Deficiency Index

Countryview Nursing & Rehabilitation

Terrell, Texas · CCN 675105

23 surveys since 2010, 14 of them producing a finding at harm level or worse.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
104
Surveys
23
Harm or worse
14
Immediate jeopardy
6
The record, 2010–2025
’10’15’20’25
No harm recordedHarm or worseNot surveyed
Immediate jeopardy6

Findings at the most serious level CMS records. 2 of these were recorded as past non-compliance — corrected before the survey.

Beyond CMS’s monthly file16/23

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
115
Ownership
Government - Hospital district
Chain
CREATIVE SOLUTIONS IN HEALTHCARE
County
Kaufman
Medicare-certified since
1993

CMS ratings

Overall
1
Health inspection
1
Staffing
2
Quality measures
4

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded more weighted findings than most of its peer group.

Weighted by harm level, against 104 government-run facilities of 100–127 beds in Texas.

Last survey on record

Aug 15, 2025

451 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day3.133.25
Registered-nurse hours per resident day0.34—
Annual nurse turnover94.4%48.1%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

Fines
$79,953 across 5 penalties
Abuse icon
Flagged by CMS on Care Compare

Federal civil money penalties and remedies as CMS currently publishes them. Amounts may still be under appeal.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ35.9%K23.9%L—
Actual harmG12.0%H—I—
No harm, potential for more than minimalD3160.8%E1019.6%F47.8%
No harm, potential for minimalA—B—C—
CMS’s current file: 51 of the 104 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F6894×

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • F6093×

    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  • F7553×

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  • F7613×

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  • F8803×

    Provide and implement an infection prevention and control program.

In the surveyor’s words

From the most serious findings on record at Countryview Nursing & Rehabilitation, in the surveyor’s own words.

  • Immediate jeopardy, patternF600Aug 15, 2025

    Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #7) of 6 Residents reviewed for abuse.The facility failed to protect Resident #7 from verbal abuse when Resident #16 made mocking statements and gestures regarding Resident #7's personal hygiene, the Administrator, LVN B, DON and Social Worker were aware of the verbal abuse. The verbal abuse led to Resident #7 being fearful, avoiding Resident #16 and Resident #7's withdrawal from former social patterns in refusing to go to the dining room and activities. An IJ was identified on 08/14/25. The IJ template was provided to the facility on [DATE] at 10:13AM. […]

  • Immediate jeopardy, patternF600Apr 23, 2025

    Based on observation, interview and record review, the facility failed to ensure residents the right to be free from abuse and/or neglect for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect. The facility failed to ensure Resident #1 was free from physical abuse. CNA A grabbed Resident #1's arm and twisted it and then CNA A put her hands on Resident #1's neck and choked her. The incident occurred on 03/03/25. An IJ was identified on 4/22/25. The IJ began on 03/03/25 and removed on 03/03/25. The facility took action to remove the IJ before the survey began. […]

  • Immediate jeopardy, isolatedF689Jul 11, 2024

    Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent elopement for 1 of 5 residents (Resident #1) reviewed for accident hazards and supervision. 1. The facility failed to ensure Resident # 1 had adequate interventions to prevent elopement on [DATE] after he had verbalized and or attempted to leave the facility on [DATE], [DATE], [DATE], and [DATE]. 2. The facility failed to prevent Resident #1 from eloping from the facility on [DATE]. Resident #1 wheeled himself approximately 0.3 miles from the facility. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:51 p.m. […]

  • Immediate jeopardy, isolatedF755Nov 14, 2023

    Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services. (Resident #1) The facility failed to follow physician order to give Resident #1 Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month. Resident #1 missed Invega in October and began hearing voices telling him to harm himself and Resident #1 had to be admitted to a psychiatric facility. […]

  • Immediate jeopardy, isolatedF760Nov 14, 2023

    Based on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services. (Resident #1) The facility failed to follow physician order to give Resident #1 Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month. Resident #1 missed Invega in October and began hearing voices telling him to harm himself and Resident #1 had to be admitted to a psychiatric facility. […]

Read 32 findings in full →The most serious and the most recent: 32 of 104 on record.

Every survey on record

FindingsAt actual harm or above

  • Aug 15, 2025Standard7 findings · 1 harm
  • Apr 23, 2025Complaint1 finding · 1 harm
  • Jul 30, 2024Standard and complaint21 findings
  • Jul 11, 2024Complaint1 finding · 1 harm
  • Nov 14, 2023Complaint5 findings · 3 harm
  • Oct 12, 2023Complaint3 findings
  • May 17, 2023Standard13 findings
  • Mar 16, 2022Standard and complaint1 finding
Show the 15 earlier surveys
  • Aug 5, 2021Infection control2 findings · 1 harm
  • Mar 3, 2021Infection control1 finding
  • Nov 26, 2019Complaint3 findings · 3 harm
  • Sep 6, 2019Standard and complaint2 findings
  • Aug 17, 2018Standard7 findings
  • Jun 13, 2018Complaint1 finding
  • Feb 15, 2018Complaint3 findings
  • Jul 14, 2016Standard and complaint3 findings
  • Jul 17, 2015Standard1 finding
  • May 14, 2014Standard2 findings
  • May 24, 2013—16 findings · 1 harm
  • May 4, 2012—5 findings
  • Jun 30, 2011—3 findings · 2 harm
  • Jan 4, 2011—1 finding · 1 harm
  • Sep 13, 2010—2 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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