Cycle 1
Health 2025-01-15 · Fire 2025-01-15
7 health deficiencies
Top issue: Environmental (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Lumberton, TX
Village Creek Rehabilitation and Nursing Center
1-star overall rating with 2-star inspections with $74,823 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
705 N Main St, Lumberton, TX
(409) 755-0100
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
69
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Nexion Health
Operator or chain grouping
Approved since
2003-07-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
52 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.26
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.84
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.51
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,359
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9833
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.03
Baseline 6.15% · Performance 6.93% · Measure score 3.03 · Achievement 3.03 · Improvement 0
Total nurse turnover
3.15
Baseline 37.93% · Performance 50.82% · Measure score 3.15 · Achievement 3.15 · Improvement 0
Adjusted total nurse staffing
0.99
Baseline 3.87 hours · Performance 3.36 hours · Measure score 0.99 · Achievement 0.99 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.02% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 12.5% · Lower 95% interval 8.08% |
| Discharge to community | 49.23% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 41.03% · Lower 95% interval 35.74% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 92.5% |
95.27%
2.8 pts worse
|
Numerator 37 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 71.43% |
53.69%
17.7 pts better
|
Numerator 20 · Denominator 28 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 14 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 40 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 37 |
| Staff flu vaccination coverage | 25.37% |
42%
16.6 pts worse
|
Numerator 17 · Denominator 67 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 16 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
2.1
0.1 pts better
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
97.1%
0.2 pts worse
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 93.8% · Q3 98.5% · Q4 97.0% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
97.9%
0.7 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.3%
1.7 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.2% · Q3 4.5% · Q4 4.5% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
2.7%
1.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
3.3%
1.4 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 3.8% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
18.9%
0.1 pts worse
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 21.2% · Q3 20.4% · Q4 14.5% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
10.8%
4.1 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.7% · Q3 11.1% · Q4 5.1% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.7% |
15.4%
4.3 pts worse
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.0% |
16.1%
12.9 pts worse
|
14.9%
14.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 19.1% · Q3 27.1% · Q4 32.6% · 4Q avg 29.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.9% |
15.0%
4.1 pts better
|
19.8%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 13.4% · Q3 12.0% · Q4 6.6% · 4Q avg 10.9% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
4.2%
1.9 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.2% · Q3 1.8% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.5% |
89.7%
4.2 pts worse
|
81.7%
3.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 73.7% · Q2 84.0% · Q3 93.9% · Q4 92.2% · 4Q avg 85.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
12.0%
4.4 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 8.1% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.5%
1.1 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.3% · Q3 3.4% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.0% |
88.0%
16 pts worse
|
79.7%
7.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.1% |
25.9%
4.2 pts worse
|
23.9%
6.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.1% · Observed 27.0% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-29 · Fire 2023-11-29
14 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-10-05 · Fire 2022-10-05
10 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-15
F · Potential for more than minimal harm
2023-11-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-18
F · Potential for more than minimal harm
2023-11-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-14
E · Potential for more than minimal harm
2023-11-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-13
E · Potential for more than minimal harm
2022-10-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-10-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-05
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-06
D · Potential for more than minimal harm
2025-12-05
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-06
J · Immediate jeopardy
2025-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
F · Potential for more than minimal harm
2025-01-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-16
E · Potential for more than minimal harm
2025-01-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-16
E · Potential for more than minimal harm
2025-01-15
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-16
D · Potential for more than minimal harm
2025-01-15
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-01-16
J · Immediate jeopardy
2024-11-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-22
J · Immediate jeopardy
2024-11-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-11-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-11-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-22
E · Potential for more than minimal harm
2023-11-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-11-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-11-29
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-11-29
F836 · Administration Deficiencies
Health
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.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-11-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-11-29
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-29
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-29
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-29
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-10-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-10-31
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-11-01
E · Potential for more than minimal harm
2023-10-31
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-10-31
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-10-31
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-11-01
E · Potential for more than minimal harm
2022-10-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-10-06
D · Potential for more than minimal harm
2022-10-05
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-06
D · Potential for more than minimal harm
2022-10-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-06
D · Potential for more than minimal harm
2022-10-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-10-06
D · Potential for more than minimal harm
2022-10-05
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2022-10-06
Penalties and ownership
What sits behind the stars
$20,385
2025-11-21
Fine
Fine · fine $20,385
Fine
$54,438
2024-11-21
Fine
Fine · fine $54,438
Fine
Ownership
Sweeny Hospital District
5% Or Greater Direct Ownership Interest · Organization
Fallon, John
Operational/Managerial Control · Individual
Kirley, Francis
Operational/Managerial Control · Individual
Lee, Brian
Operational/Managerial Control · Individual
Nexion Health At Lumberton, Inc.
Operational/Managerial Control · Organization
Oswald, John
Operational/Managerial Control · Individual
Park, Kelly
Corporate Officer · Individual
Pierce, Daniel
Operational/Managerial Control · Individual
Riner, Meera
Operational/Managerial Control · Individual
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