Inspection Reports for Parkview Nursing and Rehabilitation Center
1501 S Main St, Lockhart, TX 78644, TX, 78644
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, found deficiencies related to failure to protect a resident from physical abuse by another resident and inadequate supervision to prevent accidents, which the facility corrected before the survey. Earlier inspections showed a pattern of issues including care planning, medication management, food safety, resident supervision, and confidentiality breaches. Complaint investigations substantiated failures in abuse prevention, discharge notification, medication administration, and timely laboratory services, but enforcement actions such as fines or license suspensions were not listed in the available reports. Most complaints were substantiated, with notable cases involving resident-to-resident abuse and delayed medication or lab services. The inspection history indicates ongoing challenges with resident safety and care processes, with corrective actions taken promptly after deficiencies were identified.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
109% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding resident-to-resident abuse involving two residents, Resident #1 and Resident #2, following an altercation on 11/08/2025 where Resident #1 was physically harmed by Resident #2.
Complaint Details
The complaint investigation found that Resident #1 was physically abused by Resident #2 during an altercation on 11/08/2025. Resident #1 wandered into Resident #2's room and was pushed to the ground, sustaining a head laceration and requiring hospital treatment. Resident #2 admitted to pushing Resident #1. The facility investigation reported the incident as unfounded, but the survey found noncompliance. The facility had corrected the issues before the survey. Resident #1 had a history of aggression and wandering, and Resident #2 had a history of verbal aggression and dementia.
Findings
The facility failed to protect Resident #1 from physical abuse by Resident #2 during a resident-to-resident altercation resulting in Resident #1 sustaining a head injury requiring hospital treatment. The facility also failed to provide adequate supervision to prevent accidents related to Resident #1's wandering and aggressive behaviors. The facility corrected the noncompliance before the survey began.
Deficiencies (2)
Failed to protect residents from all types of abuse including physical abuse by another resident.
Failed to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents.
Report Facts
BIMS score: 3
BIMS score: 11
Date of incident: Nov 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Observed Resident #1 after the incident, assessed injuries, called DON, ADM, 911 and EMS |
| DON | Director of Nursing | Interviewed regarding incident and monitoring, responsible for staff in-service and care plan updates |
| ADM | Administrator | Interviewed regarding incident and facility policies, named as abuse coordinator |
| NP | Nurse Practitioner | Provided medical care and medication adjustments for Resident #1, involved in psychiatric referral |
| CNA B | Certified Nursing Assistant | Provided monitoring for Resident #1 post-incident |
| CNA D | Certified Nursing Assistant | Provided 1:1 monitoring for Resident #1 to prevent wandering and redirect behaviors |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 4, 2025
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding care planning, pharmaceutical services, and food safety in the nursing facility.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for residents, ensuring expired medications were removed from medication carts, and maintaining proper food labeling and storage practices in the kitchen. These deficiencies posed risks of inadequate resident care, medication errors, and potential foodborne illnesses.
Deficiencies (3)
Failed to develop and implement a complete care plan addressing Resident #55's contracture to left hand and wrist.
Failed to provide pharmaceutical services ensuring expired medications were removed from medication carts, including expired lorazepam and hemorrhoidal ointment.
Failed to store, prepare, distribute, and serve food in accordance with professional standards, including failure to dispose of open stored perishable food products and failure to properly label and date food products.
Report Facts
Residents reviewed for care plans: 8
Residents reviewed for pharmacy services: 8
Medication carts reviewed: 4
Residents affected by care plan deficiency: 1
Residents affected by pharmaceutical services deficiency: 1
Medication carts affected by pharmaceutical services deficiency: 2
Residents affected by food service deficiency: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA B | Stated management was responsible for initiating care plans and removing expired medications from medication carts. | |
| LVN A | Stated all staff use care plans and are responsible for checking expired medications in medication carts. | |
| DON | Director of Nursing | Responsible for ensuring care plans were completed and expected contractures to be on care plans; expected staff to check medication carts daily. |
| ADON | Assistant Director of Nursing | Responsible for implementing care plans and stated there was no process to ensure expired medications were removed from medication carts. |
| ADM | Administrator | Stated responsibility for oversight of care plans and medication cart audits. |
| LVN E | Confirmed expired hemorrhoidal ointment found on medication cart. | |
| LVN F | Agency nurse, unsure of medication cart audit process. | |
| RN G | Stated nursing management had a process for auditing medication carts but was unaware of frequency. | |
| CK | Cook | Described training and responsibility for labeling and dating food products in the kitchen. |
| DA | Dietary Aide | Described training and responsibility for labeling and dating food products. |
| DS | Dietary Supervisor | Responsible for overseeing food labeling and dating, conducting audits, and educating staff. |
| RD | Registered Dietitian | Oversees facility food safety and labeling, conducts audits, and educates staff. |
| ADMIN | Administrator | Responsible for ensuring food labeling and dating compliance and staff training. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 7, 2025
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident elopement incident that occurred on 04/18/25, where Resident #1 left the facility unsupervised after a visitor used the exit code to open the door and held it open for the resident to exit.
Complaint Details
The complaint investigation was triggered by an incident on 04/18/25 when Resident #1 eloped after a visitor used the exit code to open the door and held it open for the resident. The resident was missing for over three hours, was found a block away from her home, and was transported to the hospital for evaluation. The facility conducted a thorough search, notified family, police, and EMS, and implemented corrective actions including changing door codes and staff training. The noncompliance was identified as PNC and corrected before the survey.
Findings
The facility failed to ensure Resident #1 did not elope from the facility, resulting in immediate jeopardy to resident health or safety. The resident was found over three hours later and taken to the hospital for evaluation. The facility had corrected the noncompliance before the survey began and implemented measures including changing door codes, posting warning signs, and staff in-service training on elopement prevention and resident rights.
Deficiencies (1)
Failed to ensure the resident environment remained free of accident hazards and provide adequate supervision to prevent elopements.
Report Facts
Residents reviewed for accidents and hazards: 3
Resident #1 elopement time: 3
Distance resident found from facility: 1.6
Date of elopement incident: Apr 18, 2025
Date survey completed: May 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Reported recent training on elopement and ANE, described procedures for missing resident. |
| MA B | Medical Assistant | Described training on ANE and elopement, door code policy, and procedures for missing resident. |
| LVN C | Licensed Vocational Nurse | Reported recent training on elopement, door code policies, and abuse coordinator information. |
| DON | Director of Nursing | Provided details on Resident #1's admission assessment, elopement incident response, and corrective actions. |
| ADM | Administrator | Described incident response, corrective actions including door code changes, signage, staff training, and facility policies. |
| CNA D | Certified Nursing Assistant | Reported recent training on elopement and resident rights, and importance of frequent rounding. |
| RN E | Registered Nurse | Initiated in-service training on elopement risk identification and resident rights. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 3, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely notification and proper discharge procedures for Resident #1, including failure to provide written discharge notice and appeal information to the resident's guardian.
Complaint Details
The complaint investigation focused on Resident #1's discharge process. The resident's responsible party (RP) reported not receiving written discharge notice or appeal information and felt blindsided by the discharge. Interviews with staff revealed communication barriers, behavioral challenges, and lack of documented interventions. The facility initiated discharge due to Resident #1's physical aggression and communication difficulties, but failed to properly notify or involve the RP. Documentation and communication with the RP were inadequate.
Findings
The facility failed to permit Resident #1 to remain unless discharge was necessary for welfare and needs could not be met. The facility did not provide written discharge notice or appeal information to the guardian, failed to document interventions attempted prior to discharge, and did not involve the responsible party in discharge decisions. Resident #1 had significant communication and behavioral challenges, and the facility lacked appropriate interventions and documentation.
Deficiencies (2)
Failure to provide Resident #1's guardian a written discharge notice with appeal information.
Failure to document interventions attempted to meet Resident #1's needs prior to discharge.
Report Facts
Residents Affected: 3
Discharge date: Feb 23, 2025
Care plan date: Feb 13, 2025
Physician order date: Feb 3, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Provided progress notes and interview regarding Resident #1's compliance and behavior |
| DON | Director of Nursing | Provided interview about Resident #1's behavior, discharge process, and facility capabilities |
| SW | Social Worker | Provided interview about discharge process, communication attempts with RP, and interventions |
| CNA C | Certified Nursing Assistant | Provided interview about Resident #1's behavior and triggers |
| COTA D | Certified Occupational Therapy Assistant | Provided interview about Resident #1's communication and behavior |
| SLP E | Speech-Language Pathologist | Provided interview about Resident #1's communication abilities and interventions |
| AD | Administrator | Provided interview about admission process and knowledge of Resident #1's behaviors |
| CNA F | Certified Nursing Assistant | Provided interview about Resident #1's behavior in dining room |
| DOR | Director of Rehabilitation | Provided interview about communication strategies with Resident #1 |
| LVN G | Licensed Vocational Nurse | Provided interview about Resident #1's frustration and communication |
| RN H | Registered Nurse | Provided interview about Resident #1's behavior and care strategies |
| ADM | Administrator | Provided interview about discharge decision and communication with RP |
Inspection Report
Routine
Deficiencies: 1
Date: Jul 31, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards for food safety service, specifically focusing on food storage, preparation, distribution, and serving practices.
Findings
The facility failed to ensure proper hand hygiene by dietary staff during food preparation, which could place residents at risk of infection or cross contamination. Observations and interviews revealed inconsistent hand hygiene practices among dietary staff.
Deficiencies (1)
Failure to store, prepare, distribute, and serve food in accordance with professional standards, specifically improper hand hygiene by dietary staff during food preparation.
Report Facts
Meals observed: 2
Observation date and time: Jul 29, 2024
Observation date and time: Jul 30, 2024
Interview date and time: Jul 31, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steffanie Brand | Surveyor | Named as surveyor conducting the inspection |
| Dietary Manager | Interviewed regarding hand hygiene process in the kitchen | |
| Director of Nursing | Interviewed regarding hand hygiene policy and procedures | |
| ADM | Interviewed regarding hand hygiene policy and procedures |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 27, 2024
Visit Reason
The inspection was conducted due to a complaint or concern regarding the facility's failure to provide timely laboratory services, specifically the failure to collect a urine specimen for a urine analysis (UA) as ordered by the physician for Resident #1.
Complaint Details
The visit was complaint-related due to concerns about delayed urine analysis for Resident #1. The complaint was substantiated as the facility failed to collect the urine specimen as ordered, confirmed by interviews with the resident, nurse practitioner, RN, and Director of Nursing.
Findings
The facility failed to collect a urine specimen for Resident #1's UA ordered on 06/18/24 until 06/26/24, resulting in delayed diagnosis of blood in the urine. This failure posed risks of infection, renal failure, urinary tract infections, and pain. Interviews with staff and the resident confirmed the delay and lack of adherence to physician orders.
Deficiencies (1)
Failure to provide timely, quality laboratory services/tests to meet the needs of residents, specifically failure to collect a urine specimen for a UA as ordered.
Report Facts
Residents reviewed for laboratory services: 3
Urine specimen collection delay: 8
Urine volume observed: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Interviewed regarding failure to collect urine specimen and review of Resident #1's EMR |
| DON | Director of Nursing | Interviewed regarding awareness of UA order and facility protocols |
| Resident #1's NP | Nurse Practitioner | Interviewed regarding UA order and concerns about delayed urine specimen collection |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 16, 2024
Visit Reason
The inspection was conducted due to allegations of verbal abuse by the Director of Nursing (DON) towards Resident #1, including threatening remarks and failure to properly investigate the abuse allegations.
Complaint Details
The complaint involved verbal abuse allegations against the DON towards Resident #1. The DON allegedly made threatening remarks on 4/03/2024. The investigation was inconclusive due to lack of witnesses and documentation. The DON was suspended for 2-4 days and received education. The Hospice RN reported the incident and feared retaliation. Resident #1 had advanced Alzheimer's disease and could not recall the incident. The family was not informed timely and the ombudsman was not contacted.
Findings
The facility failed to ensure Resident #1 was free from verbal abuse, failed to thoroughly investigate the abuse allegations, failed to obtain written statements, failed to notify the ombudsman, and failed to keep the resident's family informed. The DON admitted to possible verbal abuse but claimed it was unintentional or misinterpreted. The DON was suspended and received abuse education. The investigation was inconclusive due to lack of witnesses and documentation.
Deficiencies (3)
Failed to protect Resident #1 from verbal abuse by the DON, including threatening remarks to stab the resident.
Failed to thoroughly investigate all alleged violations of abuse for Resident #1, including failure to obtain written statements and failure to notify the ombudsman.
Failed to assess Resident #1 for emotional trauma after the abuse allegation and failed to keep family informed of investigation progress.
Report Facts
Resident falls: 12
Suspension duration: 2
Suspension duration: 3
Residents interviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Named in verbal abuse allegation and investigation; admitted possible verbal abuse; suspended and received education. | |
| Hospice RN | Reported the DON's threatening remarks and feared retaliation. | |
| Administrator | Conducted investigation, suspended DON, provided education, and interviewed residents. | |
| Social Worker (SW) | Unaware of incident and had not spoken to Resident #1 regarding it. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 5, 2024
Visit Reason
The inspection was conducted due to a complaint or concern regarding the facility's pharmaceutical services, specifically the failure to provide scheduled medication to a resident.
Complaint Details
The complaint investigation found that Resident #1 went without his prescribed Naproxen for five days, causing increased pain and MS flare-ups. The medication administration error was confirmed through observation, interviews with the resident, medication aide (MA A), charge nurse (RN B), and Director of Nursing (DON). The DON stated the charge nurse was responsible for reordering medications and acknowledged the failure to meet expectations.
Findings
The facility failed to ensure Resident #1 received his prescribed Naproxen pain medication for five days, resulting in increased pain and Multiple Sclerosis flare-ups. Interviews and record reviews confirmed the medication was not reordered timely, causing actual harm to the resident.
Deficiencies (1)
Failure to provide pharmaceutical services to meet the needs of each resident, specifically Resident #1 not receiving scheduled Naproxen from 02/01/24 to 02/05/24.
Report Facts
Days without medication: 5
Resident pain rating increase: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Charge Nurse | Named in interview regarding unawareness of medication shortage and responsibility for reordering. |
| MA A | Medication Aide | Noticed missing medication and notified charge nurse; interviewed about medication administration. |
| DON | Director of Nursing | Interviewed about responsibility for medication reordering and acknowledged failure to meet expectations. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 20, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Parkview Nursing and Rehabilitation Center following a survey completed on 11/20/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 1
Date: Jun 2, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with confidentiality requirements related to residents' personal and medical records.
Findings
The facility failed to protect the confidentiality of personal health care information for 4 of 12 residents reviewed, exposing medication cards on a medication cart left unattended, which was identified as a HIPAA violation by multiple staff and administrators.
Deficiencies (1)
Failure to keep residents' personal and medical records private and confidential, exposing medication cards on a medication cart left unattended.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA I | Stated leaving residents' medication cards on top of the cart exposed confidential information. | |
| LVN B | Licensed Vocational Nurse | Agency staff who left medication cards on the cart and acknowledged it was a HIPAA violation. |
| DON | Director of Nursing | Stated leaving medication cards on the cart was a HIPAA violation and a potential risk. |
| Corporate Consultant | Stated leaving medication cards on the cart was a HIPAA violation and explained proper handling. | |
| Administrator | Stated expectation for staff to destroy used medication cards and acknowledged HIPAA violation. |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 2, 2023
Visit Reason
The inspection was conducted to assess compliance with federal regulations related to resident confidentiality, assistance with activities of daily living, food service safety, and infection prevention and control at Parkview Nursing and Rehabilitation Center.
Findings
The facility was found deficient in protecting residents' personal health information, assisting a resident with activities of daily living including feeding, ensuring food safety by measuring food temperatures, and maintaining infection prevention and control practices. Specific failures included leaving medication cards unattended exposing confidential information, failure to assist Resident #23 with meals, failure to measure temperatures of all food items before serving, and improper infection control techniques by staff.
Deficiencies (4)
Failed to protect residents' personal and medical records privacy and confidentiality by leaving medication cards unattended on a medication cart.
Failed to ensure Resident #23 was assisted with breakfast and lunch on 6/01/2023, placing residents at risk of not receiving necessary assistance with activities of daily living.
Failed to measure the temperature of all food items before serving, including pork and pureed pork, placing residents at risk of foodborne illness.
Failed to establish and maintain an infection prevention and control program; staff failed to use appropriate infection control techniques during medication administration and incontinence care.
Report Facts
Residents reviewed for confidentiality: 4
Residents reviewed for ADLs: 8
Weight loss: 3
Food temperature: 160
Food temperature: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MA I | Named in medication confidentiality and infection control findings | |
| LVN B | Licensed Vocational Nurse | Interviewed regarding medication card confidentiality |
| DON | Director of Nursing | Interviewed regarding medication confidentiality and ADL assistance |
| Corporate Consultant | Interviewed regarding medication confidentiality, ADL assistance, and infection control | |
| Administrator | Interviewed regarding medication confidentiality, ADL assistance, and infection control | |
| CNA F | Certified Nursing Assistant | Observed and interviewed regarding infection control failures during incontinence care |
| Dietary Manager | Interviewed regarding food temperature monitoring and training | |
| RD | Registered Dietitian | Interviewed regarding food temperature policy and training |
| Speech Therapist | Interviewed regarding Resident #23 feeding needs | |
| CNA E | Certified Nursing Assistant | Interviewed regarding feeding assistance for Resident #23 |
| CNA H | Certified Nursing Assistant | Interviewed regarding feeding assistance for Resident #23 |
| CNA G | Certified Nursing Assistant | Interviewed regarding feeding assistance for Resident #23 |
| CNA D | Certified Nursing Assistant | Interviewed regarding feeding assistance for Resident #23 |
| LVN A | Licensed Vocational Nurse | Interviewed regarding feeding assistance for Resident #23 |
| COTA K | Certified Occupational Therapy Assistant | Observed and interviewed regarding feeding assistance for Resident #23 |
| Director of Rehab | Interviewed regarding Resident #23 therapy and feeding needs |
Inspection Report
Routine
Deficiencies: 3
Date: May 23, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, focusing on treatment and care according to orders, resident preferences, and goals, specifically reviewing quality of care for Resident #1.
Findings
The facility failed to conduct weekly skin assessments, provide regular showers, and follow physician treatment orders for a rash on Resident #1's left iliac crest, resulting in increased itchiness, pain, and risk of physical harm. Documentation showed missed showers, lack of treatment application, and delayed skin assessments, despite known skin integrity risks.
Deficiencies (3)
Failure to conduct weekly skin assessments for Resident #1.
Failure to provide regular showers to Resident #1 as documented by missing shower sheets.
Failure to obtain and/or follow physician treatment orders for a fungal rash on Resident #1's left iliac crest.
Report Facts
Dates of weekly skin assessments: 2
Date of physician order: Jun 6, 2022
Date range with no showers documented: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse (TN) | Conducted weekly skin assessments on 04/25/23 and 05/02/23; responsible for skin assessments for residents with ongoing skin integrity issues | |
| Director of Nursing (DON) | Assessed rash on 05/23/23; stated expectations for weekly skin assessments and shower frequency | |
| Assistant Director of Nursing (ADON) | Resident #1's aide; provided incontinent care and applied PRN nystatin powder on 05/22/23; notified NP for routine order | |
| Administrator (ADM) | Interviewed regarding awareness of Resident #1's rash and shower documentation | |
| TN A | Treatment Nurse | Conducted facility in-service on showers on 03/27/23 |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
Annual survey inspection of Parkview Nursing and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Viewing
Loading inspection reports...
