Parkview Manor: Discharge Records Left Blank After ER Transfer - TX
For at least a week after that March 4 transfer, Parkview Manor Nursing and Rehabilitation had no clinical notes explaining why the resident had been rushed to a hospital, no documentation of physician contacts, no record of family notifications, and no discharge summary. The resident's location and condition were, on paper, unknown.
The doctor who ordered the transfer, MD B, described the call she received from the nurse, identified in inspection records as LVN A: the resident's eyes were rolling back, her blood pressure was elevated. MD B directed LVN A to send her out immediately for what she described as stroke-like symptoms.
That call happened at 3:29 p.m. on March 4. LVN A was terminated at 3:00 p.m. that same day, for unrelated reasons, according to the facility's administrator. What LVN A did not do before leaving was complete an SBAR, the standardized clinical summary required to document a resident's change of condition and trigger the facility's discharge paperwork. Without it, nothing else followed.
No discharge summary was generated. The resident did not appear correctly on the facility's ADT log, the admission-discharge-transfer record that CMS requires facilities to maintain. The interim director of nursing told inspectors that LVN A's failure to complete the SBAR meant the discharge was not reflected on the ADT report within the required 24-hour window.
The charge nurse who handed off to LVN A that day told inspectors she had informed LVN A to watch for any changes in the resident's condition. She said she was not aware the clinical chart had no notes about the hospital discharge, and she placed responsibility for the documentation squarely on LVN A as the resident's nurse of record.
A medication aide interviewed on March 11 said she had checked the resident's records after the transfer and found nothing. No clinical notes. No explanation for why the resident had left. She said she would have expected LVN A to complete the discharge documentation before ending the shift.
The administrator said he learned the resident had been discharged to the hospital and went to LVN A for answers. He got a brief explanation, a change in condition, and then nothing more. LVN A stopped responding to his follow-up attempts.
When the resident's family, identified as Family 3, asked for her clinical records on March 5, the administrator gave them only the last hospital notes in her progress file. He told inspectors he held back the full records because he wanted to gather more information from staff before releasing anything. He was still waiting.
The discharge summary that should have been completed on March 4 was finally signed on March 11 at 8:56 p.m., after inspectors intervened. It was completed not by LVN A but by the interim director of nursing. It confirmed what staff had known for a week: the resident had been transferred to an acute care hospital on March 4 due to a change in condition.
The interim DON told inspectors the missing documentation mattered beyond the paperwork itself. Without the SBAR and discharge summary, there was no record of physician contacts, no account of what the family had been told, and no way to track the resident's status or ensure continuity of her care after she arrived at the hospital.
The inspection was conducted as a complaint investigation, completed March 30. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents.
The resident had gone to the emergency room with her eyes rolling back and her blood pressure climbing. For seven days, the facility where she had lived had no official record of any of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parkview Manor Nursing and Rehabilitation from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 18, 2026 · Our methodology
Parkview Manor Nursing and Rehabilitation in Weimar, TX was cited for violations during a health inspection on March 30, 2026.
The resident's location and condition were, on paper, unknown.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.