Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Stephenville Nursing And Rehabilitation during CMS and state inspections, most recent first.
Food items in the kitchen were found out of original containers without required dates or labels, including meat, egg rolls, zucchini, and breaded okra. The Vegetable Freezer and Meat Freezer also had no daily temp logs for several days, and the DM and ADMN stated dietary staff were responsible for labeling food and recording freezer temps.
Two CNAs failed to follow infection control and peri-care standards while providing care to two residents. One CNA did not perform hand hygiene before or after peri-care, used the same wipe multiple times, and did not follow a dirty-to-clean sequence. The other CNA used the same wipe multiple times, did not change gloves or sanitize hands before placing a new brief, and applied cream to the peri-area with contaminated gloves. Record review showed no skill competency checkoffs for either CNA.
Survey Results Not Posted for Resident and Visitor Review: The facility failed to make the most recent survey results and plan of correction readily accessible for resident, family, legal rep, and visitor review. Survey documents were found in a binder near the main entrance, but the Administrator could not explain why the required materials were not included in the binder, and the BOM only confirmed the binder was present without checking the dates on the survey results.
The facility's kitchen was found to be unsanitary, with food particles and grease on the floors beneath appliances and shelves. Despite cleaning logs indicating tasks were completed, the kitchen remained unclean. Interviews with staff highlighted an expectation to follow cleaning schedules and policies, but the failure to maintain cleanliness could risk foodborne illness.
A facility failed to develop a comprehensive care plan for a resident with an indwelling urinary catheter and on antidepressant medication. The care plan did not include necessary details such as catheter care, medication orders, and triggered care areas from the MDS assessment. Staffing issues, including the departure of the ADON and reliance on remote MDS assessments, contributed to this deficiency.
Two LVNs failed to adhere to Enhanced Barrier Precautions while providing care to a resident with a colostomy and pressure injury. Despite clear signage and available gowns, the LVNs did not wear gowns during high-contact activities, citing nervousness as the reason. The facility's policy required gown use to prevent the transmission of multidrug-resistant organisms, and the expectation was reinforced through training.
Food items not dated or labeled and freezer temperatures not recorded
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. During an observation on 9/23/2025 between 9:30 AM and 10:00 AM, surveyors found food items out of original containers that were not dated or labeled, including 3 packages of bologna and 1 package of ham in Freezer #1, 1 bag of egg rolls in Freezer #2 that was not sealed and did not have a date, and 3 bags of zucchini and 3 bags of breaded okra in the Vegetable Freezer that were not labeled with a date. The Vegetable Freezer and Meat Freezer temperature logs showed no temperature checks for 9/20/2025, 9/21/2025, 09/22/2025, and 09/23/2025. During interview, the DM stated all freezers were expected to be checked daily and temperatures logged daily, and that food items out of original containers should have been labeled with a received date, expiration date, and item description. The DM and ADMN stated dietary staff were responsible for labeling food and recording freezer temperatures daily, and the DM was responsible for monitoring staff. The ADMN stated residents could have been affected by poor food safety.
Infection Control Failures During Peri-Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 residents and 2 CNAs reviewed for infection control. During an observation, CNA A provided peri-care to Resident #13 without performing hand hygiene before or after care, used the same soiled wipe multiple times while cleaning the peri area, and did not follow a dirty-to-clean sequence. CNA A removed the resident’s brief, wiped the labia, right groin, and left groin with the same wipe, discarded the wipe, and then placed a clean brief on the resident before removing gloves and wheeling the resident out of the shower room without hand hygiene. During another observation, CNA B provided peri-care to Resident #25 and sanitized hands before donning gloves, but then used the same wipe multiple times to clean the peri area, stuffed the wipe between the resident’s legs in the brief, rolled the resident over without wiping the buttocks, and did not change gloves or sanitize hands before placing a new brief and applying cream to the peri-area with the same gloves. Record review showed no skill competency checkoffs for either CNA, although both had infection control training in February 2025. The ADON stated hands should have been washed before and after peri-care, gloves should have been changed, and hands sanitized before applying a clean brief and cream. The Administrator stated peri-care should be performed correctly, hands should always be washed before and after, and cleaning should always be worked from dirty to clean.
Survey Results Not Posted for Resident and Visitor Review
Penalty
Summary
The facility failed to post the most recent survey results of the facility, including the plan of correction, in a place readily accessible to residents, family members, legal representatives, and visitors. During observation and record review on 09/25/2025 at 9:45 AM, the last State survey results, plan of correction, and report of contact dated 04/14/2022 were found in a black 3-ring binder in a wall pocket located by the main entrance door. The report states that the required survey results were not posted in the binder as expected for public review. During interview on 09/25/2025, the Administrator stated the policy was for recent survey results to be made available for public review with signage indicating where to locate them, and she said her expectation was that the results would be in the binder. She stated she had asked the BOM to check the binder, but could not explain why the required survey results were not included. The BOM stated she only checked that the binder was in the wall pocket and did not open it to verify the dates on the survey results. Review of the facility policy titled Facility Required Postings, dated 01/01/2023, showed that the facility must post the most recent survey results of the facility.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain proper sanitation standards in the kitchen, as observed during a survey. Food particles and grease were found on the floors beneath appliances and stainless-steel shelf units throughout the kitchen, including the dry storage area. This was noted during an observation on July 29, 2024. The Dietary Manager acknowledged that the dietary staff is supposed to follow a daily cleaning schedule and initial a form upon completion of cleaning tasks. However, despite the cleaning logs indicating that all duties for the morning of July 29, 2024, had been completed and initialed, the kitchen remained unclean. Interviews with the Dietary Manager, Director of Nursing (DON), and the Administrator revealed an expectation for the dietary staff to adhere to the cleaning schedule and company policy. The facility's policy on sanitation, revised in January 2024, mandates that food service areas be kept clean and sanitary, with inspections conducted to ensure compliance with state and federal regulations. The U.S. Food and Drug Administration's 2017 Food Code was also referenced, emphasizing the need for food to be stored in clean, dry locations and for premises to be free of pests. Despite these guidelines, the facility's failure to maintain cleanliness in the kitchen could potentially place residents at risk for foodborne illness.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as Resident #20, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. The resident, who had an indwelling urinary catheter upon admission, did not have the indication for use, care, and monitoring of input and output included in the care plan. Additionally, the care plan did not address the resident's admission order for the antidepressant medication Cymbalta, despite it being documented in the Medication Administration Record. The resident's Admission MDS Assessment triggered several care areas, including cognitive loss/dementia, communication, functional abilities for self-care and mobility, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer/injury, psychotropic drug use, and pain. However, the comprehensive care plan failed to address these triggered areas. The care plan also did not include the physician's orders for catheter care every shift and changing the catheter every 30 days, nor did it address the resident's depression diagnosis adequately. The deficiency was further compounded by staffing issues, as the Assistant Director of Nursing (ADON), who was responsible for completing MDS assessments and care plans, had left the facility, and the position had not been filled. The MDS Coordinator from a sister facility was completing assessments remotely, and the Director of Nursing (DON) was in the process of learning to complete comprehensive care plans. This lack of adequate staffing and training contributed to the failure to develop a comprehensive care plan for the resident.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of two Licensed Vocational Nurses (LVNs) who did not adhere to Enhanced Barrier Precautions (EBP) while providing care to a resident. The resident, a male with a colostomy and pressure injury, was on EBP due to his medical conditions. The facility had clear signage and available gowns outside the resident's room, indicating the need for gown and glove use during high-contact activities such as changing briefs and wound care. During an observation, the two LVNs were seen providing incontinent and wound care to the resident without donning gowns, despite having sanitized their hands and worn gloves. The failure to wear gowns was contrary to the instructions on the EBP signage posted in the resident's room. Both LVNs acknowledged their oversight, attributing it to nervousness due to the presence of a surveyor. Interviews with the Director of Nursing (DON) and the facility administrator confirmed that the expectation was for staff to follow the EBP guidelines, which had been reinforced through multiple in-service training sessions. The facility's policy on Enhanced Barrier Precautions required staff to comply with designated precautions to prevent the transmission of multidrug-resistant organisms, particularly during high-contact resident care activities.
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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 | 1.1 mi | ★★★★★ | 9 | 0 |
| Avir At Stephenville | 1.2 mi | ★★★★★ | 7 | 0 |
| Deleon Nursing And Rehabilitation | 18.6 mi | ★★★★★ | 5 | 0 |
| Hico Nursing And Rehabilitation | 19.2 mi | ★★★★★ | 3 | 0 |
| Legacy Estate Long Term Care | 24.4 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.