Inspection Reports for Lake Village Nursing & Rehabilitation Center
TX, 75057
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
209% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Sep 16, 2025
Visit Reason
The inspection was conducted as part of the annual interdisciplinary team meeting and review of compliance with PASARR services and infection prevention and control programs.
Findings
The facility failed to incorporate PASARR recommendations into resident care planning and failed to submit a complete request for specialized services for one resident. Additionally, the facility failed to maintain proper infection prevention practices, specifically hand hygiene by a licensed vocational nurse during medication administration to another resident.
Deficiencies (4)
Failed to incorporate PASARR evaluation recommendations into resident assessment, care planning, and transitions of care for one resident.
Failed to submit a complete and accurate request for nursing facility specialized services within 20 business days after the annual interdisciplinary team meeting.
Resident did not receive a recommended repositioning wedge as per PASRR Comprehensive Service Plan.
Failed to maintain an infection prevention and control program; specifically, LVN B did not perform hand hygiene before and after medication administration to a resident.
Report Facts
Residents reviewed for PASRR services: 3
Residents observed for infection control: 5
BIMS score: 15
BIMS score: 8
Date of annual interdisciplinary team meeting: Mar 4, 2025
Date of last PCSP meeting: Aug 25, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Named in infection control deficiency for failure to perform hand hygiene during medication administration |
| MDS Coordinator | Interviewed regarding PASARR assessments and care plan follow-up | |
| DON | Director of Nursing | Interviewed regarding care plan meetings and infection control expectations |
| Administrator | Interviewed regarding follow-up on PASARR services and infection control policies | |
| Habilitation Coordinator | Interviewed regarding recommendation for repositioning wedge |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 6, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident dignity, privacy, care planning, respiratory care, pharmaceutical services, medication storage, and infection control.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity during mealtime assistance, failure to secure confidential medical records, incomplete care plans especially regarding CPAP usage, lack of physician orders for CPAP, improper disposal of narcotics, unlocked medication carts, and inadequate infection control practices such as failure to change gloves and sanitize equipment between residents.
Deficiencies (7)
Failed to treat Resident #45 with dignity by allowing CNA to stand behind resident during feeding.
Failed to secure confidential medical records of Resident #8 by leaving laptop monitor open and visible.
Failed to develop and implement a comprehensive care plan including CPAP usage for Resident #62.
Failed to provide safe respiratory care by not having a physician order for Resident #62's CPAP.
Failed to properly dispose of Resident #36's Tramadol medication.
Failed to ensure nurse's medication cart was locked while unattended.
Failed to implement infection prevention and control program including failure to change gloves and perform hand hygiene during incontinent care and failure to sanitize blood pressure cuff and pulse oximeter between residents.
Report Facts
Residents reviewed for dignity: 20
Residents reviewed for privacy and confidentiality: 20
Residents reviewed for care plans: 8
Residents reviewed for respiratory care: 12
Residents reviewed for pharmaceutical services: 5
Nurse's carts observed: 7
Residents reviewed for infection control: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nursing Assistant | Named in dignity deficiency for standing behind Resident #45 during feeding |
| LVN G | Licensed Vocational Nurse | Named in privacy deficiency for leaving laptop monitor open and unlocked nurse's cart |
| LVN H | Licensed Vocational Nurse | Named in care plan and respiratory care deficiencies related to Resident #62 |
| LVN J | Licensed Vocational Nurse | Named in pharmaceutical services and infection control deficiencies related to medication disposal and sanitizing equipment |
| CNA D | Certified Nursing Assistant | Named in infection control deficiency for failure to change gloves and hand hygiene during incontinent care |
| CNA E | Certified Nursing Assistant | Named in infection control deficiency for failure to change gloves and hand hygiene during incontinent care |
| ADON A | Assistant Director of Nursing | Interviewed regarding privacy, pharmaceutical services, and infection control deficiencies |
| ADON B | Assistant Director of Nursing | Interviewed regarding dignity and infection control deficiencies |
| Administrator | Facility Administrator | Interviewed regarding dignity, privacy, pharmaceutical services, medication cart locking, and infection control deficiencies |
| DON | Director of Nursing | Interviewed regarding dignity, privacy, care planning, respiratory care, pharmaceutical services, medication cart locking, and infection control deficiencies |
| MDS Nurse | Minimum Data Set Nurse | Interviewed regarding care plan deficiencies for Resident #62 |
| MA I | Medication Aide | Interviewed regarding proper disposal of narcotics |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 6, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident dignity, privacy, care planning, respiratory care, pharmaceutical services, medication storage, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding, failure to secure resident medical information, incomplete care plans especially regarding CPAP usage, lack of physician orders for CPAP, improper disposal of narcotics, unlocked medication carts, and inadequate infection control practices such as improper glove use and failure to sanitize equipment between residents.
Deficiencies (7)
Failed to treat Resident #45 with dignity by allowing CNA F to stand behind the resident while assisting with eating.
Failed to secure confidential medical records by leaving Resident #8's information visible on an unlocked laptop monitor.
Failed to develop and implement a comprehensive care plan including CPAP usage for Resident #62.
Failed to ensure Resident #62 had a physician order for CPAP usage.
Failed to properly dispose of Resident #36's Tramadol medication, discarding it in the trash without using the required narcotic disposal solution.
Failed to lock nurse's medication cart, leaving medications accessible in hall 300.
Failed to ensure proper infection control: CNAs did not change gloves or sanitize hands appropriately during incontinent care for Resident #35; LVN J did not sanitize blood pressure cuff and pulse oximeter between residents.
Report Facts
Residents reviewed for dignity: 20
Residents reviewed for privacy and confidentiality: 20
Residents reviewed for care plans: 8
Residents reviewed for respiratory care: 12
Residents reviewed for pharmaceutical services: 5
Nurse's carts observed: 7
Residents reviewed for infection control: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nursing Assistant | Named in dignity deficiency for standing behind Resident #45 during feeding |
| LVN G | Licensed Vocational Nurse | Named in privacy deficiency for leaving laptop monitor open with Resident #8's information and medication cart unlocked |
| LVN H | Licensed Vocational Nurse | Named in care plan and respiratory care deficiencies related to Resident #62's CPAP |
| LVN J | Licensed Vocational Nurse | Named in pharmaceutical services and infection control deficiencies related to improper narcotic disposal and failure to sanitize equipment |
| CNA D | Certified Nursing Assistant | Named in infection control deficiency for improper glove use during incontinent care |
| CNA E | Certified Nursing Assistant | Named in infection control deficiency for improper glove use during incontinent care |
| ADON A | Assistant Director of Nursing | Interviewed regarding privacy, pharmaceutical services, and infection control deficiencies |
| ADON B | Assistant Director of Nursing | Interviewed regarding dignity and infection control deficiencies |
| MDS Nurse | Minimum Data Set Nurse | Interviewed regarding care plan deficiencies for Resident #62 |
| Administrator | Facility Administrator | Interviewed regarding dignity, privacy, care planning, pharmaceutical services, medication cart locking, and infection control deficiencies |
| DON | Director of Nursing | Interviewed regarding dignity, privacy, care planning, pharmaceutical services, medication cart locking, and infection control deficiencies |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 4, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding cleanliness, food safety, and maintaining a safe, clean, comfortable, and homelike environment for residents.
Findings
The facility failed to ensure that resident rooms 303b and 307b, as well as all hallway handrails, were thoroughly cleaned and sanitized. Additionally, the ice scoop, ice scoop holder, and ice machine in the dining area were not properly cleaned, posing risks for infection control and cross contamination.
Deficiencies (2)
Failed to provide a safe, clean, comfortable, and homelike environment including proper cleaning and sanitization of resident rooms 303b and 307b and all hallway handrails.
Failed to ensure the ice scoop, ice scoop holder, and ice machine in the dining area were cleaned, risking cross contamination and air-borne illnesses.
Report Facts
Residents affected: 6
Housekeeping supervisor years of service: 19
Ice machine cleaning frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Interviewed regarding cleaning practices and acknowledged concerns about unclean areas | |
| Administrator | Interviewed and shown photos of concerns; stated intention to address issues with housekeeping and dietary supervisors | |
| Dietary Supervisor | Interviewed about cleaning practices of ice machine and related equipment |
Inspection Report
Routine
Deficiencies: 12
Date: Jan 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident dignity, reasonable accommodation, safety, care planning, respiratory care, infection control, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity (privacy bags for catheter bags), failure to ensure call lights were accessible, inadequate cleaning and maintenance of resident rooms, improper use of physical restraints, incomplete care plans, inconsistent ADL care, inadequate fall prevention measures, improper respiratory care, insufficient RN coverage, food safety violations, inaccurate medical record documentation, and failure to maintain an effective infection prevention and control program during a flu outbreak.
Deficiencies (12)
Failure to treat residents with dignity by not providing privacy bags for catheter bags.
Failure to ensure call light systems were accessible to residents at risk of falls.
Failure to maintain resident rooms in a safe, clean, comfortable, and homelike environment.
Failure to ensure residents were free from physical restraints without physician orders.
Failure to develop and implement comprehensive person-centered care plans for residents.
Failure to provide consistent ADL care including showers for dependent residents.
Failure to provide a safe environment free from accident hazards including proper placement of fall mats.
Failure to provide safe and appropriate respiratory care including proper storage of nasal cannulas and humidifier water.
Failure to maintain required RN coverage of at least 8 consecutive hours a day, 7 days a week for 14 days.
Failure to procure, store, prepare, distribute, and serve food in accordance with professional standards including labeling, sanitation, and staff hygiene.
Failure to accurately document medical records and timely notify responsible parties following resident falls.
Failure to maintain an infection prevention and control program during a flu outbreak including proper signage, PPE use, cohorting, family notification, and prophylactic treatment.
Report Facts
RN coverage hours: 4
Residents with flu: 10
Shower refusals: 3
BIMS scores: 10
BIMS scores: 15
BIMS scores: 5
Oxygen liters per minute: 3
Oxygen liters per minute: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON | Assistant Director of Nursing | Acknowledged catheter bags must have privacy bags; responsible for reminding staff |
| CNA S | Certified Nursing Assistant | Noted catheter bag without privacy bag; responsible for placing privacy bags |
| DON | Director of Nursing | Stated catheter bags should have privacy bags; responsible for care planning and infection control |
| Administrator | Stated dignity issues with exposed catheter bags; responsible for monitoring catheter bag privacy | |
| LVN S | Licensed Vocational Nurse | Educated CNAs on call light importance; responsible for ensuring call lights are accessible |
| RN R | Registered Nurse | Checked care plans for catheter care and fall interventions; replaced nasal cannulas |
| Dietary Manager | Responsible for kitchen sanitation and food safety; admitted not wearing hair covering | |
| LPN S | Licensed Practical Nurse | Documented family notification inaccurately after resident fall |
Inspection Report
Routine
Deficiencies: 10
Date: Jan 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, reasonable accommodation of resident needs, restraint use, care planning, activities of daily living, accident prevention, respiratory care, RN coverage, medical record accuracy, and infection control.
Findings
The facility was found deficient in multiple areas including failure to treat residents with dignity (privacy bags for catheter bags), failure to ensure call lights were accessible, lack of physician orders for physical restraints, incomplete care plans for catheter care and fall interventions, inconsistent provision of showers, failure to maintain a safe environment (fall mats), improper respiratory care (humidifier water and nasal cannula storage), inadequate RN coverage, inaccurate medical record documentation regarding family notification, and failure to maintain an effective infection prevention and control program during a flu outbreak.
Deficiencies (10)
Failure to treat residents with dignity by not providing privacy bags for catheter bags.
Failure to ensure call lights were accessible to residents at risk for falls.
Failure to have physician orders for the use of a scoop mattress as a physical restraint.
Failure to develop and implement comprehensive care plans for catheter care and fall interventions.
Failure to provide consistent showers to a resident requiring assistance with activities of daily living.
Failure to maintain a safe environment by not placing a fall mat alongside a resident's bed.
Failure to provide appropriate respiratory care including proper storage of nasal cannulas and ensuring humidifier bottles had water.
Failure to maintain required RN coverage of at least 8 consecutive hours a day, 7 days a week, for 14 days.
Failure to accurately document family notification following a resident fall.
Failure to maintain an effective infection prevention and control program during a flu outbreak, including lack of appropriate signage, PPE use, family notification, resident cohorting, and prophylactic treatment.
Report Facts
RN coverage hours missed: 14
Residents with flu: 10
Residents reviewed for dignity: 5
Residents reviewed for reasonable accommodation: 12
Residents reviewed for restraints: 8
Residents reviewed for care plans: 6
Residents reviewed for ADL care: 3
Residents reviewed for accident hazards: 6
Residents reviewed for respiratory care: 3
Residents reviewed for medical record accuracy: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN R | Registered Nurse | Checked care plans for catheter care and fall interventions; replaced nasal cannulas |
| ADON | Assistant Director of Nursing | Acknowledged catheter bag privacy bag issue; provided improvised cover; responsible for respiratory care oversight and staff education |
| CNA S | Certified Nursing Assistant | Noticed catheter bag without privacy bag; responsible for catheter bag privacy |
| DON | Director of Nursing | Oversaw catheter care expectations, call light accessibility, respiratory care, care planning, and infection control training |
| Administrator | Facility Administrator | Monitored catheter bag privacy, call light accessibility, respiratory care, RN coverage, and infection control |
| LVN S | Licensed Vocational Nurse | Educated CNAs on call light importance; responsible for call light placement |
| LVN B | Licensed Vocational Nurse | Refilled humidifier bottles for residents |
| LPN S | Licensed Practical Nurse | Nurse on duty during Resident #2 fall; documented family notification inaccurately |
| CNA V | Certified Nursing Assistant | Provided care to Resident #51; reported resident refusal of showers |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
The inspection was conducted as an annual survey of Lake Village Nursing and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 1
Date: Nov 29, 2022
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program, specifically focusing on hand hygiene practices during incontinent care.
Findings
The facility failed to maintain an effective infection prevention program as a CNA did not change gloves and perform hand hygiene after providing incontinent care, risking cross-contamination and infection. The Director of Nursing confirmed expectations for hand hygiene and reported in-service training was initiated.
Deficiencies (1)
CNA A failed to change gloves and perform hand hygiene after providing incontinent care and before assisting Resident #4 with dressing and positioning back into her wheelchair.
Report Facts
Staff trained in hand hygiene in-service: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nursing Assistant | Named in deficiency for failure to perform proper hand hygiene |
| DON | Director of Nursing | Provided interview regarding hand hygiene expectations and training |
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