and wrist contracture. The resident was observed with the contracture and no intervention in place, while the ADON, DON, LVN, MA, and ADM stated contractures should be included in the care plan because staff use care plans to guide resident care.
Expired medications were found in two medication carts, including hemorrhoidal ointment in one cart and lorazepam prescribed to a resident in another. Staff gave inconsistent accounts of who checked for expired meds and how often, and the ADON stated there was no process in place to ensure expired medications were removed from the carts. The resident involved had dementia, Parkinson's disease, and expressive language disorder, and was on hospice care.
A resident with a history of stroke, aphasia, and mobility issues was able to leave the facility unsupervised after a visitor used the exit code and held the door open. The resident was not identified as an elopement risk and was missing for over three hours before being found and transported to the hospital. Staff interviews indicated that door codes had previously been shared with visitors, and there was no locked unit or Wander guard system in place.
A resident with multiple disabilities was discharged from an LTC facility without a written notice or appeal information provided to their guardian. The facility did not document interventions to meet the resident's needs or involve the guardian in the discharge process. Staff interviews revealed communication challenges and a lack of formal training on how to handle the resident's behaviors, contributing to the deficiency.
The facility failed to follow professional standards for food safety during meal preparation, as observed in two separate instances. Dietary staff did not consistently perform proper hand hygiene after removing gloves and before handling kitchen equipment, leading to potential cross-contamination risks. Interviews revealed inconsistencies in understanding and executing hand hygiene procedures, contrary to the facility's policy.
A resident with a history of UTIs and sepsis did not receive a timely urine analysis (UA) as ordered by a physician. The UA was delayed by several days, despite the resident's concerns about dark urine, which was similar to previous UTI episodes. Facility staff, including an RN and the DON, were unaware of the order and did not follow up, and the facility's policies lacked procedures for following physician orders for a UA.
A facility failed to protect a resident with severe dementia from verbal abuse by the DON, who allegedly made life-threatening remarks. The incident was reported by a Hospice RN, and the DON admitted to being frustrated but could not recall the exact words spoken. The facility's investigation concluded without definitive proof of abuse, and the DON received counseling and additional training.
The facility failed to thoroughly investigate an alleged incident of verbal abuse involving a resident with severe cognitive impairment. The incident, reported by a Hospice RN, involved the DON making a threatening statement towards the resident. The facility did not obtain written statements from staff, contact the ombudsman, or assess the resident for emotional trauma, and the resident's family was not kept informed of the investigation's progress.
Elopement Due to Unsecured Egress Door and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment remained as free of accident hazards as possible and to provide adequate supervision and assistance devices to prevent accidents, resulting in an elopement. The resident involved was an elderly female with vascular dementia, generalized anxiety disorder, major depressive disorder, insomnia, difficulty walking, unsteadiness on her feet, and a history of falling. Her quarterly MDS showed a BIMS score of 6, indicating severe cognitive impairment, and documented that she used a wheelchair and required substantial assistance to propel at least 150 feet. Prior to the incident, her care plan reflected impaired physical functioning and visual impairment, with interventions including independent wheelchair use and orientation to her environment, and there was no care-plan focus on elopement risk until after the event. In the days leading up to the elopement, progress notes documented increased confusion and wandering-type behaviors. On one day, the resident was observed confused, out in the hallway and in another resident’s room, and was redirected back to her room. Bruising to her lower extremities was noted, with the resident unable to explain how it occurred. The DON discussed with the family member the possibility of moving the resident closer to the nurse’s station for closer supervision due to increased confusion, but the family member preferred that she remain in her current room at the end of the hall. Staff interviews later indicated that the resident had been noted to roam the halls, including being found on another hall and being redirected, and that she had attempted to go out the egress door near her room at approximately 3:00 AM a day or two before the elopement, with this behavior reported to a charge nurse. On the day of the elopement, there was a thunderstorm and the facility’s power flickered or went out briefly, causing the delayed-egress magnetic locks on the doors to disengage and require resetting. Staff divided responsibility for checking and resetting doors, and 9 of 10 doors were reportedly reset and functioning properly; however, the egress door on the 200 hall near the dining room and the resident’s room was not reset or checked and remained unsecured. That evening, the resident was the last person in the dining room, taking a long time to finish her meal and milkshake. Staff who were aware she tended to wander left the area to assist on another hall and became busy, and the agency CNA who passed through the dining room later did not recognize the significance of the resident’s absence. The unsecured egress door between the dining room and the resident’s room allowed the resident to self-propel out of the building. She was later found outside on a side road behind the facility, next to an overturned wheelchair, and was brought back by a community member. Subsequent checks by the nurse revealed that the egress door near the resident’s room swung open and would not latch closed until maintenance staff manipulated the wall button and addressed the door closer, confirming that the door had remained disengaged at the time of the elopement.
Removal Plan
- Ensured all other residents were safe and accounted for.
- Ensured all doors functioned properly.
- Identified doors not functioning properly.
- Placed a CNA on doorwatch until the door was fixed.
- Assessed the resident with no adverse effects noted.
- Sent the resident to the hospital for further evaluation.
- Made notifications to the family, physician, DON, and administrator.
- Completed elopement risk assessments for all residents and updated care plans.
- Purchased a wander guard system for installation.
- Purchased and installed door alarms.
- Assessed outside surroundings near the door for hazards.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect two residents from abuse and neglect when a resident-to-resident altercation occurred. One resident with significant cognitive impairment and a history of wandering and agitation entered another resident's room. The second resident, who also had cognitive impairment and a history of verbal and physical behavioral symptoms, became upset and physically assaulted the first resident, resulting in a head injury and scalp laceration that required hospital treatment. Prior to the incident, staff were aware of both residents' behavioral histories, including the first resident's increased wandering and aggression, and the second resident's verbal threats toward the first resident if he entered the room again. Documentation and interviews revealed that staff had been notified of the risk, as a CNA had informed an LVN that the second resident had threatened to harm the first resident if he returned to the room. Despite this warning, the first resident was able to re-enter the second resident's room, leading to the altercation. The facility's records showed that the first resident had a care plan addressing wandering and behavioral risks, and the second resident had a care plan for behavioral symptoms and risk of aggression. However, interventions to prevent resident-to-resident altercations were not effectively implemented, and staff did not prevent the incident despite being aware of the escalating risk. The incident was witnessed by another resident, who confirmed that the second resident punched the first resident in the face, causing him to fall and sustain injuries. Staff responded after the altercation had already occurred, and the first resident was found on the floor with bleeding and facial discoloration. The facility's investigation did not include all relevant witness statements or documentation, and the administrator did not initially recognize a system failure, despite staff being aware of the risk and the incident resulting in serious injury.
Failure to Provide Adequate Supervision and Accident Hazard Prevention
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for a resident with aggressive and wandering behaviors. The resident, who had a history of Alzheimer's disease, dementia, unsteady gait, and recent behavioral changes, was known to wander daily and had exhibited increased agitation, aggression, and confusion in the weeks leading up to the incident. Despite these documented behaviors, the care plan did not reflect all of the resident's aggressive actions, and interventions for supervision and monitoring were inconsistently implemented and documented. On the day of the incident, the resident wandered into another resident's room, despite a prior verbal threat from that resident earlier in the day. The second resident, who also had a history of behavioral symptoms and moderate cognitive impairment, responded by physically assaulting the wandering resident, resulting in a head injury and scalp laceration that required hospital treatment. Staff interviews revealed that there was confusion and lack of clarity regarding who was responsible for monitoring the resident, how monitoring should be documented, and whether there was an official order for 1:1 supervision. Several staff members were not adequately trained or in-serviced on monitoring procedures or documentation requirements for the resident in question. The facility's own policy required identification, evaluation, and intervention for hazards and risks, as well as monitoring for effectiveness and modification of interventions as necessary. However, the report documents that the resident's care plan was not updated to include all aggressive behaviors, and staff were not consistently informed or trained on the monitoring expectations. This lack of comprehensive and coordinated supervision and documentation directly contributed to the incident in which the resident was injured after wandering into another resident's room and being assaulted.
Unlabeled and Undated Food Stored in Kitchen Refrigerators and Freezers
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one reviewed kitchen. During an observation on 09/02/2025, surveyors found two undated and unlabeled cut-in-half deli-meat and cheese sandwiches in one refrigerator, along with a bag containing seven undated and unlabeled yogurts of unknown origin in the residents' refrigerator. The same observation also identified five undated and unlabeled frozen pie crusts and undated, unlabeled open frozen sliced green peppers in two of the four freezers. During interviews, the Dietary Supervisor stated she observed the food products and would throw away the undated or unlabeled items, including the bag of yogurts because it was unknown whether they belonged to a resident or staff. On the following day, surveyors again observed undated and unlabeled open frozen sliced green peppers remaining in one of the freezers. In interviews, the cook, Dietary Supervisor, Dietary Assistant, Registered Dietitian, and Administrator all stated that food in the kitchen, refrigerator, pantry, and freezer must be labeled and dated, and that any food that is not labeled or dated should be discarded and not served to residents. Record review showed the facility had in-services on labeling and dating food and had policies requiring all foods stored in refrigerators or freezers to be covered, labeled, and dated. The Date Marking for Food Safety policy stated that the individual opening or preparing food is responsible for date marking it at the time it is opened or prepared, and that the Head Cook or designee is responsible for checking the refrigerator daily for expiring items. Despite these stated expectations and policies, the surveyor found multiple unlabeled and undated food items in the kitchen storage areas.
Incomplete Care Plan for Left Hand and Wrist Contracture
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #55 that included measurable objectives and timeframes to meet his medical, nursing, mental, and psychosocial needs. Resident #55 was admitted on 09/04/2025 and had diagnoses including type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and generalized anxiety disorder. His Quarterly MDS assessment dated 08/22/2025 reflected a BIMS score of 12, indicating mild cognitive impairment. Record review of the resident’s care plan, dated 12/31/2024 and last revised on 08/27/2025, reflected impaired physical functioning related to decreased mobility and other paralytic syndrome following CVA affecting the left side. The care plan did not mention the resident’s contracture to the left hand and wrist. During observation and interview on 09/04/2025, the resident stated therapy had placed a rolled-up washcloth in his left hand, and the resident was observed to have a contracture to the left hand and wrist without any intervention in place at that time. No skin breakdown was observed to the left hand and wrist. During interviews, the ADON, MA B, LVN A, DON, and ADM stated that care plans were used by staff to determine resident care needs and that a contracture should be included in the care plan. The ADON stated that without a care plan for the contracture, staff would not know how to adequately care for it, and it could get worse. The DON stated she expected contractures to be on the care plan, and the facility policy titled Comprehensive Care Plans required a comprehensive person-centered care plan that included measurable objectives and timeframes and all services identified in the comprehensive assessment.
Expired Medications Found in Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring expired medications and supplies were removed from medication carts. During observation, one tube of hemorrhoidal ointment with an expiration date of 05/2025 was found in the 400-hall nurses' medication cart, and one medication card of lorazepam 1 mg with an expiration date of 08/18/2025 prescribed to Resident #46 was found in the 100-hall nurses' medication cart. Resident #46 was admitted with diagnoses including unspecified dementia, Parkinson's disease without dyskinesia, and expressive language disorder, and his quarterly MDS reflected that a BIMS was not conducted because he was rarely or never understood. Staff interviews showed inconsistent understanding of who was responsible for checking medication carts and how often expired medications were removed. An LVN stated the cart should be checked weekly but was unsure of the schedule or responsibility, while another LVN said she assumed the person responsible for the cart handled expired medications but was unsure of the frequency or audit process. An RN stated the person responsible for the cart should remove expired medications and supplies every shift, but she was unaware of the audit process or frequency. The ADON stated nurses and medication aides responsible for the carts were to check for expired medications as they gave medications, and that there was not a process at that time to ensure expired medications were removed from the carts. The DON stated staff responsible for the carts were expected to check for expired supplies daily and that the pharmacy consultant performed monthly audits, while the ADM stated staff assigned to the cart were responsible for removing expired medications every shift and that the pharmacy consultant audited monthly. The facility policy stated pharmaceutical services should assure accurate acquiring, receiving, dispensing, and administering of drugs and biologicals, and the medication storage policy stated the consultant pharmacist routinely inspected medication rooms for outdated medications, but the policy did not mention expired medications.
Resident Elopement Due to Inadequate Supervision and Exit Security
Penalty
Summary
A deficiency occurred when a resident was able to elope from the facility after a visitor used the exit code and held the door open, allowing the resident to leave the building unsupervised. The incident took place in the evening, and the resident was not discovered missing until routine rounds were conducted. Staff initiated a search of the facility and, upon failing to locate the resident, notified facility management and law enforcement. The resident was eventually found over three hours later, more than a mile from the facility, and was transported to the hospital for evaluation after reporting shortness of breath. The resident involved was an elderly female with a history of cerebral infarction (stroke), hypertension, aphasia, expressive language disorder, and difficulty walking. Her admission assessments indicated she was not considered an elopement risk, though she was at risk for falls. The resident was described as not very verbal and occasionally unable to express her needs, but able to respond to yes or no questions and aware of her surroundings. At the time of the incident, she was observed independently leaving her room, walking through the hallway, and exiting the facility after a visitor held the door open for her. Staff interviews revealed that the door code had previously been shared with visitors, and staff would often assist visitors in and out of the building. The elopement risk assessment for the resident had not identified her as a risk, and there was no indication of prior exit-seeking behavior. The facility did not have a locked unit or use a Wander guard system. The deficiency was identified as placing residents at risk for elopements, which could result in falls, injuries, dehydration, and hospitalization.
Failure to Provide Written Discharge Notice and Appeal Information
Penalty
Summary
The facility failed to provide a written discharge notice with appeal information to the guardian of a resident who was discharged. The resident, who had spastic quadriplegic cerebral palsy, anxiety disorder, profound intellectual disabilities, and was deaf-nonspeaking, was discharged without proper documentation or notification to the resident's representative. The facility did not document any interventions attempted to meet the resident's needs prior to the discharge, and there was no documentation from a physician regarding the facility's inability to meet the resident's needs. The resident had been involved in an incident where he hit another resident, but subsequent progress notes did not reflect any additional incidents or documented interventions. Interviews with staff revealed that the resident's communication challenges and behaviors were known, but there was no formal in-service training provided to staff on how to effectively communicate with the resident. The facility's social worker and other staff members attempted to communicate with the resident's representative but did not document these attempts or provide a written discharge notice. The facility's policy requires that a written discharge notice be provided, including information on the right to appeal the discharge. However, the resident's representative only received voicemail notifications about the discharge and was not involved in selecting the new facility. The facility's failure to follow its own policy and document interventions or communication attempts contributed to the deficiency in handling the resident's discharge.
Failure to Adhere to Hand Hygiene Protocols in Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food safety service during the preparation and handling of meals, as observed during two separate meal preparations. On July 29, 2024, Dietary [NAME] A (DC A) was observed not performing hand hygiene after removing gloves and before handling kitchen equipment. Specifically, after completing the chicken puree, DC A placed the blender in the dishwashing compartment with gloves on, removed the gloves, and discarded them in the trash without washing her hands before grabbing the blender again. Although DC A later performed hand hygiene, she turned off the faucet with her clean hand, which is not in accordance with the facility's hand hygiene policy. On July 30, 2024, Dietary [NAME] B (DC B) was observed completing the beef tips puree and properly performing hand hygiene after removing gloves. However, similar to DC A, DC B turned off the faucet with his clean hand, which contradicts the facility's policy. Interviews with DC A, DC B, the Dietary Manager, the Director of Nursing, and the Administrator revealed inconsistencies in the understanding and execution of proper hand hygiene procedures, which could lead to cross-contamination and infection risks. The facility's hand hygiene policy, dated August 2019, outlines specific steps for washing hands, including using a towel to turn off the faucet, which was not consistently followed by the staff.
Failure to Obtain Timely Laboratory Services for Resident
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident, who was ordered a urine analysis (UA) by a physician on 06/18/24. The UA was not collected until 06/26/24, despite the resident's history of urinary tract infections (UTIs) and sepsis. The resident, a male with quadriplegia and neuromuscular dysfunction of the bladder, expressed concern about the delay, noting that his urine was dark and similar to when he previously had a UTI or sepsis. The nurse practitioner (NP) who ordered the UA was not informed of the results and was unaware of the delay until contacted by the surveyor. The facility's staff, including RN A and the Director of Nursing (DON), were unaware of the UA order and did not follow up on the physician's instructions. The DON stated that the facility's protocol was to collect urine samples on specific days when the lab picked up specimens, but a STAT pick-up could have been ordered. The facility's policies on physician visits and catheter care did not include procedures for following physician orders for a UA, contributing to the oversight and delay in obtaining the necessary laboratory services for the resident.
Verbal Abuse Incident Involving DON
Penalty
Summary
The facility failed to ensure all residents were free from abuse, specifically verbal abuse, as evidenced by an incident involving the Director of Nursing (DON) and a resident with severe cognitive impairment. The DON allegedly made serious life-threatening remarks towards the resident, stating, 'if you don't do something with this fucking patient, I am going to stab her in the neck.' This incident was witnessed by a Hospice RN, who reported the event and expressed concerns about potential retaliation from the DON. The resident in question had a history of severe dementia, frequent falls, and required substantial assistance with daily activities. The DON admitted to being frustrated due to a heavy workload and understaffing but could not recall the exact words spoken during the incident. The DON acknowledged that threatening to stab a resident would be considered verbal abuse but maintained that any such statement would have been made in jest and not intended seriously. The facility's Administrator conducted an investigation, including interviews with other residents and staff, but ultimately concluded that the incident was a 'he said, she said' situation without definitive proof of abuse. The DON was suspended for a few days and received counseling and additional training on professional behavior and language around residents. The facility's policies on resident rights and abuse prevention were reviewed, highlighting the importance of treating residents with dignity and respect and protecting them from all forms of abuse. Despite these policies, the incident revealed gaps in the facility's ability to prevent and address verbal abuse effectively. The Hospice RN's report and the DON's admission of frustration underscore the challenges faced by staff in managing high-stress situations and the need for adequate support and training to prevent similar incidents in the future.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an alleged incident of verbal abuse involving a resident with severe cognitive impairment. The incident was reported by a Hospice RN who overheard the Director of Nursing (DON) making a threatening statement towards the resident. Despite the severity of the allegation, the facility did not obtain written statements from the staff involved, including the alleged perpetrator, and failed to contact the ombudsman as required by policy. Additionally, the social worker did not assess the resident for emotional trauma following the incident, and the resident's family was not kept informed of the investigation's progress. The resident in question was an elderly female with a history of unspecified dementia, depression, hypertension, delusional disorder, Alzheimer's disease, lymphedema, anxiety disorder, and gastro-esophageal reflux disease. She had a severely impaired cognition with a BIMS score of 00 and required substantial assistance with daily activities. The resident had experienced multiple falls and was on hospice care. On the day of the incident, the Hospice RN witnessed the DON making a threatening gesture and statement towards the resident, which led to the RN reporting the incident to the facility's administration. Interviews with the DON and other staff revealed a lack of clarity and consistency in the facility's response to the allegation. The DON admitted to being frustrated but could not recall making the specific threatening statement. The facility's administrator acknowledged that the investigation was inconclusive and that the DON was suspended for a few days. However, the investigation lacked thorough documentation, and the facility did not follow its own policies for reporting and investigating abuse allegations, including notifying the ombudsman and obtaining written statements from all involved parties.
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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 Lockhart
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chisolm Trail Nursing And Rehabilitation Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Avir At Magnolia | 11.8 mi | ★★★★★ | 21 | 2 |
| Avir At Luling | 12.5 mi | ★★★★★ | 17 | 0 |
| Diversicare Of Luling | 13.7 mi | ★★★★★ | 0 | 0 |
| San Marcos Rehabilitation And Healthcare Center | 16.6 mi | ★★★★★ | 3 | 0 |
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