ROUND ROCK, TX - Federal inspectors identified immediate jeopardy conditions at Park Valley Inn Health Center during a January 2025 inspection, citing serious failures in equipment maintenance, infection control, and nutritional monitoring that placed residents at risk of injury and illness.
Mechanical Lift Malfunction Results in Resident Injury
The most serious violation occurred when a resident experienced a fall during a transfer with a mechanical lift on January 3, 2025. The incident resulted in the resident being transported to the emergency room, where medical staff diagnosed a transverse fracture of the second lumbar vertebra. The resident also required monitoring for potential brain bleeding.
Investigation revealed the mechanical lift involved in the incident had not been properly maintained or inspected. When a service technician examined equipment at the facility following the incident, they identified a different lift with a malfunctioning motor that controlled the wheel-spreading mechanism. Critically, this defective lift had remained in service and available for resident transfers despite its mechanical failure.
The resident involved in the fall required two-person assistance with mechanical lift transfers, according to facility records. At the time of the incident, the resident was being transferred using equipment that facility staff had not adequately inspected or maintained. Following the fall and subsequent hospitalization, the resident returned to the facility on January 4, 2025, at her previous level of care with no changes to her transfer requirements.
Mechanical lifts serve as essential safety equipment in nursing facilities, enabling staff to transfer residents with limited mobility while minimizing injury risk to both residents and caregivers. When these devices malfunction during transfers, residents face serious hazards including fractures, head injuries, and traumatic falls. Spinal fractures, particularly in elderly residents with conditions like osteoporosis, can lead to chronic pain, reduced mobility, permanent disability, and increased mortality risk.
The facility's maintenance director was relieved of duty pending investigation, retraining, and demonstrated skills competency evaluation. Inspectors found that two mechanical lifts had been removed from service and secured by January 16, 2025, with zip ties placed through battery compartments to prevent unauthorized use. The facility maintained three other mechanical lifts that passed inspection and remained operational.
Federal surveyors determined this failure constituted immediate jeopardy—the most serious citation level—because residents requiring mechanical lift assistance faced imminent risk of serious injury or death from equipment that had not been properly maintained or removed from service when defects were identified.
Widespread Infection Control Failures During Influenza Outbreak
Inspectors identified a second immediate jeopardy situation related to infection control practices during an influenza outbreak that affected multiple residents. The facility failed to implement appropriate isolation precautions, conduct timely testing, and properly notify medical providers when residents developed flu-like symptoms.
The outbreak began around January 12, 2025, when multiple residents on the 700 and 800 halls began exhibiting symptoms including coughing, congestion, diarrhea, vomiting, and reduced appetite. One resident, Resident #21, developed flu-like symptoms while out on pass with family members, who took her directly to the hospital where she tested positive for influenza.
Despite multiple residents displaying classic influenza symptoms, facility nursing staff did not immediately contact attending physicians or the nurse practitioner. The nurse practitioner later confirmed he was not notified on Sunday, January 12, 2025, when symptoms began appearing, but was instead contacted Monday morning, January 13, 2025. This delay of approximately 24 hours prevented timely implementation of antiviral treatment and isolation protocols.
Influenza poses particularly serious risks in nursing facility populations, where residents often have compromised immune systems, chronic medical conditions, and advanced age. Rapid identification of cases, prompt isolation of affected individuals, and immediate antiviral treatment are critical to preventing severe complications and limiting transmission. Delays in implementing these measures can result in rapid outbreak spread, severe respiratory distress, hospitalizations, and increased mortality among vulnerable residents.
During the outbreak period, staff members were observed entering rooms of residents with suspected or confirmed influenza without donning appropriate personal protective equipment. On January 14, 2025, at 12:45 PM, inspectors observed a certified nursing assistant delivering meal trays to multiple residents with flu-like symptoms without wearing proper protective equipment. Rooms lacked required signage indicating droplet precautions, which should have alerted all staff members to don masks and other protective equipment before entering.
Specific residents affected included:
- Resident #68, who had an acute upper respiratory infection, heart failure, and asthma, creating elevated risk for respiratory complications - Resident #80, who reported feeling ill over the weekend with diarrhea, cough, congestion, and body aches but was not offered flu testing - Resident #159, who had congestive heart failure, asthma, and pneumonia—conditions that significantly increased her vulnerability to influenza complications - Resident #39, who reported feeling sick with symptoms possibly related to allergies
The facility reportedly ran out of flu testing supplies, which contributed to delays in testing symptomatic residents. This shortage meant staff could only test residents who appeared "very sick," rather than conducting comprehensive testing of all residents with flu-like symptoms as recommended by infection control protocols.
The infection preventionist stated she worked a double shift on January 13, 2025, and noticed many residents sleeping in during breakfast, then heard coughing and congestion throughout the morning. By noon, diarrhea and vomiting had begun. Despite recognizing "something was going on with the residents," she did not contact physicians and instead followed guidance from the Director of Nursing to document symptoms as the day progressed.
Severe Weight Loss and Inadequate Nutritional Monitoring
Inspectors documented serious nutritional care failures for Resident #159, who experienced dramatic unintended weight loss without appropriate monitoring or intervention. The resident's weight declined from 103.6 pounds on December 10, 2024, to 85.8 pounds on January 17, 2025—a loss of 17.8 pounds (17.2%) in just 38 days.
Most alarmingly, the resident lost 14.8 pounds in just 13 days between January 4, 2025 (100.4 pounds) and January 17, 2025 (85.8 pounds). This rapid weight loss occurred in a resident with congestive heart failure, hypertension, asthma, vascular dementia, and other serious conditions that required careful nutritional monitoring.
The resident's medical conditions included congestive heart failure, which typically requires daily weight monitoring to detect fluid retention or loss that could indicate worsening cardiac function. Despite this diagnosis, facility staff did not obtain any weights for the resident between January 4 and January 17, 2025—a 13-day gap during which the resident's condition was rapidly deteriorating.
Rapid unintended weight loss in elderly nursing facility residents indicates serious underlying problems that require immediate medical attention. Weight loss of this magnitude can reflect inadequate caloric intake, difficulty swallowing, progression of underlying diseases, medication side effects, or depression. When left unaddressed, severe weight loss leads to muscle wasting, weakened immune function, increased infection risk, pressure injury development, functional decline, and elevated mortality risk.
Food intake records for Resident #159 revealed inconsistent and inadequate documentation. Multiple meals showed no recorded intake data, making it impossible for nursing staff or the dietitian to assess whether the resident was consuming adequate nutrition. When intake was documented, it frequently showed consumption of 50% or less of meals, with some meals showing 0-25% consumption.
Observations revealed additional concerning findings. When inspectors observed the resident on January 14, 2025, at 9:35 AM, she was groaning in bed, stated she did not feel well, and displayed severely sunken eyes, pale coloring, and severe muscle atrophy in her temples—physical signs consistent with severe malnutrition and dehydration. On January 15, 2025, inspectors observed the resident sitting alone in her wheelchair at 11:35 AM with her meal tray set up, but she appeared unable to bring the fork to her mouth and was only picking at food. At 12:35 PM, her meal tray was on the cart outside her room with less than 10% eaten.
The speech-language pathologist had evaluated the resident for dysphagia (swallowing difficulty) and downgraded her diet to ground consistency. However, the resident's care plan was not updated to reflect this swallowing evaluation or her need for feeding assistance. The speech-language pathologist acknowledged the resident had experienced poor meal intake since returning from the hospital in December and had lost weight, but did not know the amount of weight loss or whether it was significant. She did not communicate with team members about the weight loss or notify the physician or dietitian.
The registered dietitian conducted her nutritional consultation on December 23, 2024, virtually without seeing the resident in person or contacting family members. Although the resident had a 3.6% weight loss in less than a week at the time of assessment, the dietitian only placed her on a small-dose oral nutrition supplement. The dietitian stated she had been at the facility for three weeks following her consultation but had not visited the resident or seen her in person during that time.
Evidence-based practice guidelines from the Academy of Nutrition and Dietetics recommend weekly body weight monitoring for older adults with unintended weight loss until weight stabilizes. Research demonstrates strong associations between unintended weight loss and increased mortality in this population.
The resident's family member reported that when visiting on January 17, 2025, he found nurses placing meal trays in front of the resident without providing eating assistance. On January 10, 2025, he discovered the meal tray delivered to his mother was not the ordered diet and had to request a replacement. The family member subsequently transferred the resident to an assisted living facility where staff provided daily eating assistance.
Controlled Medication Management Failures
The facility failed to properly manage discontinued controlled medications, creating potential for medication errors and raising concerns about accountability. Inspectors found discontinued controlled medications for two residents had remained in medication carts for months after discontinuation rather than being promptly destroyed according to facility policy.
For Resident #31, a bottle of Clonazepam (Klonopin) 0.5mg had been discontinued on August 15, 2024, due to a recent fall. The medication administration record showed the last documented count on August 18, 2024, with 22 pills remaining. When inspectors examined the medication cart on January 17, 2025, the bottle still contained 21 pills—one pill less than the final documented count from nearly five months earlier, with no documentation explaining the discrepancy.
For Resident #35, Tramadol 50mg had been discontinued on May 6, 2024. Records showed the last administration on September 16, 2024, with a final count of 30 pills. When inspectors checked the medication cart on January 17, 2025, only 26 pills remained—four pills fewer than documented, again with no explanation for the missing medications.
Additional Issues Identified
Food Service Safety Violations: Kitchen staff repeatedly failed to perform hand hygiene when changing gloves during food preparation on January 14, 2025. One dietary aide was observed changing gloves multiple times without washing hands between changes, wearing gloves with visible holes while preparing food, and touching multiple surfaces without changing contaminated gloves. Hair restraints did not fully cover staff members' hair, creating risk of hair contamination in food. These practices violate basic food safety principles and create risk for foodborne illness transmission.
Enhanced Barrier Precautions: Staff failed to wear required gowns when providing care to residents under enhanced barrier precautions. A licensed vocational nurse did not wear a gown when administering medications via gastrostomy tube, and a state-tested nursing assistant did not wear a gown while providing perineal care and wound care assistance.
The immediate jeopardy determinations were removed on January 18, 2025, after the facility implemented corrective measures including equipment inspections, staff retraining, infection control protocol implementation, and enhanced monitoring systems. However, the facility remained out of compliance pending evaluation of the effectiveness of corrective systems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Valley Inn Health Center from 2025-01-18 including all violations, facility responses, and corrective action plans.
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