Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 University Park Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that food items in dry storage and refrigerators were not properly labeled with food descriptions, open dates, or use by dates, and some items were not disposed of within required timeframes. Dietary staff and management acknowledged these lapses, citing staff oversight and lack of education as contributing factors.
A resident with diabetes, leukemia, and malnutrition did not receive the items listed on his lunch meal ticket, including missing fruit and yogurt, and received an unappealing, overcooked meal. The Dietary Manager and RN confirmed that meal tickets were not followed, and staff cited lack of thoroughness and education as contributing factors.
Two residents did not consume their lunch meal due to the food being unappealing, overcooked, and served at a lukewarm temperature. Observations confirmed the manicotti was dry, lacked sauce, and had burnt ends, with a measured temperature of 100°F. Dietary staff and management acknowledged the food was not prepared or served according to expectations for appearance and temperature.
A resident with dementia and other medical conditions, requiring a pureed diet and thickened fluids, was served pureed zucchini that was not the correct texture due to a cook failing to follow the recipe and add thickener. The issue was identified by the Dietary Manager and Administrator during a spot check, and interviews indicated the cook was inadequately trained and did not follow established procedures.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, with issues including improper food storage, lack of temperature logs, unclean equipment, and poor staff hygiene practices. These deficiencies were acknowledged by the facility's dietary manager and regional dietician.
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their MDS records. One resident's significant weight gain was not documented, another's weight loss and hemodialysis were not captured, and a third resident's significant weight loss was missed. These oversights could result in inadequate care for the residents.
The facility failed to provide appropriate respiratory care for two residents by not changing their oxygen tubing weekly and not keeping their nasal cannula and nebulizer in a bag while not in use. Both residents had severe cognitive impairment and chronic obstructive pulmonary disease (COPD).
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Observations revealed that food served was often cold, unappetizing, and not flavorful. Interviews with staff indicated that this issue had been ongoing, despite attempts to address it. The facility's Dietary Services & Policy & Procedure Manual states that resident food preferences should be honored, but this was not consistently achieved.
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN Form CMS-10055) to a resident's representative when the resident was discharged from skilled services. The resident, who had multiple diagnoses and received Medicare Part A services, switched to private pay without the required notice being issued. Interviews and policy reviews revealed a lack of clarity and adherence to guidelines regarding the use of the SNF ABN form.
A CNA failed to follow infection control protocols by not washing or sanitizing her hands before feeding a resident and making contact with her own face, hair, and other objects during the feeding. The resident required assistance with meals and had multiple health conditions.
Failure to Properly Label and Store Food Items
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen inspection, multiple food items in dry storage and refrigerators were found without proper labeling, including missing food descriptions, open dates, and use by dates. Specific items included bowls of cereal, bags of chips, containers of beans, glasses of liquid, and various thickened beverages, some of which were not labeled according to manufacturer instructions or facility policy. Additionally, a pan of Jello with fruit was found uncovered and unlabeled. These findings were corroborated by interviews with dietary staff and management, who acknowledged the lapses in labeling and monitoring. The dietary manager and weekend supervisor both stated that all dietary staff were responsible for ensuring food was labeled correctly and disposed of when needed, and that monitoring was done through spot checks. The dietary manager attributed the failure to staff being nervous and not thorough, while the registered nurse noted a lack of education or need for reeducation as contributing factors. Review of facility policy and FDA Food Code confirmed the requirement for proper labeling and timely disposal of perishable items, which was not consistently followed in this instance.
Failure to Follow Resident-Specific Menu and Meal Preferences
Penalty
Summary
The facility failed to ensure that the menu was followed for a resident with multiple medical conditions, including Type 2 Diabetes, leukemia, and protein calorie malnutrition. On the specified date, the resident's lunch meal ticket indicated he was to receive two cheese manicotti with marinara, sautéed zucchini, garlic bread, smooth yogurt, and fruit as a dessert substitute per his request. However, observation revealed that the resident received only one manicotti without marinara sauce, zucchini, garlic bread, and vanilla pudding with a chocolate cookie instead of the requested fruit and yogurt. The resident reported that the food was unappealing, dry, and overcooked, and that the kitchen often forgot to include his fruit and yogurt. The lunch tray appeared untouched, and the resident stated he had snacks in his room instead. Interviews with the Dietary Manager (DM) and Registered Nurse (RRN) confirmed that meal tickets are expected to be followed as they reflect each resident's dietary needs and preferences. The DM acknowledged responsibility for monitoring kitchen staff and stated that the failure was due to staff being nervous and not thorough. The RRN indicated that the DM and Administrator are responsible for ensuring residents receive appropriate meals and attributed the failure to a lack of education or need for staff reeducation. Facility policy review confirmed residents' rights to a dignified existence and self-determination.
Failure to Provide Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature for two residents reviewed for nutritive value, flavor, and appearance. One resident, a male with Type 2 Diabetes, leukemia, and protein calorie malnutrition, did not eat his lunch because the manicotti appeared overcooked and unappealing. His lunch tray was observed untouched in his room. Another male resident with multiple sclerosis, heart failure, and paraplegia also did not eat the manicotti served at lunch, stating it looked horrible, was dry, and had black burnt ends. A test tray of the manicotti was observed to be dry, lacking marinara sauce, and with black crusty ends. The temperature of the manicotti was measured at 100 degrees, and it was described as lukewarm and overcooked. Dietary staff and management interviews confirmed that food was not prepared or served according to expectations for appearance and temperature, and that monitoring was insufficient. The facility's policy states that each resident has the right to a dignified existence and self-determination.
Failure to Provide Pureed Food at Correct Texture for Resident on Mechanically Altered Diet
Penalty
Summary
A deficiency occurred when a resident with dementia, pulmonary embolism, and heart disease, who was on a mechanically altered diet requiring pureed food and honey thickened fluids, was served pureed zucchini that did not meet the required texture. During meal preparation, the cook failed to add thickener to the zucchini, resulting in a thin, liquid consistency that did not hold its shape, contrary to the facility's policy and recipe, which specified a pudding or mashed potato-like texture. The Dietary Manager (DM) and Administrator (ADMN) identified the issue during a spot check, and the DM subsequently re-pureed the food to the correct consistency. Interviews revealed that the cook was trained by a previous Dietary Manager and admitted to being nervous and not following the recipe. The DM stated that kitchen staff are responsible for following recipes and ensuring correct food texture, and that she monitors compliance through spot checks. The Registered Nurse (RRN) confirmed that the DM is responsible for ensuring pureed food is served at the correct texture and noted that the failure was due to lack of education or need for reeducation among staff. Facility policy and the specific recipe for pureed zucchini both emphasized the importance of achieving the correct consistency for resident safety.
Failure to Adhere to Food Safety and Hygiene Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an initial tour of the kitchen, it was observed that the trash can had a lid that did not fit properly, requiring hands to remove it, and a large bag of orange juice was placed on top of the trash can lid. Additionally, a dietary aide was noted to have hair outside her hairnet. Temperature logs for two freezers had not been recorded since 5/7/24, and the refrigerator lacked an internal thermometer and a temperature log. Opened food items in the dry pantry were not sealed, and there were food items on the floor. The dishwashing machine area had no record of chemical usage checks, and the machine itself was not clean. The stove and surrounding areas were also found to be dirty and greasy. Further observations revealed that dietary staff did not follow proper hygiene practices. Staff members were seen handling food and utensils with bare hands, not washing hands after touching contaminated surfaces, and wearing long painted acrylic nails without gloves. The facility's dietary manager and regional dietician acknowledged these issues, noting that the facility had a new dietary manager who had just started. The daily cleaning schedule was not signed for the past week, and the dish machine was not checked for sanitation chemicals before and after each meal. The facility's policies and procedures for food storage, equipment sanitation, and hand hygiene were not being followed. Interviews with various staff members, including the regional dietician, dietary aides, and the administrator, confirmed the ongoing issues with dietary services. The dietary manager admitted that the facility was not meeting cleaning requirements and that the kitchen cleaning schedule was not being followed. Staff members were unclear about their responsibilities for checking dishwashing chemicals, and there was a general lack of adherence to hand hygiene protocols. The facility's policies clearly outlined the need for proper food storage, equipment sanitation, and hand hygiene, but these were not being implemented effectively, leading to potential risks for residents' nutritional health and safety.
Failure to Ensure Accurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate assessments for three residents, leading to discrepancies in their Minimum Data Set (MDS) records. Resident #5's MDS did not accurately reflect a significant weight gain of 9.51% over a six-month period. The MDS Coordinator admitted to missing the weight change due to an error and inconsistent attendance at Standards of Care meetings. This oversight could result in the resident not receiving appropriate care for her weight gain and associated conditions like edema and hypertension. Resident #15's MDS failed to document a significant weight loss of 8.90% and the fact that she was receiving hemodialysis three times a week. The MDS Coordinator stated that she could not capture dialysis on the MDS without proof from the dialysis center, which often did not provide the necessary documentation. Despite completing a Significant Change MDS for weight loss, the coordinator acknowledged that the weight loss should have been identified earlier. Resident #50's MDS did not reflect a significant weight loss of 11.11% over six months. The resident had diagnoses including hypertension, protein-calorie malnutrition, and a liver transplant. Despite a care plan that included monitoring for weight changes, the MDS failed to capture the significant weight loss. The resident's family member also noted her difficulty swallowing and the potential need for a PEG tube for nutrition. The facility's policy requires that the MDS accurately reflect the resident's status, but this was not adhered to in these cases.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that two residents, who required respiratory care, received care consistent with professional standards of practice and their comprehensive person-centered care plans. Specifically, the facility did not change the oxygen tubing weekly for both residents, as ordered by their physicians. Additionally, the nasal cannula and nebulizer for both residents were not kept in a bag while not in use, which could increase the risk of infections and transmission of communicable diseases. Resident #19, a [AGE] year-old female with severe cognitive impairment and chronic obstructive pulmonary disease (COPD), was observed with her nasal cannula uncovered and the nose prongs on the floor. Her care plan did not include an intervention regarding when the oxygen tubing needed to be changed. Similarly, Resident #183, a [AGE] year-old male with severe cognitive impairment and COPD, was observed with his nebulizer uncovered on the nightstand. He could not recall when the oxygen tubing was last changed. His care plan also lacked an intervention regarding the frequency of changing the oxygen tubing. These observations and record reviews indicate that the facility did not adhere to the prescribed respiratory care protocols, potentially compromising the residents' health and safety.
Failure to Provide Palatable and Appetizing Meals
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. During an observation, the holding food temperatures were recorded as follows: chicken corn casserole at 154°F, rice at 158°F, and beans at 148°F. However, during a sample test tray observation, the chicken corn casserole was found to be at 110°F, which was room temperature and not appetizing. The rice was described as gummy and not flavorful, making it difficult to swallow due to its texture. Additionally, the Kool-aide was at room temperature with melted ice, which residents found unappealing. Interviews with staff, including Cook E, MDS Nurse B, the DON, the Regional Compliance Nurse, and the Administrator, revealed that the issue of cold and unappetizing food had been an ongoing problem in the facility. The Administrator mentioned that the food was frequently a concern in Resident Council meetings, and attempts had been made to address the issue, such as changing the order in which meal tray carts were sent from the kitchen. The facility's Dietary Services & Policy & Procedure Manual 2012 states that every attempt will be made to honor resident food preferences and that the menu will reflect the needs of the resident population as well as input from residents and resident groups. Despite this, the facility failed to ensure that the food served was at an appetizing temperature, flavor, and texture. This deficiency could potentially affect the residents who received their meals from the kitchen by contributing to poor intake of nutrition, weight loss, and illness. The report highlights the ongoing issues with food quality and temperature, as well as the facility's awareness of these problems through various interviews with staff members.
Failure to Provide Advance Notice of Non-Coverage for Medicare Services
Penalty
Summary
The facility failed to provide advance notice of change in services and charges not covered under Medicare for a resident reviewed for Medicaid and Medicare Coverage Liability Notices. Specifically, the facility did not ensure that the resident's representative was given a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN Form CMS-10055) when the resident was discharged from skilled services. This oversight was identified during an interview and record review, which revealed that the resident had received Medicare Part A services and was discharged from these services without the required notice. The resident's family member had opted for private pay to avoid co-pay days, but there was no documentation of this conversation, and the SNF ABN form was not provided as required by policy and procedure guidelines. The facility's MDS Coordinator admitted to not providing the SNF ABN form and stated that there was no clear policy or procedure for its use in such situations. The resident involved had multiple diagnoses, including congestive heart failure, hypertension, polycythemia vera, anemia, hyperlipidemia, cerebrovascular disease, neuropathy, chronic atrial fibrillation, hemiplegia, and joint pain. The resident had been hospitalized and received Medicare Part A services for skilled nursing care. Despite the resident's family member's decision to switch to private pay, the facility did not follow the proper protocol for issuing the SNF ABN form. Interviews with the MDS Coordinator and review of the facility's policy and procedure revealed a lack of clarity and adherence to guidelines regarding the use of the SNF ABN form, leading to the deficiency noted in the report.
Infection Control Deficiency
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program, which led to a deficiency in the care of a resident. Specifically, a CNA did not wash or sanitize her hands before feeding a resident who required assistance with meal intake. During the feeding, the CNA made contact with her own face, hair, and other objects without performing hand hygiene, which is against the facility's infection control policy. The CNA was unaware of the proper hand hygiene protocols and the potential negative outcomes of not following them. The resident involved was a male with cerebral palsy, protein calorie malnutrition, intellectual disability, and dysphagia. He was dependent on assistance for meals. The Director of Nursing (DON) confirmed that the expectation was for all personnel to use hand sanitizer as part of infection control when feeding residents and after touching faces, hair, or other objects. The facility's policy on infection control emphasizes the importance of hand hygiene in preventing the transmission of infections.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 35 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Wichita Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rolling Meadows | 1.1 mi | — | 0 | 0 |
| Advanced Rehabilitation And Healthcare Of Wichita | 1.8 mi | ★★★★★ | 0 | 0 |
| Texhoma Christian Care Center Inc | 3.4 mi | ★★★★★ | 1 | 0 |
| Swan Health At Wichita Falls | 4.2 mi | ★★★★★ | 0 | 0 |
| Courtyard Gardens | 4.3 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for University Park Nursing And Rehabilitation.
100% money-back within 48 hours.
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.