Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0637
Assess the resident when there is a significant change in condition
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, and record reviews, the facility failed to complete a comprehensive assessment within 14 days
after a significant change in the physical condition for 1 of 4 residents (Residents #1) whose records were
reviewed for assessments.
Residents Affected - Few
The facility failed to recognize and re-assess Resident #1 after an improvement in mood, significant weight
gain, and an improvement in ADL function. This failure placed residents at risk for not developing
interventions to meet their needs for care assistance and treatments.
Findings include:
Record review of Resident #1's Face Sheet, dated 12/07/2023, revealed a [AGE] year-old female, admitted
to the facility on [DATE] with an admitting diagnosis of Dementia (decline in cognitive abilities that impacts a
person's ability to perform everyday activities), protein calorie malnutrition (inadequate intake of food such
as protein, calories and other essential nutrients) and bipolar (periods of depression and periods of
abnormally elevated mood that last from weeks to days).
Record review of Resident #1's admission MDS assessment, dated 04/14/2023, revealed the following:
Section D (Mood) showed a score of 08.
Section K (Weight) Showed a weight of 130 pounds.
Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in
last 6 months, resident not a physician prescribed weight regimen.
Section G (Functional Status)- Required Extensive assistance for bed mobility and limited assistance for
transfers.
Record review of Resident #1's Quarterly MDS assessment, dated 06/27/2023, revealed the following:
Section D (Mood) showed a score of 03.
Section K (Weight)- Showed a weight of 142 pounds.
Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in
last 6 months, resident not a physician prescribed weight regimen.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
455916
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455916
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
University Park Nursing and Rehabilitation
4511 Coronado Ave
Wichita Falls, TX 76310
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0637
Section G (Functional Status)- Required no assistance with Bed Mobility and transfers.
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #1's Quarterly MDS assessment, dated 09/22/2023, revealed the following:
Section D (Mood) showed a score of 03.
Residents Affected - Few
Section K (Weight)- Showed a weight of 151 pounds.
Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in
last 6 months, resident not a physician prescribed weight regimen.
Section G (Functional Status)- Required no assistance with Bed Mobility and transfers.
Record review of Resident #1's MDS assessments revealed there was no MDS Significant Change
Assessments.
Record review of Resident #1's Care Plan, last revised on 08/15/2023, revealed care plans for:
Problem: Weight loss- has nutritional potential problem with weight loss due to Terminal prognosis related to
multiple CVA'S (cerebral vascular accident).
Goal: will maintain adequate nutritional status as evidenced by maintaining weight, no signs, or symptoms
of malnutrition, and consuming at least 50% of at least three meals a day.
In an interview on 12/06/2023 at 12:05 PM, the MDS coordinator revealed Resident #1 had a significant
weight gain of more than 10%, her mood improved, and her functional status all improved since her
admission assessment. She revealed that she should have completed a significant Change MDS
Assessment on June 27, 2023, instead of completed a Quarterly Assessment. She revealed that the
resident was admitted into the facility on [DATE] weighing 130lbs and in August she weighed 151 after they
started snacks BID (twice daily) to increase the weight. She revealed that since the resident's Annual
admission the resident has had an improvement in her ADL's, and that she was triggering as Independent
in ADL areas. She revealed that this failure could cause the resident to miss care areas not being identified
and/or a comprehensive care plan being completed.
In an interview on 12/06/2023 at approximately 1:30 PM, the DON revealed that it was the MDS
coordinator's responsibility to complete the MDS assessment accurately, which include the Significant
Change Assessments. She revealed that the resident had adjusted and that her mood has improved since
her admission. She revealed Resident #1 had a significant weight gain, after the resident adjusted to being
admitted into the facility.
Record review of the facility's policy covering MDS inaccuracies was requested to the MDS coordinator on
12/07/2023 and was not provided at the time of exit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455916
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455916
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
University Park Nursing and Rehabilitation
4511 Coronado Ave
Wichita Falls, TX 76310
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to accurately assess each resident's status for 1 of 5
(Resident #1) reviewed for assessment accuracy in that:
Residents Affected - Few
Resident #1's Quarterly MDS assessment records, was not coded yes for weight gain of 5% or more in the
last month or gain of 10% or more in last 6 months.
This failure could place residents at risk of not receiving the proper care and services due to inaccurate
assessment records.
Finding included:
Record review of Resident #1's Face Sheet, dated 12/07/2023, revealed a [AGE] year-old female, admitted
to the facility on [DATE] with an admitting diagnosis of Dementia (decline in cognitive abilities that impacts a
person's ability to perform everyday activities), protein calorie malnutrition (inadequate intake of food such
as protein, calories and other essential nutrients) and bipolar (periods of depression and periods of
abnormally elevated mood that last from weeks to days).
Record review of Resident #1's admission MDS assessment, dated 04/14/2023, revealed the following:
Section D (Mood) showed a score of 08.
Section K (Weight) Showed a weight of 130 pounds.
Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in
last 6 months, resident not a physician prescribed weight regimen.
Section G (Functional Status)- Required Extensive assistance for bed mobility and limited assistance for
transfers.
Record review of Resident #1's Quarterly MDS assessment, dated 06/27/2023, revealed the following:
Section D (Mood) showed a score of 03.
Section K (Weight)- Showed a weight of 142 pounds.
Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in
last 6 months, resident not a physician prescribed weight regimen.
Section G (Functional Status)- Required no assistance with Bed Mobility and transfers.
Record review of Resident #1's Quarterly MDS assessment, dated 09/22/2023, revealed the following:
Section D (Mood) showed a score of 03.
Section K (Weight)- Showed a weight of 151 pounds.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455916
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455916
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
University Park Nursing and Rehabilitation
4511 Coronado Ave
Wichita Falls, TX 76310
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Section K (Weight gain)- No, weight gain of 5% or more in the last month or weight gain of 10% or more in
last 6 months, resident not a physician prescribed weight regimen.
Level of Harm - Minimal harm
or potential for actual harm
Section G (Functional Status)- Required no assistance with Bed Mobility and transfers.
Residents Affected - Few
Record review of Resident #1's weight and vital summary revealed the following weights and dates:
08/31/2023- 151.4lbs- wheelchair
08/08/2023- 143lbs- wheelchair
04/06/2023- 130lbs- wheelchair
In an interview on 12/06/2023 at 12:05 PM, the MDS coordinator revealed the resident had a significant
weight gain of more than 10% in the month of August 2023. She revealed that the resident was admitted
into the facility on [DATE] weighing 130lbs and in August she weighed 151 after they started snacks BID
(twice daily) to increase the weight. She revealed that on the resident's Quarterly MDS assessment dated
[DATE] she should have coded yes; the resident had a weight gain that was not physician prescribed in
section K. She revealed that this failure could cause the resident to miss care areas not being identified and
care planned accurately.
In an interview on 12/06/2023 at approximately 1:30 PM, the DON revealed that it was the MDS
Coordinator's responsibility to complete the MDS assessment accurately. She revealed that the resident
had a significant weight gain, after the resident adjusted to being in the facility.
Record review of the facility's policy covering MDS inaccuracies was requested to the MDS coordinator on
12/07/2023 and not received at the time of exit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455916
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455916
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
University Park Nursing and Rehabilitation
4511 Coronado Ave
Wichita Falls, TX 76310
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on observation, interview and record review, the facility failed to ensure medications were secured
on 1 of 2 medication carts reviewed for pharmacy services.
The facility did not ensure medications carts were secured and locked.
This failure could place the residents at risk of gaining access to unlocked medications not prescribed to
them.
Findings included:
During an observation on 12/06/2023 at 3:30 PM, LVN A left a prescription IV medication of Vancomycin on
top of the cart 2, unsecured and out of LVN A's sight, while she was in another resident's room. There was
not any other staff in visual sight of the medication, and there was a resident that was within 3 feet of the
medication cart. Surveyor was unsure where the nurse went and took the medication to the Administrator's
office without LVN A realizing it was gone.
During an interview on 12/06/2023 at 3:35 PM, LVN A said that she walked away to go into a resident's
room to help him. She said that she should have locked the medication up before she left it unattended with
residents around it. She said that this could cause a patient to get into it or take the medication.
During an interview on 11/06/2023 at 12:45 PM, the DON said that her expectations were for medications
to be locked up anytime a nurse walks away from it. She said that staff are all trained on medication
expectations and know not to leave medications out or unattended.
A policy and procedure titled Storage of Medication was requested on 12/07/2023 and was not received at
the time of exit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455916
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455916
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
University Park Nursing and Rehabilitation
4511 Coronado Ave
Wichita Falls, TX 76310
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to maintain an infection prevention
and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the
development and transmission of disease and infection for 2 staff (CNA A, CNA B) of 5 staff reviewed for
infection control, in that:
Residents Affected - Few
1. CNA A entered a COVID-19 Red Zone (COVID positive zone) room, without eye protection (face shield
or goggles) on and proceeded to care for and speak with a resident that was unmasked, while the
resident's door was open.
2. CNA B entered a COVID-19 Red Zone (COVID positive zone) room, without eye protection (face shield
or goggles), a gown, or a N95 mask or respirator and proceeded to clean the COVID positive room.
These failures could place residents at risk for contamination and infection.
The findings included:
Observation on 12/06/2023 at 10:20 AM, CNA A was in Resident #2's room performing resident care on
Resident #2, a COVID-19 positive resident, without an eye shield (goggles or face shield). Resident #2 did
not have a face mask on, and CNA A was near the resident. The resident's door was left open while CNA A
was going in and out of the resident's room.
Observation on 12/06/2023 at 10:22 AM there was a posting on Resident #2's door, revealed the resident
was on aerosol precautions. A sign was posted on the door that read STOP- Aerosol Contact Precautions,
only essential personnel should enter this room.
The instructions below revealed the following: EVERYONE MUST:
1)
Clean hands when entering and leaving room.
2)
Use approved N95 or equivalent respirator especially during aerosolizing procedures,
3)
Mask- Face mask is acceptable if respirator is not available and for visitors.
4)
Wear eye protection- Face Shield and Goggles.
5)
KEEP DOOR CLOSED
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455916
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455916
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/07/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
University Park Nursing and Rehabilitation
4511 Coronado Ave
Wichita Falls, TX 76310
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 12/06/2023 at 10:25 AM, CNA A stated that she knew she was supposed to have goggles on,
but she forgot. She said that she has received training on the Covid policy and that she just forgot to wear
eye protection when in the resident's room or when she makes direct contact with the resident. She stated
that she saw the postings on the resident's door.
Observation on 12/06/2023 at 10:30 AM, CNA B was in Resident #3's room, a COVID positive resident
without an eye shield (goggles or face shield), a gown, and a N95 mask, while his door was open. CNA B
was changing Resident #3's bedding while coming in direct contact with the bedding that was touching
CNA B's scrubs in the front. CNA B proceeded to gather Resident #3's dirty clothes while it touched her
scrubs in the front.
Interview and observation on 12/06/2023 at 10:35 AM, CNA B stated that she should have followed the
PPE postings that were on the outside of the resident's door. She stated that she was trying to hurry and
clean the resident's room while he was in the shower. She stated that she knew that her scrubs were
touching his dirty bedding and that she should have had a gown on to cover her. She stated that she knew
she should have worn an N95 mask and eye protection. She revealed this failure could place residents at
risk for cross contamination. CNA B left the resident's room and did not change from her contaminated
scrubs that shift.
Interview on 12/06/2023 at 11:00 AM, the Administrator revealed that the postings should be followed
exactly as posted and that all employees have been thoroughly in-serviced on infection control and COVID.
Record review of the Coronavirus Disease (COVID-19)-Infection Prevention and Control Measures Policy
not dated: stated,
Patient Placement:
Place a patient with suspected or confirmed COVID infection in a single-person room. The door should be
kept closed (if safe to do so).
Personal Protection Equipment:
HCP (Health Care Provider) who enters the room of a patient with suspected or confirmed COVID infection
should adhere to standard precautions and use a NIOSH approved particulate respirator with N95 filters or
higher, gown, gloves, and eye protection) goggles or a face shield that covers the front and side of the
face).
Record review of the CDC (Centers for Disease Control) Guidelines Recommendation dated Sept. 27,
2022, When COVID Community Transmission levels are high, source control is recommended for everyone
in a healthcare setting when they are in areas of the healthcare facility where they could encounter
patients.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455916
If continuation sheet
Page 7 of 7
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F637 - Within 14 days after the facility determines, or should have determined,
Assess the resident when there is a significant change in condition
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F761 - Labeling of Drugs and Biologicals
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.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the December 7, 2023 survey of UNIVERSITY PARK NURSING AND REHABILITATION?
This was a inspection survey of UNIVERSITY PARK NURSING AND REHABILITATION on December 7, 2023. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at UNIVERSITY PARK NURSING AND REHABILITATION on December 7, 2023?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Assess the resident when there is a significant change in condition"
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.