Village Creek Rehabilitation and Nursing Center Inspection Report, Violations & Safety Grade (Lumberton, Texas)

705 N Main St, Lumberton, Texas 77657

Phone: 4097550100

CMS Overall:1/5

Overview & Bed Count

Certified Beds

120

Avg Residents/Day

75.3

Ownership

Government - Hospital district

Provider Type

Medicare and Medicaid

County

Hardin

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall1/5

Health1/5

Staffing1/5

Quality3/5

Nurse Staffing Check

Metric	This Facility	Texas Avg	Difference
RN Hours per Resident per Day	0.20	0.44	-0.24
Total Nurse Hours per Resident per Day	3.44	3.42	+0.02
CMS Staffing Rating	1/5	1.9/5	-
Nursing Staff Turnover	47.7%	50.8%	-

Health Citation History

38 health citations on record

Date	Category	Description	Severity
2026-03-26	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	K – Immediate Jeopardy
2026-03-26	Nursing and Physician Services Deficiencies	Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.	J – Immediate Jeopardy
2026-03-26	Quality of Life and Care Deficiencies	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.	G – Actual Harm
2026-03-26	Resident Rights Deficiencies	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	E – Moderate Harm Potential
2026-03-26	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	E – Moderate Harm Potential
2026-03-26	Pharmacy Service Deficiencies	Ensure medication error rates are not 5 percent or greater.	E – Moderate Harm Potential
2026-03-26	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	E – Moderate Harm Potential
2026-03-26	Nutrition and Dietary Deficiencies	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	E – Moderate Harm Potential
2026-03-26	Resident Assessment and Care Planning Deficiencies	Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.	D – Moderate Harm Potential
2026-03-26	Pharmacy Service Deficiencies	Ensure each resident’s drug regimen must be free from unnecessary drugs.	D – Moderate Harm Potential
2026-03-26	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	D – Moderate Harm Potential
2026-03-26	Environmental Deficiencies	Keep all essential equipment working safely.	D – Moderate Harm Potential
2025-12-05	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2025-12-05	Pharmacy Service Deficiencies	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.	D – Moderate Harm Potential
2025-11-21	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	J – Immediate Jeopardy
2025-01-15	Infection Control Deficiencies	Provide and implement an infection prevention and control program.	F – Moderate Harm Potential
2025-01-15	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2025-01-15	Environmental Deficiencies	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.	E – Moderate Harm Potential
2025-01-15	Resident Rights Deficiencies	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.	D – Moderate Harm Potential
2024-11-21	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	J – Immediate Jeopardy
2024-11-21	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	J – Immediate Jeopardy
2024-11-21	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	D – Moderate Harm Potential
2024-11-21	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	D – Moderate Harm Potential
2023-11-29	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	E – Moderate Harm Potential
2023-11-29	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	E – Moderate Harm Potential
2023-11-29	Pharmacy Service Deficiencies	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.	E – Moderate Harm Potential
2023-11-29	Administration Deficiencies	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.	E – Moderate Harm Potential
2023-11-29	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	E – Moderate Harm Potential
2023-11-29	Nursing and Physician Services Deficiencies	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	E – Moderate Harm Potential
2023-11-29	Resident Rights Deficiencies	Keep residents' personal and medical records private and confidential.	D – Moderate Harm Potential
2023-11-29	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	D – Moderate Harm Potential
2023-11-29	Resident Assessment and Care Planning Deficiencies	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	D – Moderate Harm Potential
2023-11-29	Resident Assessment and Care Planning Deficiencies	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	D – Moderate Harm Potential
2023-10-31	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	E – Moderate Harm Potential
2023-10-31	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	E – Moderate Harm Potential
2023-10-31	Resident Assessment and Care Planning Deficiencies	Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.	E – Moderate Harm Potential
2023-10-31	Resident Assessment and Care Planning Deficiencies	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	D – Moderate Harm Potential
2023-10-31	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential

Fire Safety Citation History

5 fire safety citations on record

Date	Category	Description	Severity
2026-03-26	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	D – Moderate Harm Potential
2025-01-15	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	F – Moderate Harm Potential
2023-11-29	Smoke Deficiencies	Provide properly protected cooking facilities.	F – Moderate Harm Potential
2023-11-29	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	F – Moderate Harm Potential
2023-11-29	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	E – Moderate Harm Potential

Total Penalties & Fines

$105,486

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2026-03-26	Fine	$37,798	-
2025-11-21	Fine	$13,250	-
2024-11-21	Fine	$54,438	-

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