The incident at Harker Heights Nursing & Rehabilitation unfolded in late September when staff relocated Resident #1 without the family present. When the responsible party called the facility, staff informed her that her relative's belongings had already been moved and she would need to come handle the camera removal personally.
The responsible party told state inspectors that when she arrived at the facility the next day, all of Resident #1's belongings had been transferred to the new room. The administrator then made a revealing statement: "I had to move [Resident #1] to prove to the state that we did it."
That comment exposed the pressure driving the hasty relocation. The director of nursing later confirmed that a state surveyor had instructed the facility to move Resident #1 to a room with a working toilet, creating urgency to complete the transfer.
The director of nursing, who started working at the facility in August 2025, told inspectors she had called the responsible party on Monday, September 23, to discuss the upcoming move. She said the administrator later notified her that the responsible party didn't come to the facility that day.
"She further stated a state surveyor told the facility to have Resident #1 moved to a different room with a working toilet, so they were under pressure to complete Resident #1's room move," the inspection report states. "She stated they were trying to do the right thing by completing the room move and to be in compliance with the state."
The facility's own staff described conflicting procedures for room changes. The social worker, employed for four months, explained that room changes typically involved team meetings to identify available rooms, followed by outreach to families and showing the room to residents. She said families provided verbal consent, which was documented in progress notes in the electronic health record, but nothing was required in writing.
The assistant director echoed this process, stating that room changes were discussed during interdisciplinary team meetings after checking room availability. Families and residents were notified verbally, and families were asked if they wanted to be present during the move.
However, a licensed vocational nurse told inspectors that "the family must be notified and present during the Residents' move from the other room" — a requirement that clearly wasn't met in this case.
The administrator defended the move, explaining that the bathroom wasn't working in Resident #1's previous room. He said the director of nursing had verbally notified the responsible party about the room change, but acknowledged the family member became upset about the facility moving the resident without them present.
According to the administrator, the responsible party "became aggressive towards staff members, and threatening if they were to come near Resident #1" after discovering the unauthorized move.
The camera removal became a particular point of contention. The assistant director said cameras should be removed by families in person "to make sure it's not broken and re-installed correctly." The director of nursing admitted uncertainty about whether the facility was supposed to remove the camera from the previous room.
When inspectors asked for the facility's written policy on room changes, administrators couldn't produce one. The inspection report notes: "Attempted a review on 10/15/25 at 4:20 PM from the ADM and did not obtain a Policy & Procedure of Resident Room Changes and whether the resident and/or RP should be notified in writing and/or verbally."
The facility does have a policy regarding resident rights, dated January 2023, which states residents have the right "to not be relocated within the community, except in accordance with nursing community regulations." The policy also requires documenting reasons for room transfers and refusals.
The social worker's statement that room changes required only verbal consent contradicted what other staff described as proper procedure. She said she wasn't involved in Resident #1's room change and didn't remember the specific case.
The director of nursing emphasized the compliance pressure they faced, telling inspectors she discussed "the urgency to be in compliance" with the responsible party. She maintained that she had spoken with the family member "on multiple occasions" about the move.
The administrator's comment about moving the resident "to prove to the state that we did it" suggests the facility prioritized regulatory compliance over family notification requirements. The broken toilet provided justification for the move, but staff acknowledged the family should have been present or properly notified in advance.
The responsible party's anger appears justified given the facility's failure to follow their own described procedures for room changes, leaving a family member to discover their relative had been relocated without their knowledge or presence.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Harker Heights Nursing & Rehabilitation from 2025-11-18 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Harker Heights Nursing & Rehabilitation
- Browse all TX nursing home inspections