Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Stephenville during CMS and state inspections, most recent first.
A cognitively intact male resident with bipolar disorder was prescribed medroxyprogesterone acetate (Provera) 5 mg daily by an NP for sexual behaviors, despite no sexual behaviors being addressed in his care plan. The MAR showed he received two doses, and a nursing note documented he was started on Provera and paroxetine with general medication education, but there was no signed consent for Provera on file. The resident later reported he learned from an outside case manager that he had been prescribed a hormone without his knowledge, stated he had not signed consent and did not want medication for his sex drive, and interviews confirmed the psych physician had not ordered Provera and that the facility had no written consent policy available. The DON and ADON acknowledged responsibility for obtaining consents lay with the prescriber or the nurse taking the order, yet no consent form for Provera could be produced.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice care, but the facility failed to document hospice services in the care plan and did not maintain required hospice forms, such as the certificate of terminal illness and hospice election form. Communication between hospice and facility staff was verbal, with no documented evidence as required by policy.
Staff failed to follow infection control protocols during perineal care for two male residents with incontinence and complex medical histories. Observed deficiencies included reusing wipes, not retracting the foreskin for cleaning, and wiping from back to front, all contrary to facility policy and recent staff training. These actions placed residents at risk for infection.
Two residents reported unsanitary conditions in their rooms and bathrooms, including the presence of roaches and unsafe bathroom fixtures. One resident's bathroom had an unsteady sink and toilet, and both residents expressed distress over the roach infestation. The facility's pest control measures were documented, but issues persisted, and the administrator was unaware of the specific bathroom fixture problems.
The facility failed to ensure a safe environment by allowing the DON to bring a dog that bit a resident and acted aggressively towards another. The incidents were not reported, and the facility lacked a clear policy on staff pets, contributing to the deficiency.
The facility failed to protect two residents from verbal abuse by a CNA, who was witnessed yelling and slamming doors. Despite initial denials from the residents, they later confirmed the abuse, indicating a failure in the facility's abuse prevention measures. The facility did not follow its policies for reporting and investigating the incident, as the DON did not document interviews or conduct an investigation, and the incident was not reported to the state agency.
A facility failed to report an alleged verbal abuse incident involving two residents to state authorities within the required timeframe. An RN witnessed a CNA yelling and slamming a door on the residents, but the incident was not documented or thoroughly investigated by the DON. The residents, both with significant medical conditions, denied the allegations, and the CNA continued working without suspension, contrary to facility policy.
The facility failed to investigate allegations of verbal abuse by a CNA towards two residents, despite a report by an RN. The residents, both with moderate cognitive impairments, denied the allegations when interviewed by the DON. The facility did not follow its abuse investigation policy, which requires thorough documentation and suspension of the accused employee during the investigation.
A resident in a LTC facility did not receive IV antibiotics as ordered due to a failure to mix the medication properly. The central line dressing was not changed as required, and weekly lab tests were not conducted. These deficiencies in care placed the resident at risk of infection relapse and complications.
Two residents in a LTC facility experienced significant medication errors. One resident did not receive IV antibiotics as ordered due to improper mixing and labeling, while another missed multiple doses of Insulin Glargine. These errors were attributed to misunderstandings and poor adherence to protocols, placing residents at risk of complications.
The facility failed to develop comprehensive care plans for residents, leading to missed PASRR services and lack of ADL goals. Insulin was not administered as ordered for a resident, and central line dressings were not changed as documented, highlighting significant lapses in care and communication.
A facility failed to change and date a resident's oxygen tubing weekly as required, leading to a deficiency in respiratory care. The resident, with chronic respiratory failure, had nebulizer tubing that was not replaced according to the schedule. The DON acknowledged the oversight and the lack of a clear policy on tubing dating, contributing to the deficiency.
The facility failed to ensure timely physician visits for several residents, with two not seen every 30 days during the first 90 days post-admission, and four not seen every 60 days thereafter. Missing documentation for specific months highlighted this deficiency. Interviews with the DON and ADMN revealed awareness of the issue, attributing it to physicians not visiting as required. The facility's policy mandates visits every 30 days initially and every 60 days thereafter, which was not followed.
The facility failed to maintain adequate nursing staff levels, as evidenced by timesheet reviews and resident interviews. On several occasions, the facility did not meet the required direct care staff hours, leading to concerns about delayed care and insufficient response to resident needs. The DON and ADMN acknowledged staffing issues due to unexpected staff resignations and absences, which were not aligned with the facility's policy of maintaining adequate staffing.
The facility failed to store medications securely and in their original containers, as observed with three medication carts containing unlabeled pill cups with various medications, including narcotics. Staff interviews revealed pre-filling of pill cups due to workload, risking incorrect medication administration. The DON acknowledged this practice was against policy, which requires medications to be stored securely and in original packaging.
A resident with a stage 4 pressure wound was treated without the privacy curtain being pulled, compromising their dignity and privacy. The LVN acknowledged the oversight, and both the DON and ADON confirmed the importance of using the curtain to prevent exposure. The facility's policy on maintaining resident dignity and privacy was not followed.
A resident's privacy was compromised when staff failed to pull the privacy curtain during peri-care and a transfer using a Hoyer Lift. The resident, who is cognitively intact and requires assistance due to incontinence and lack of coordination, was exposed to potential embarrassment. Facility policy requires maintaining resident dignity and privacy, which was not adhered to in this instance.
A resident was transferred using a Hoyer lift without locking the lift's legs in the required position, despite staff training on proper use. The resident, who was cognitively intact and dependent on staff for transfers, was at risk due to this oversight. The CNA admitted to not locking the lift previously, and the ADON confirmed the importance of locking the brakes to prevent falls.
Two staff members failed to follow proper infection control protocols during peri-care for a resident, neglecting to change gloves and perform hand hygiene between tasks. The resident, who was incontinent and had conditions such as hypertension and diarrhea, was at risk due to these lapses. The staff cited nervousness and lack of supplies, while the DON and ADON acknowledged insufficient training and monitoring.
The facility failed to store medications in locked compartments and keep them in their original containers. Observations revealed loose pills in the Hall 3 and Hall 5 medication carts. Staff acknowledged the issue, citing hurried actions and lack of attention as causes. The facility's policy requires drugs to be stored securely and in their original packaging.
A facility failed to respect a resident's right to smoke, revoking his smoking privileges without attempting other safety measures. The resident, with severe cognitive impairment and a history of elopement, was denied the only activity he enjoyed, despite being assessed as safe to smoke under supervision.
The facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment, resulting in inadequate supervision and care. The care plan lacked person-centered interventions and measurable objectives, particularly concerning smoking safety and elopement. Interviews with the DON and ADMN confirmed the care plan's deficiencies.
Failure to Obtain Informed Consent for Hormone Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact male resident was fully informed of, and consented to, a hormone medication (medroxyprogesterone acetate/Provera) prescribed for sexual behaviors before it was administered. The resident, with a diagnosis of bipolar disorder and a BIMS score of 15/15, had no sexual behaviors identified or addressed in his comprehensive care plan. Nonetheless, an NP entered an order for Provera 5 mg by mouth daily for sexual behaviors, and the MAR showed the resident received two doses on consecutive evenings. Review of the electronic medical record revealed no evidence of a signed consent for Provera using the required HHSC Form 3713 prior to administration. Progress notes showed that on the same date the Provera order was initiated, the psychiatric provider evaluated the resident for worsening depression and anxiety, discontinued escitalopram (Lexapro), and started paroxetine (Paxil). A subsequent nursing note documented that the resident was started on Provera and paroxetine, and that he was educated on his medications and given printed information at his request, but there was still no documented written consent for Provera. The psychiatric physician later confirmed he did not prescribe Provera, only discussed it briefly as a medication ordered by the NP, and stated that obtaining signed consents was the facility’s responsibility. Interviews with staff and the resident further demonstrated that the resident had not been informed in advance or given the opportunity to consent in writing to Provera before receiving it. The resident reported learning from an outside case manager that he had been prescribed a hormone without his knowledge and stated he had not signed a consent and did not want medication for his sex drive. The DON and ADON each stated that the prescriber or the nurse taking the order was responsible for obtaining signed consent, but the facility was unable to produce a signed consent form for Provera or a policy on obtaining written consent for medications. This sequence of events shows the resident received Provera without the required informed, written consent.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, there was no evidence in the resident's comprehensive care plan that hospice services were being provided, despite the resident being admitted to hospice care. The clinical records lacked required hospice documentation, including the certificate of terminal illness, hospice election form, and documentation of communication between the facility and the hospice provider. The resident in question had severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, kidney disease, and a urinary tract infection. Interviews and record reviews revealed that communication between hospice staff and facility staff was conducted verbally, and required communication forms were not being completed as per facility policy. The Director of Nursing acknowledged that the necessary documentation was missing and that it was her responsibility to ensure these documents were present. Facility policy required collaboration with hospice representatives, documentation of communication, and maintenance of specific hospice-related forms, none of which were found in the resident's records.
Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during the provision of incontinent care for three staff members observed. Specifically, staff did not follow proper perineal care procedures for two male residents who were always incontinent. During observations, one CNA reused wipes by folding them instead of using a new wipe for each stroke, and did not retract and clean the foreskin of an uncircumcised resident. Another instance involved staff cleaning from back to front rather than the required front to back method. These actions were contrary to the facility's perineal care policy, which specifies the use of the one wipe, one swipe technique and proper cleaning of the foreskin for uncircumcised males. The residents involved had significant medical histories, including severe cognitive impairment, hypertension, lack of coordination, diabetes mellitus, generalized edema, and peripheral vascular disease. Despite recent in-service training and documented competencies indicating that staff had met pericare skills, the observed failures in technique placed residents at risk for infection. Interviews with the DON confirmed that the observed practices did not align with facility policy and could have led to infection, particularly due to improper cleaning of the foreskin and incorrect wiping technique.
Deficiency in Resident Rights Due to Unsanitary Conditions
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents, leading to a deficiency in resident rights. Resident #8's bathroom was found to be unsafe and unsanitary, with a sink that was unsteady and appeared to be pulling away from the wall, and a toilet that was unsteady at its base. The bathroom floor was covered in a yellow substance with dirt and fuzz, and a dead roach was observed under the sink. Resident #8 expressed concerns about the safety of the bathroom fixtures, fearing potential injury due to their instability. Both Resident #8 and Resident #10 reported issues with roaches in their rooms and bathrooms. Resident #10 described seeing large roaches in her room and bathroom, which caused her distress due to her upbringing associating roaches with uncleanliness. Resident #8 also reported seeing cockroaches in his bathroom, particularly at night, which added to his discomfort and dissatisfaction with the living conditions. The facility's pest control service log indicated that the facility had been serviced for roaches, spiders, and beetles, but the presence of roaches persisted, as reported by the residents. The administrator was unaware of the specific issues with Resident #8's bathroom fixtures and acknowledged the need for a more secure mounting solution for the sink. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, which includes maintaining a clean and safe environment.
Unsafe Environment Due to Staff Pet in LTC Facility
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by the Director of Nursing (DON) bringing a dog to the facility, which resulted in incidents involving two residents. The dog bit one resident on the ankle and exhibited aggressive behavior towards another resident. These incidents were not reported immediately, and the facility lacked a clear policy regarding staff bringing pets to work, contributing to the deficiency. Resident #7, a female with a history of major depressive disorder, chronic obstructive pulmonary disease, and dysphagia, was bitten on the ankle by the DON's dog. The bite broke the skin, but the resident did not report the incident to avoid causing trouble. Resident #8, a male with a history of acute upper respiratory infection, spinal cord injury, and heart failure, experienced aggressive behavior from the dog while sitting on his scooter. He was not afraid of dogs but was concerned about the safety of other residents. Interviews with staff and residents revealed that the dog had been brought to the facility multiple times and had interacted with residents and staff, sometimes aggressively. The facility's existing dog policy did not adequately address situations involving staff pets, and there was no signed agreement from the DON regarding the facility's dog policy. The lack of a comprehensive policy and failure to report incidents contributed to the unsafe environment.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a Certified Nursing Assistant (CNA), identified as CNA D. The incident occurred on July 4, 2024, when CNA D was witnessed by a Registered Nurse (RN C) yelling, screaming, and slamming the door in the presence of the residents. Despite the allegations, the Director of Nursing (DON) did not report the incident to the Health and Human Services Commission (HHSC) Regulatory because the residents denied the abuse when interviewed by the DON. However, the residents later expressed nervousness and confirmed that CNA D yelled at them, indicating a failure in the facility's abuse prevention measures. The residents involved were both females with significant medical conditions. Resident #4, a female with ataxic cerebral palsy, anxiety disorder, and dysphagia, had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. Resident #5, also a female, had cerebral palsy and Parkinsonism, with a BIMS score reflecting moderate cognitive impairment as well. During interviews, both residents expressed fear and nervousness about being yelled at by CNA D, although they initially denied the allegations to the DON. The facility's response to the incident was inadequate, as the DON did not document interviews with the residents or witnesses, nor was an investigation conducted. The facility's policies on abuse prevention and reporting were not followed, as the incident was not reported to the state agency, and the accused CNA was not removed from duty pending an investigation. The lack of documentation and failure to conduct a thorough investigation highlight significant lapses in the facility's handling of abuse allegations.
Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to report alleged abuse incidents involving two residents to the appropriate authorities within the required timeframe. Specifically, an incident of verbal abuse was witnessed by an RN, who reported that a CNA yelled at and slammed the door on two residents. Despite the RN's immediate report to the Director of Nursing (DON) and the Administrator, the incident was not reported to the Health and Human Services Commission State Survey Agency or other officials as required by state law. The residents involved were both females with significant medical conditions, including cerebral palsy and cognitive impairments, as indicated by their BIMS scores. The DON conducted interviews with the residents, who denied the allegations, and with the CNA, who also denied the incident. However, the DON did not document the incident, conduct a thorough investigation, or interview the RN who reported the abuse. The CNA continued to work on the floor without suspension, contrary to the facility's policy. The facility's policies on abuse prevention and reporting were not followed, as the incident was not thoroughly investigated or reported to state agencies. The facility's policy requires immediate reporting of suspected abuse to the Administrator or DON, and the suspension of the accused employee until the investigation is complete. These procedures were not adhered to, resulting in a deficiency in handling the abuse allegation.
Failure to Investigate Allegations of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents, Resident #4 and Resident #5, by a Certified Nursing Assistant (CNA D) on July 4, 2024. The incident was witnessed by a Registered Nurse (RN C), who reported that CNA D entered the residents' room, yelled at them in a loud and irritated tone, and slammed the door. Despite RN C's immediate report to the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), no comprehensive investigation was conducted, and CNA D continued to work on the floor. Resident #4, a female with moderate cognitive impairment and multiple diagnoses including ataxic cerebral palsy and anxiety disorder, and Resident #5, a female with cerebral palsy and Parkinsonism, were both interviewed by the DON following the incident. Both residents denied the allegations of verbal abuse. The DON reported the incident to the Administrator but did not document the incident or conduct further interviews with RN C or other potential witnesses, as required by the facility's abuse investigation policy. The facility's policies on preventing resident abuse and conducting abuse investigations were not followed. The policy mandates that all reports of abuse be promptly and thoroughly investigated, including interviewing the person reporting the incident, witnesses, and other staff members. Additionally, the accused employee should be suspended pending the investigation's outcome. However, these procedures were not adhered to, as evidenced by the lack of documentation and the failure to remove CNA D from duty during the investigation.
Failure in IV Antibiotic Administration and Central Line Care
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids and antibiotics for a resident, leading to a deficiency in care. The resident, a female with a history of methicillin-resistant Staphylococcus aureus infection and recent knee surgery, was receiving IV antibiotics through a central line. The facility did not adhere to professional standards and physician orders, as evidenced by the failure to mix the antibiotic medication properly before administration. The Licensed Vocational Nurse (LVN) responsible for administering the medication did not activate the vial containing the antibiotic powder, resulting in the resident not receiving the prescribed dose. Additionally, the facility did not change the resident's central line dressing as ordered by the physician. The dressing was observed to be loose and not sealed, which compromised the sterile environment necessary to prevent infection. The Director of Nursing (DON) acknowledged that the dressing should have been changed every seven days or as needed, but it had not been changed since a specific date. This oversight was attributed to a lack of communication and verification among the nursing staff, as one nurse assumed another had completed the task. Furthermore, the facility failed to draw the required laboratory tests weekly as ordered by the physician while the resident was on IV antibiotics. The lack of lab work monitoring could have impacted the resident's treatment and recovery. The DON admitted that the facility had not performed the necessary lab draws and was unaware of the oversight until contacted by the infectious disease physician's office. This deficiency in care placed the resident at risk of infection relapse and potential complications from untreated conditions.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who were reviewed for medication errors. Resident #7 did not receive her IV antibiotics as ordered by the physician on multiple occasions. The medication, meropenem, was not properly mixed before administration, resulting in the resident not receiving the antibiotic doses as prescribed. This failure was attributed to a misunderstanding by the nursing staff, who believed the medication was pre-mixed, and a lack of proper labeling and monitoring of the IV administration process. Additionally, the central line dressing for Resident #7 was not maintained properly, which could have increased the risk of infection. Resident #51 also experienced medication errors, with multiple instances of missed Insulin Glargine doses by various nursing staff members over a two-month period. These omissions were not in accordance with the physician's orders and placed the resident at risk of diabetic complications. The report highlights the lack of adherence to medication administration protocols and the failure to ensure that treatments were performed and documented accurately. The deficiencies in medication administration and documentation were observed through interviews and record reviews, revealing a pattern of non-compliance with established protocols. The facility's staff, including the DON and various LVNs, acknowledged the errors and provided explanations for the lapses, such as being busy or assuming tasks were completed by others. However, these explanations did not mitigate the fact that the residents were placed at risk due to the facility's failure to administer medications as ordered and maintain proper documentation and monitoring practices.
Deficiencies in Care Planning and Medication Administration
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, which led to deficiencies in meeting their medical, nursing, and psychosocial needs. For Resident #2, the facility did not incorporate PASRR services into the care plan, despite the resident being PASRR positive. Resident #28's care plan lacked specific goals related to activities of daily living (ADL) functions, which are crucial for ensuring appropriate care and support. These omissions indicate a lack of thoroughness in the care planning process, potentially affecting the quality of care provided to these residents. Resident #51 experienced multiple instances where insulin glargine was not administered as per physician orders. Several licensed vocational nurses (LVNs) and a registered nurse (RN) failed to administer the insulin on numerous occasions over a two-month period. The nurses did not contact the physician to discuss holding or adjusting the insulin dosage, which is a critical step in ensuring proper diabetes management. This lack of communication and adherence to physician orders could have significant implications for the resident's health, particularly in managing blood glucose levels. Additionally, the facility failed to ensure that central line dressings for Resident #7 were changed as documented. LVNs B and C signed off on dressing changes that were not performed, citing distractions and assumptions that another nurse had completed the task. This oversight in documentation and execution of care tasks highlights a breakdown in the facility's processes for ensuring accurate and timely care. The failure to perform these essential tasks could lead to increased risk of infection and other complications for the resident.
Failure to Change and Date Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in changing and dating the oxygen tubing weekly as required. Resident #70, a female with chronic respiratory failure and other health issues, was observed to have nebulizer tubing dated 05/06/2024, indicating it had not been changed in accordance with the order to replace it every Sunday. This oversight was confirmed during an observation with the Director of Nursing (DON), who acknowledged that the tubing should have been changed and that the staff should not have dated the tubing per policy. The DON admitted to not knowing who was responsible for monitoring the tubing changes and mentioned that the interdisciplinary team should have been making rounds to ensure compliance. The lack of a clear policy on dating the tubing and the failure to follow the electronic medication administration record (EMAR) contributed to the deficiency. The facility did not provide evidence of a policy requiring the dating of respiratory tubing when changed, which could potentially place residents at risk of respiratory infections.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted as required for several residents. Specifically, two residents were not seen by a physician every 30 days during the first 90 days after admission, and four residents were not seen every 60 days thereafter. This lack of compliance with physician visit schedules was identified through interviews and record reviews, which revealed missing documentation for specific months when the visits should have occurred. Resident #2, a male with multiple diagnoses including hypertension, type 2 diabetes, and paranoid schizophrenia, was not seen by a physician in April 2024, despite the requirement for monthly visits during the initial 90 days post-admission. Similarly, Resident #73, diagnosed with Alzheimer's disease and acute kidney failure, missed physician visits in March, April, and May 2024. Other residents, such as Resident #25, #46, #51, and #56, also had gaps in their required 60-day physician visits, with missing documentation for various months in 2023 and 2024. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) revealed that the facility was aware of the issue with timely physician visits. The DON acknowledged the responsibility for monitoring these visits and noted that the failure was due to physicians not visiting residents as required. The ADMN also recognized the problem and stated that the DON was working on improving the tracking system for physician visits. The facility's policy mandates physician visits every 30 days for the first 90 days and every 60 days thereafter, which was not adhered to in these cases.
Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by a review of timesheets and interviews with residents and staff. On three specific days, the facility did not meet the required direct care staff hours as per their PPD budget, with significant shortfalls noted. Interviews with residents revealed concerns about long wait times for care, such as waiting an hour to be changed, insufficient showers, and fears of inadequate response in case of falls. Staff interviews indicated a reluctance to discuss staffing issues due to fear of retaliation, and some staff expressed relief at the presence of state surveyors, hoping it would lead to better staffing. The Director of Nursing (DON) and Administrator (ADMN) acknowledged the staffing issues, attributing them to unexpected staff resignations, call-ins, and no-shows. The DON outlined expectations for staffing levels, which were not met, leading to potential risks such as increased falls and delayed care. The facility's policy stated that adequate staffing should be maintained to meet residents' needs, but this was not achieved, as confirmed by the facility's own records and staff admissions.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications in locked compartments and maintain them in their original containers, as observed during a survey. Specifically, three medication carts were found with unlabeled pill cups containing various medications, including narcotics, outside of their original blister pack containers. These medications were not stored behind two locks as required, posing a risk of drug diversion. RN K was observed with seven unlabeled pill cups on top of medication cart #1, and three unlabeled pill cups containing narcotics inside an unlocked drawer. Similarly, RN J's medication cart #2 had unnamed pill cups with crushed medications, and cart #3 had an unlabeled pill cup with medication outside its original container. Interviews with staff revealed that RN J was pre-filling pill cups due to being busy and covering multiple halls, which could lead to administering the wrong medication to residents. The Director of Nursing (DON) acknowledged that pre-popping medications was against facility policy and could have detrimental effects on residents. The DON and Administrator emphasized the importance of following policies and proper medication disposal if refused by residents. The facility's policy from 2007 mandates that drugs and biologicals be stored in their original packaging and in a secure manner, which was not adhered to in this instance.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident during wound care, as observed by surveyors. The incident involved a resident with a stage 4 pressure wound who was receiving treatment without the privacy curtain being pulled, despite the door being closed. This oversight was acknowledged by the LVN performing the care, who admitted that the curtain should have been closed to prevent exposure if someone entered the room. The resident expressed a preference for the curtain to be pulled to avoid embarrassment. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the privacy curtain should have been used to ensure the resident's dignity and privacy. Both the DON and ADON emphasized the importance of privacy during care and acknowledged that the failure to pull the curtain could lead to embarrassment for the resident. The facility's policy on dignity and respect, which mandates the protection of resident privacy during personal care, was not adhered to in this instance.
Privacy Breach During Resident Care
Penalty
Summary
The facility failed to protect the privacy and dignity of a resident during personal care activities. Specifically, staff did not pull the privacy curtain while performing peri-care and transferring the resident from bed to chair using a Hoyer Lift. This oversight was observed during a specific incident where another CNA entered the room without the curtain being drawn, compromising the resident's privacy. The resident involved was a cognitively intact male with a history of hypertension, lack of coordination, and incontinence. The facility's policy mandates that residents be treated with dignity and respect, including maintaining bodily privacy during personal care. Interviews with the ADON and DON confirmed that the failure to pull the privacy curtain was a breach of expected standards, potentially leading to embarrassment for the resident.
Failure to Lock Hoyer Lift During Resident Transfer
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents. Specifically, during a transfer of a resident using a Hoyer lift, the CNA and NA did not lock the lift's legs in the maximum opened/locked position as required. This oversight occurred while transferring a cognitively intact male resident with a BIMS score of 15, who was dependent on staff for all efforts in activities such as chair/bed-to-chair transfers. The resident's diagnoses included hypertension, lack of coordination, and incontinence. During an observation, it was noted that the CNA did not lock the Hoyer lift during the transfer, and in an interview, the CNA admitted to not having locked the lift previously. The ADON confirmed that all nursing staff were trained on the use of the Hoyer lift and that the brakes should have been applied to prevent potential falls. The ADON also mentioned that the failure occurred because the CNA did not take the time to calm herself while being observed. The facility's records showed that the CNA had received training on the equipment, including the requirement to lock the wheels, but this was not adhered to during the incident.
Inadequate Infection Control During Peri-Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper peri-care and hand hygiene practices observed among two staff members, CNA L and an NA, during the care of Resident #28. The resident, a cognitively intact male with diagnoses including hypertension, lack of coordination, and diarrhea, was always incontinent. During an observation, the staff members did not perform hand hygiene or change gloves between dirty and clean tasks while providing peri-care, which is a violation of the facility's infection control protocols. Interviews with the staff revealed that CNA L was aware of the lapse in protocol but cited nervousness and lack of supplies as reasons for the oversight. The DON and ADON acknowledged the failure in ensuring staff adherence to infection control protocols, attributing it to inadequate in-service training and monitoring. The facility's policy on standard precautions mandates frequent hand washing and glove changes to prevent contamination, which was not followed in this instance, placing residents at risk of infection.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications in locked compartments and to keep each resident's drugs in their original containers/packaging. During an observation, the Hall 3 medication cart was found to have seven loose pills in the second drawer, identified as Lisinopril, Midodrine, Furosemide, Keppra, Zoloft, and Buspirone. LVN B acknowledged the presence of loose pills and stated that staff sometimes get in a hurry, accidentally drop pills, and forget to dispose of them. LVN B also mentioned that all staff were responsible for ensuring their medication carts were clean, organized, and free from any loose pills. Similarly, the Hall 5 medication cart was observed to have three loose pills, identified as Atorvastatin, a Multi-vitamin, and Protonic. The ADON confirmed that there should not be loose pills in the medication carts and stated that every night shift was responsible for cleaning the medication carts, with every shift nurse also expected to clean the carts themselves. The ADON and DON both stated that they randomly checked medication carts at least once per week. The DON emphasized that the night shift was to check medication carts once per week and that staff should be aware and check each shift. The facility's policy on medication storage, dated April 2007, requires that all drugs and biologicals be stored in a safe, secure, and orderly manner in their original packaging or containers.
Failure to Respect Resident's Right to Smoke
Penalty
Summary
The facility failed to treat a resident with respect, dignity, and care in a manner that promotes the maintenance or enhancement of his quality of life. Specifically, the facility did not allow Resident #1 to smoke as per his request and smoking assessment. Resident #1, a male with severe cognitive impairment and a history of elopement attempts, had his smoking privileges revoked indefinitely after an elopement incident. The decision to revoke smoking privileges was made without attempting other measures to ensure his safety while allowing him to smoke, such as one-on-one supervision or allowing him to smoke in a secure courtyard. Interviews with staff and the resident's family member revealed that the facility's decision to revoke smoking privileges was intended for the resident's safety but was perceived as punitive. The family member expressed that smoking was the only activity the resident still enjoyed and that he could smoke safely. The Director of Nursing acknowledged that the care plan appeared punitive and admitted that no other measures were attempted to balance the resident's safety and his right to smoke. The facility's policy on resident rights emphasizes treating residents with respect, kindness, and dignity, which was not upheld in this case.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident that included measurable objectives and person-centered interventions specific to smoking safety and elopement. The resident, a male with severe cognitive impairment and multiple diagnoses including nicotine dependence and major depressive disorder, had a history of elopement attempts. Despite these incidents, the care plan did not include individualized and measurable goals to address these behaviors effectively. The resident's care plan was found to be lacking in person-centered approaches and measurable objectives. For instance, after an elopement incident, the care plan included general actions such as moving the resident to a different room and conducting window audits, but it did not provide specific, individualized interventions. Additionally, the care plan failed to address the resident's smoking needs adequately, as it only mentioned the revocation of smoking privileges without considering alternative solutions like nicotine patches. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) revealed that the care plans were not person-centered and lacked measurable objectives. The DON acknowledged that the care plan should have included different approaches and not just the suspension of smoking privileges. The ADMN also stated that the care plans should have been person-centered and that the failure to do so could result in residents not having all their needs met. The oversight in creating a comprehensive, individualized care plan led to the deficiency in providing appropriate supervision and care for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Stephenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lone Star Rehabilitation & Wellness Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Stephenville Nursing And Rehabilitation | 1.2 mi | ★★★★★ | 6 | 0 |
| Deleon Nursing And Rehabilitation | 19.2 mi | ★★★★★ | 5 | 0 |
| Hico Nursing And Rehabilitation | 20.1 mi | ★★★★★ | 3 | 0 |
| Legacy Estate Long Term Care | 25.2 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.