Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Lone Star Rehabilitation & Wellness Center during CMS and state inspections, most recent first.
A meal service deficiency occurred when boiled okra served at lunch measured 115 degrees and was described as not warm or palatable by surveyors. The DM stated it should have been warmer, and residents reported that food was served cold, lacked flavor, and that meat was tough and hard to eat. The grievance log also reflected prior complaints about late meals and cold food, while the facility policy required hot foods to be held above 135 degrees F and temperatures to be monitored during service.
Meals were not consistently served at posted times. During lunch observation, dietary staff had to repeatedly check cold items such as tuna salad and other salads and return them to the refrigerator to reach safe temperatures, which delayed plating and tray delivery. The DM, Dietician, and ADMN all stated meals were expected to be served on time, and the grievance log showed prior complaints about late and cold meals.
Missing Criminal History and EMR/NAR Checks for Employees: Record review and interviews showed the facility did not maintain required pre-employment and annual criminal history/EMR-NAR checks for 4 of 16 employees reviewed, including the SW, ADMN, and 2 CNAs. Payroll E stated she was responsible for the checks and had uploaded available files, while the ADMN stated the checks were expected prior to hire and annually and that she was ultimately responsible for ensuring they were completed.
A resident with aphasia, hemiplegia/hemiparesis, and dependence for bed mobility was observed in bed with his call light hanging on the wall behind the head of the bed rather than within reach. A CNA, the resident’s representative, the responsible LVN, and the DON all acknowledged he could not reach the call light in that position, despite facility guidance stating call lights should be within easy reach when a resident is in bed.
A facility failed to maintain an effective infection control program during incontinence care for a resident with diabetes and Alzheimer's. Two CNAs did not perform hand hygiene or change gloves after handling soiled materials, contrary to facility policy. Interviews revealed a lack of recent infection control training for one CNA and a basic understanding of cross-contamination by both. The DON acknowledged awareness of infection control concerns, emphasizing the importance of hand hygiene in preventing infections.
A resident with Alzheimer's, Hyperlipidemia, and Type II Diabetes did not receive a dessert or mixed vegetables as per their pureed diet menu. The dietician and dietary manager acknowledged the oversight, which was due to unprepared marinated vegetables and an unpureed dessert. The administrator confirmed the menu was not followed, potentially affecting the resident's nutritional intake.
The facility failed to serve meals at appropriate temperatures, with food items like BBQ burger patties and French fries not meeting required temperature standards. The dietary manager cited the use of Styrofoam containers and delays in tray washing as reasons for the temperature discrepancies, which could lead to poor food intake and potential weight loss among residents.
The facility failed to coordinate hospice care and maintain necessary documentation for residents receiving hospice services. This included missing hospice orders and care plans for several residents, leading to inadequate end-of-life care. Staff interviews revealed a lack of awareness and understanding of hospice procedures, with missing records needing to be faxed from the hospice provider.
A facility exceeded the acceptable medication error rate with two errors involving undiluted Potassium Chloride for a resident with hypokalemia and incorrect Ferrous Gluconate dosage for a resident with anemia. The errors were due to staff not following physician's orders, as confirmed by the DON.
The facility failed to secure a medication cart on the 200 hall, leaving it unlocked and unattended with various medications inside. This occurred while the responsible nurse was engaged in other tasks, and a visitor was observed nearby. The LVN later acknowledged the cart should have been locked, citing a mechanical issue with the locking button. The DON confirmed that medication carts are expected to be locked when not in use, as per facility policy.
Cold and Unpalatable Meal Served at Lunch
Penalty
Summary
The facility failed to ensure that food served at lunch was palatable, attractive, and at a safe and appetizing temperature. During an observation on 09/03/2025 at 12:37 PM, the DM obtained temperatures for the noon meal of jambalaya, boiled okra, and cornbread, and the boiled okra measured 115 degrees and was not warm or palatable when eaten by 3 surveyors. During an interview shortly after, the DM stated the boiled okra should have been warmer and declined tasting the meal. During a confidential meeting later that day, 6 residents voiced complaints that the food was served cold and had no flavor, and that the meat was tough and hard to eat. The grievance log also showed prior complaints that lunch and supper were served late and that food was cold when served. The facility policy stated that foods are to be held at appropriate temperatures, with hot foods greater than 135 degrees F, and that temperatures for TCS foods are to be recorded at the time of service and monitored periodically during meal service periods.
Meals Not Served at Posted Times
Penalty
Summary
Meals were not consistently served at the facility’s posted mealtimes. On 09/02/2025, survey observation showed the posted lunch schedule in the dining room, with lunch delivery beginning at 12:00 PM, but the first cart of trays was delivered to the assisted dining room at a later time and the kitchen staff did not begin plating lunch until 12:50 PM. The last hall tray was not served until 2:14 PM on Hall 3. During the lunch meal observation, dietary staff had to repeatedly check the temperature of tuna salad and other salads and place the salads back into the refrigerator to obtain safe serving temperatures. Interviews with the Dietician, DM, and ADMN confirmed that meals were expected to be served on time per posted schedules and that the DM and cook were responsible for ensuring timely meal service. The DM stated the delay occurred because the lunch meal consisted of cold entrees and salads that were difficult to keep at safe temperatures. The grievance log also showed prior complaints that lunch was served late and that meals were cold. The facility policy stated that at least three daily meals are to be provided at regular times comparable to normal mealtimes in the community and that each meal is to be served within the designated time frame unless there is an emergency situation or resident request.
Missing Criminal History and EMR/NAR Checks for Employees
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after record review and interviews showed the facility did not maintain required employability documentation for 4 of 16 employees reviewed. The SW's file showed a hire date of 03/28/2022 with no evidence that a criminal history check or EMR/NAR check was completed prior to hire, and no evidence that annual EMR/NAR checks were completed. The ADMN's file showed a hire date of 02/07/2023 with no evidence of an annual EMR/NAR check. The CNA C's file showed a hire date of 03/30/2023 with no evidence of an annual EMR/NAR check, and the CNA D's file showed a hire date of 11/11/2022 with no evidence of an annual EMR/NAR check. During interview, Payroll E stated she had only been in the position since March 2025 and was responsible for completing criminal history and EMR/NAR checks. She stated these checks were supposed to be completed prior to hire and annually, and that when she started she was told to upload employee files to electronic files and uploaded all documents she could find. The ADMN stated her expectation was that criminal history checks and EMR/NAR checks were to be run prior to hire and annually, that Payroll was responsible for completing them, and that she was ultimately responsible to ensure the checks were completed. The ADMN also stated residents could have been affected by being exposed to staff who should not have been hired. Facility policy titled Personnel Records dated 2/17/2023 stated criminal history checks were to be completed prior to hire and misconduct registry and nurse aide registry checks were to be completed prior to hire and annually.
Call Light Not Within Reach for Bedbound Resident
Penalty
Summary
The facility failed to accommodate Resident #6’s needs by not ensuring his call light was within reach while he was in bed. Resident #6 was a male resident admitted with aphasia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction, and cerebral infarction. His quarterly MDS showed he was rarely or never understood, BIMS could not be performed, he had impaired range of motion in one upper extremity and both lower extremities, and he was dependent on staff for bed mobility and bed-to-chair transfers. His care plan also documented recent falls with no injury. During observations on 09/02/2025 and 09/03/2025, Resident #6 was lying in bed with a fall mat beside the bed, and his call light was hanging on the wall behind and to the right of the head of his bed where the cable exited the wall. Staff observed that he could not reach it in that position. A CNA stated the call light was Resident #6’s and that he would not be able to reach it while it was hanging on the wall. The resident’s representative stated he was not able to get out of bed without help. The LVN responsible for the resident and the DON both stated that if the call light was hanging on the wall behind the bed, he would not be able to reach it, and that call lights were expected to be within reach when residents were in bed. The facility policy and fall-reduction guidance also stated that call lights should be within easy reach or within reach when a resident is in bed.
Infection Control Deficiency in Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during incontinence care for a resident. The resident, a 78-year-old female with diabetes mellitus and Alzheimer's disease, required dependent assistance with most activities of daily living and was always incontinent of bladder and bowel. During the care, both CNAs did not perform hand hygiene before starting the care, and they failed to change gloves after handling soiled materials. CNA A continued to use visibly soiled gloves to clean the resident and did not wash her hands or change gloves before retrieving and placing a clean brief on the resident. Similarly, CNA B did not change gloves or wash hands after repositioning the resident and before fastening the clean brief. Both CNAs exited the resident's room without performing hand hygiene. Interviews with the CNAs revealed a lack of recent infection control training for CNA A, who had just returned to work at the facility, and a basic understanding of cross-contamination by both CNAs. The Director of Nursing acknowledged awareness of infection control concerns and stated that staff were expected to wash hands before providing care and change gloves appropriately. The facility's policy on hand hygiene emphasized its importance in preventing the spread of infections, requiring all personnel to be trained and regularly in-serviced on hand hygiene procedures. However, the observed practices during the care of the resident did not align with these policies, placing residents at risk for the spread of infection.
Failure to Follow Prescribed Menu for Resident's Meal
Penalty
Summary
The facility failed to adhere to the prescribed menu for a lunch meal, which was observed during a survey. Specifically, a resident on a pureed diet did not receive a dessert or mixed vegetables as per the menu. The resident, a female with Alzheimer's Disease, Hyperlipidemia, and Type II Diabetes Mellitus, was affected by this oversight. The dietician confirmed that the menu should have been followed unless a documented substitution was made, which was not the case. The dietician emphasized the importance of following the menu to ensure proper nutrition and resident rights. The dietary manager admitted that the marinated vegetables were not prepared, and the dessert was not pureed due to being occupied with other tasks. The dietary manager acknowledged that this failure could lead to weight loss in residents. The administrator also confirmed that the menu was not followed due to an oversight by the dietary aide, which could result in decreased nutritional intake for the resident. The facility's policy mandates that meals be assembled according to individualized diet orders and that menus be served as written unless a substitution is necessary.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that residents received food that was palatable, attractive, and at a safe and appetizing temperature during a lunch meal. On the observed date, the temperatures of the food items served were not within the required range. The BBQ burger patty was served at 100.5 degrees Fahrenheit, which is below the required 165 degrees. The coleslaw was at 54.6 degrees, above the required 41 degrees or lower. French fries were served at 94.1 degrees, below the required 135 degrees or higher, and the salad components were at 70.1 degrees, above the required 41 degrees or lower. These temperature discrepancies were noted during an observation and confirmed by the dietary manager (DM) and dietician. The DM attributed the failure to maintain appropriate food temperatures to the use of Styrofoam containers and delays caused by hand washing and drying trays before meal distribution. The DM acknowledged that these issues could lead to poor food intake and potential weight loss among residents. The facility's policy on meal distribution, dated 2017, requires that all food items be transported promptly to maintain appropriate temperatures. The administrator (ADMN) confirmed that all but one resident eats meals from the kitchen and expressed expectations that food should be served at a palatable temperature.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was identified for three residents who were reviewed for hospice services. The facility did not maintain the required hospice forms and documentation, including the hospice plan of care and certificate of terminal illness, which are essential to ensure adequate end-of-life care. Additionally, there were no physicians' orders for hospice care for these residents, which could lead to inadequate care due to a lack of documentation, coordination, and communication. For Resident #80, the facility's records showed no evidence of an order for hospice services or the required hospice documentation. Despite being on hospice services, the staff, including LVN B, were unaware of the resident's hospice status due to the absence of orders. Similarly, Resident #63's records lacked updated hospice care plans, and there was no evidence of a hospice order. Resident #46 also had no hospice orders or required documentation in their records, indicating a systemic issue in maintaining hospice care records. Interviews with facility staff, including the DON and ADON, revealed a lack of awareness and understanding of the necessary hospice documentation and procedures. The DON admitted that hospice residents should have orders in the computer and a binder on-site, but she was unsure of the required documents. The ADON confirmed that the hospice records were missing from the facility and had to be faxed from the hospice provider. This lack of documentation and coordination highlights the facility's failure to ensure proper hospice care for its residents.
Medication Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 5.88% due to two errors out of 34 opportunities. The first error involved a resident with a diagnosis of hypokalemia who was supposed to receive Potassium Chloride Solution diluted with 4-6 oz of water via G-tube. However, the LVN administered the medication without diluting it, contrary to the physician's orders. The LVN admitted to not fully reading the physician's order, which led to the error. The second error involved another resident with anemia who was prescribed Ferrous Gluconate 324 mg to be taken twice daily. Instead, the MA administered a 240 mg tablet, which was not the correct dosage as per the physician's orders. The MA did not recognize the dosage error at the time of administration. The DON later confirmed that the wrong dosage had been given and that the physician was notified. Both errors were identified during observations and interviews with the facility staff. The DON stated that staff are expected to follow physician's orders and should notify her or the ADON if there are any discrepancies or unavailability of the correct medication dosage. The facility's policy on administering medication emphasizes the importance of following physician's orders and verifying the correct medication, dosage, and administration method.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During an observation, it was noted that the medication cart on the 200 hall was left unlocked and unattended, with no staff present or within eyesight. This cart contained various medications, including albuterol inhaler, insulin pens, and other prescription drugs. A visitor was observed walking down the hall near the unlocked cart, while the nurse responsible was engaged in other tasks, such as checking meal tickets and assisting with lunch trays. In a subsequent observation, the same medication cart was again found unlocked and unattended while the responsible LVN was in a resident's room with the door closed. The LVN later stated that the cart should have been locked and attributed the failure to a button on the cart that needed to be pushed hard to lock it. The Director of Nursing (DON) confirmed that medication carts are expected to be locked when not in use and that nurses had been trained on this procedure. The facility's policy on medication storage, dated April 2007, mandates that all compartments containing drugs and biologicals must be locked when not in use.
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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) |
|---|---|---|---|---|
| Avir At Stephenville | 0.7 mi | ★★★★★ | 7 | 0 |
| Stephenville Nursing And Rehabilitation | 1.1 mi | ★★★★★ | 6 | 0 |
| Hico Nursing And Rehabilitation | 19.5 mi | ★★★★★ | 3 | 0 |
| Deleon Nursing And Rehabilitation | 19.6 mi | ★★★★★ | 5 | 0 |
| Legacy Estate Long Term Care | 25.5 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.