Village Creek Rehabilitation and Nursing Center
705 N Main St, Lumberton, TX 77657 · Hardin County · 120 certified beds · avg 76 residents/day · certified since Jul 3, 2003
Part of chain: NEXION HEALTH (51 facilities, chain avg rating 2.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Mar 26, 2026 · F-0607 · triggered by a complaint
The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Why it matters: Without working prevention policies, mistreatment is more likely to happen and less likely to be caught.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 27, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Mar 26, 2026 · F-0726
The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident.
Why it matters: Undertrained caregivers are more likely to miss warning signs and make care mistakes.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 27, 2026 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 21, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
▲ Immediate jeopardy, one-off · Nov 21, 2024 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 22, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Nov 21, 2024 · F-0656 · triggered by a complaint
The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Why it matters: Without a complete, working care plan, important needs can slip through the cracks and no one is accountable for results.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 22, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 26, 2026 · F-0690
The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Why it matters: Poor continence and catheter care leads to infections, skin breakdown, and loss of dignity.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 27, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (38)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 26, 2026 | ▲ K · Immediate jeopardy, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Mar 26, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Mar 26, 2026 | ▲ G · Actual harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Mar 26, 2026 | E · Potential for harm, repeated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Mar 26, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Mar 26, 2026 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 26, 2026 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Mar 26, 2026 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 26, 2026 | D · Potential for harm, one-off | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Nov 21, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 15, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 15, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 15, 2025 | E · Potential for harm, repeated | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. · from a complaint |
| Jan 15, 2025 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Nov 21, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 21, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Nov 21, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Nov 29, 2023 | E · Potential for harm, repeated | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Nov 29, 2023 | E · Potential for harm, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Nov 29, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 29, 2023 | E · Potential for harm, repeated | The facility was not properly licensed, or did not operate in compliance with federal, state, and local laws, regulations, and accepted professional standards. |
| Nov 29, 2023 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Nov 29, 2023 | E · Potential for harm, repeated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Nov 29, 2023 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Nov 29, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 29, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Nov 29, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Oct 31, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Oct 31, 2023 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Oct 31, 2023 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Oct 31, 2023 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Oct 31, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 12).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 15 | 0 | E |
| 2024 | 4 | 2 | J ▲ |
| 2025 | 7 | 1 | J ▲ |
| 2026 | 12 | 3 | K ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $105,486.
| Date | Type | Amount / length |
|---|---|---|
| Mar 26, 2026 | Fine | $37,798 |
| Nov 21, 2025 | Fine | $13,250 |
| Nov 21, 2024 | Fine | $54,438 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.19 | 3.46 | 3.95 | bottom 38% in Texas; bottom 21% in the U.S. |
| Registered Nurse hours | 0.20 | 0.44 | 0.69 | bottom 7% in Texas; bottom 2% in the U.S. |
| Weekend total nurse staffing | 2.71 | 3.04 | 3.50 | bottom 31% in Texas; bottom 17% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.21 | 0.34 | 0.48 | bottom 26% in Texas; bottom 14% in the U.S. |
| Total nursing staff turnover (%) | 40.3 | 55.3 | 45.8 | top 21% in Texas; top 37% in the U.S. |
| RN turnover (%) | 40.0 | 54.6 | 42.9 | top 30% in Texas; top 46% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.27, RN 0.20, weekend 2.77. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Who owns this facility
Government - Hospital district
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Sweeny Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2017 |
| Fallon, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Kirley, Francis | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Lee, Brian | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Nexion Health at Lumberton, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Oswald, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/22/2022 |
| Park, Kelly | Individual | Corporate Officer | NOT APPLICABLE | 08/01/2019 |
| Pierce, Daniel | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/16/2021 |
| Riner, Meera | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Silsbee Oaks Health Care LLP | 5.9 mi | Silsbee, TX | ★★★☆☆ | 4/5 | |
| Mill Creek | 6.1 mi | Silsbee, TX | ★★★☆☆ | 3/5 | |
| Paradigm at the Pines | 6.9 mi | Silsbee, TX | ★★☆☆☆ | 2/5 | abuse |
| Jefferson Nursing and Rehabilitation Center | 10.0 mi | Beaumont, TX | ★☆☆☆☆ | 2/5 | |
| Paradigm at Kountze | 10.3 mi | Kountze, TX | ★★★★☆ | 3/5 | |
| Harmony Care at Beaumont | 11.7 mi | Beaumont, TX | —/5 | abuseSFF | |
| Calder Woods | 13.1 mi | Beaumont, TX | ★★★☆☆ | 3/5 | |
| Beaumont Health Care Center | 13.6 mi | Beaumont, TX | ★★★★☆ | 4/5 | |
| Spindletop Hill Nursing and Rehabilitation Center | 13.8 mi | Beaumont, TX | ★☆☆☆☆ | 2/5 | |
| College Street Health Care Center | 13.8 mi | Beaumont, TX | ★★★★☆ | 4/5 | |
| Beaumont Nursing and Rehabilitation | 13.9 mi | Beaumont, TX | ★★☆☆☆ | 2/5 | |
| Avir at Beaumont | 13.9 mi | Beaumont, TX | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 675975.