D62

VILLAGE CREEK REHABILITATION AND NURSING CENTER

Grade D 62/100 composite score

Government - Hospital district

CMS Star Ratings

Overall
1/5
Health Insp.
2/5
Quality
4/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

120

Ownership

Government - Hospital district

Total Fines

$54,438

Last Survey

N/A

705 N MAIN ST, LUMBERTON, TX 77657
4097550100

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.27h
LPN
0.91h
CNA
2.34h
Total
3.51h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

SWEENY HOSPITAL DISTRICT

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Apr 2017

100%

NEXION HEALTH AT LUMBERTON, INC.

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Apr 2017

FALLON, JOHN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2017

KIRLEY, FRANCIS

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2017

LEE, BRIAN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2017

OSWALD, JOHN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Mar 2022

PIERCE, DANIEL

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Mar 2021

RINER, MEERA

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Apr 2017

PARK, KELLY

IndividualCORPORATE OFFICERSince Aug 2019

Penalties & Fines (1)

$54,438total fines
DateTypeDescriptionAmount
Nov 21, 2024Fine$54,438

Health Inspection Deficiencies (29)

November 21, 2025Health1 deficiency1 severe
0689JImmediate jeopardy, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

January 15, 2025Health4 deficiencies
0584DMinimal harm, Isolated

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Rights Deficiencies

Corrected Jan 16, 2025
0812EMinimal harm, Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Jan 16, 2025
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Jan 16, 2025
0921EMinimal harm, Pattern

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Jan 16, 2025
November 21, 2024Health4 deficiencies2 severe
0600JImmediate jeopardy, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 22, 2024
0609DMinimal harm, Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 22, 2024
0656JImmediate jeopardy, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 22, 2024
0842DMinimal harm, Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 22, 2024
November 29, 2023Health10 deficiencies
0583DMinimal harm, Isolated

Keep residents' personal and medical records private and confidential.

Resident Rights Deficiencies

Corrected Nov 30, 2023
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 30, 2023
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 30, 2023
0645EMinimal harm, Pattern

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Corrected Nov 30, 2023
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 30, 2023
0686EMinimal harm, Pattern

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Corrected Nov 30, 2023
0761EMinimal harm, Pattern

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Pharmacy Service Deficiencies

Corrected Nov 30, 2023
0836EMinimal harm, Pattern

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Administration Deficiencies

Corrected Nov 30, 2023
0842EMinimal harm, Pattern

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 30, 2023
0947EMinimal harm, Pattern

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies

Corrected Nov 30, 2023
October 31, 2023Health5 deficiencies
0607EMinimal harm, Pattern

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 1, 2023
0609EMinimal harm, Pattern

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Nov 1, 2023
0644DMinimal harm, Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 1, 2023
0655DMinimal harm, Isolated

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Corrected Nov 1, 2023
0842EMinimal harm, Pattern

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies

Corrected Nov 1, 2023
October 5, 2022Health5 deficiencies
0641EMinimal harm, Pattern

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 6, 2022
0656DMinimal harm, Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies

Corrected Oct 6, 2022
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Oct 6, 2022
0755DMinimal harm, Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Corrected Oct 6, 2022
0813DMinimal harm, Isolated

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Nutrition and Dietary Deficiencies

Corrected Oct 6, 2022

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Frequently Asked Questions

What is the CareGrader rating for VILLAGE CREEK REHABILITATION AND NURSING CENTER?

VILLAGE CREEK REHABILITATION AND NURSING CENTER in LUMBERTON, Texas has a CareGrader grade of D (Below Average), with a composite score of 62.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for VILLAGE CREEK REHABILITATION AND NURSING CENTER?

VILLAGE CREEK REHABILITATION AND NURSING CENTER has an overall CMS star rating of 1 out of 5, a health inspection rating of 2/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does VILLAGE CREEK REHABILITATION AND NURSING CENTER have?

VILLAGE CREEK REHABILITATION AND NURSING CENTER has 29 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

Has VILLAGE CREEK REHABILITATION AND NURSING CENTER been fined?

Yes. VILLAGE CREEK REHABILITATION AND NURSING CENTER has $54,438 in total fines from CMS enforcement actions across 1 penalty.

How many beds does VILLAGE CREEK REHABILITATION AND NURSING CENTER have?

VILLAGE CREEK REHABILITATION AND NURSING CENTER has 120 certified beds with approximately 69 current residents (57% occupancy). The facility is located at 705 N MAIN ST, LUMBERTON, Texas 77657. It is a government - hospital district facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.