Parkview Manor: Stroke Transfer Paperwork Failures - TX
The nurse who made that call, LVN A, was terminated the following day. Not for anything related to CR. For something else entirely.
What she left behind, according to a March 30 complaint inspection by federal surveyors, was a documentation gap that the facility's own administrator acknowledged had still not been filled weeks later. The change-of-condition report, the SBAR, the skin assessment, the pain assessment — the paperwork that is supposed to capture when a resident left, why, and in what condition — none of it had been completed. The administrator told inspectors that LVN A's failure to file those documents resulted in "untimely information being reported to CMS."
CR's family had already figured out something was wrong.
A family member identified in the report as Family #3 contacted the facility after CR was transferred and asked for more details. The administrator told inspectors he had not provided that information yet because he was still trying to find out from his own staff what had happened. He said he reached out to LVN A, the nurse who had sent CR to the hospital, and got no response. Then, on the evening of March 5, Family #3 arrived at the facility with a truck and took all of CR's personal belongings.
The administrator confirmed to inspectors that as of the time of the interview, LVN A had still not completed the required documentation. He could not say when, where, or under what circumstances CR had been prepared for discharge, because no one had written it down.
The night before CR was airlifted, two certified nursing assistants worked her unit and neither reported anything unusual. CNA B, who worked the evening shift on March 3 into March 4, told inspectors she had not noticed any changes in CR's condition. CNA C, who had cared for CR on many overnight shifts and described herself as familiar with CR's baseline, said the last time she saw CR was at 5:00 a.m. on March 4, when she provided incontinent care. CR was wet. CR thanked her for the brief change. CNA C told inspectors CR was sleepy, but that was normal for the overnight shift. She said CR had not looked sick. She had nothing to report to the oncoming nurse.
The morning of March 3, a physician assistant had assessed CR and documented no issues, with instructions to report any signs or symptoms of concern. CR's medication records showed she had received her doses on March 2, administered by a medication aide.
By March 4 at 3:29 p.m., her eyes were rolling back in her head.
CR was listed on the facility's transfer log as discharged to an acute care hospital on March 4. The discharge summary, which should have been completed at the time of transfer, was not signed until March 11 — a week later, after surveyors had already intervened. It was completed by the interim director of nursing.
The inspection classified the violation as causing minimal harm or potential for actual harm, affecting few residents. CR's condition after her medflight to the hospital is not described in the inspection record. What happened to her is not in the report.
Family #3 came with a truck and cleared out the room.
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 nurse who made that call, LVN A, was terminated the following day.
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.