Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Stonecreek Nursing & Rehabilitation during CMS and state inspections, most recent first.
Gas Stove Burner Did Not Light Properly: A gas stove in the kitchen had one burner that did not light properly when turned on. The cook said it had been that way since that morning, and the Mnt Supv had not yet checked it when notified. The Administrator later said the issue had been reported and a technician came for service and made repairs.
Pest Control Program Not Maintained in Kitchen: Rodent droppings were observed in the kitchen dry storage area on top of a condiment bin and on the floor near mouse bait. The DM said maintenance used bait as needed, while Maintenance stated pest control had not treated inside the kitchen for rodents and only treated outside the kitchen door. Record review showed monthly pest control service with no additional rodent treatment requested, and the Administrator acknowledged mice droppings in the pantry and that sanitation requirements, including pest control, were the DM's responsibility.
Unsafe Vape Use and Inadequate Smoking Assessment: A resident with severe cognitive impairment was observed in bed with an electronic vape device taped to his finger, despite a safe smoking assessment requiring direct supervision and storage of smoking materials at the nurse's station. Another resident had vape pens in his room without a documented smoking assessment before being identified as a smoker, and a cognitively intact resident was observed using a vape in her room even though the facility policy required supervised use in designated smoking areas only.
Medication labeling and storage were not maintained for an insulin pen in a nurse cart. An insulin pen for a resident with DM2 was found without an open date, even though pharmacy directions and facility policy required opened insulin to be dated and discarded within the applicable timeframe. Staff interviews confirmed the pen should have been labeled when opened, and the DON and Administrator stated staff were expected to place open or expiration dates on medications.
The facility's kitchen failed to meet food service safety standards, with multiple food items in the freezer found unlabeled, undated, and unsealed, and a dented can of tomato sauce not separated from non-dented cans. Staff interviews confirmed that food items should be checked, labeled, and stored properly upon delivery, as per the facility's Food Storage Policy. These lapses could lead to serving expired or contaminated food to residents.
The facility failed to maintain an effective infection prevention and control program, with lapses in hand hygiene and improper handling of medical equipment. A CNA did not sanitize her hands between handling meal trays and during incontinent care. A suction tip was left uncovered, posing an infection risk. Enhanced barrier precautions were not implemented for a resident with an indwelling medical device, as CNAs did not wear appropriate PPE. The ADON and Administrator acknowledged these oversights, which could increase infection risk.
The facility failed to develop comprehensive care plans for two residents regarding bed rail use. One resident with multiple health issues, including dementia, had all four bed rails up without a care plan or physician orders. Another resident with multiple sclerosis used a bed rail for assistance, but this was not documented in their care plan. Staff interviews revealed a lack of awareness and documentation, contrary to facility policy requiring comprehensive care plans.
The facility failed to assess and document the use of bed rails for two residents, leading to potential risks of entrapment and injury. One resident had full bed rails without an order or assessment, while another used a 1/2 rail without documentation. Staff were unaware of the need for assessments, and the facility's policy on side rails was not followed.
A resident was found with Caladryl lotion at their bedside, which was not ordered by a physician and was self-administered without facility approval. The resident was cognitively intact but not care planned to self-administer medications. Staff interviews revealed that the lotion was brought in by the family without notifying the facility, violating the policy that requires medications to be stored in locked compartments.
The facility failed to ensure that two nursing staff members, the ADON and an RN, maintained current licenses as required by state laws. The ADON's license expired for a period, and RN A's license expired without verification. The Administrator had previously been responsible for checking licenses but transferred this duty to the BOM without adequate training. The DON was aware of the ADON's expired license but did not report it. The facility's policy on license verification was not effectively implemented.
A CNA in a long-term care facility was reported to have purposefully tossed water onto a resident with severe cognitive impairment, as observed by witnesses. The incident was confirmed by the facility's investigation, revealing a failure to protect the resident from abuse, despite existing policies on resident dignity and abuse prevention.
Gas Stove Burner Did Not Light Properly
Penalty
Summary
The facility failed to maintain the gas stove in safe operating condition when one of four burners, the right front burner, did not light properly when the knob was turned. During an observation and interview on 03/30/26 at 9:40 AM, the stove was observed with four burners total, and the right front burner did not light. The cook stated the stove had been that way since that morning and had been working well on Friday. During interviews, the Maintenance Supervisor said he was made aware that the burner was not working properly that morning and had not yet looked at it. The Administrator later stated the burners not lighting properly had been reported to her the previous day, and that a technician came to the facility the next day for a service call and made repairs to the stove. Record review showed the facility policy titled Policy Regarding Gas Appliance in a Nursing Home Setting dated 11/13/22 addressed gas appliance safety and stated that if the pilot light does not light after multiple attempts, a professional technician must be called for assistance.
Pest Control Program Not Maintained in Kitchen
Penalty
Summary
An effective pest control program was not maintained in the kitchen dry storage area. During observation and interview, small rodent droppings were seen on top of a plastic bin containing condiments and below the bottom shelf on the floor there was a plastic container with mouse bait and small droppings. The Dietary Manager said maintenance treats the storage area with mouse bait as needed, and no mouse traps were noted by the surveyor or live rodents observed. The DM stated the area would be cleaned and identified the rodent droppings as a sanitation issue. Record review showed pest control was last on site for monthly service with no additional treatments requested by the facility, and invoices showed no treatment for rodents in the kitchen on the reviewed dates. Maintenance stated pest control had not treated inside the kitchen for rodents and only treated outside the kitchen door. He said he treats the kitchen with pellets when he is made aware that mice are visible, and the last treatment was about 2 weeks earlier when he was informed of a problem. The Administrator stated she was aware of mice droppings in the pantry and said her expectation was for the Dietary Manager to ensure sanitation requirements were followed, including pest control.
Unsafe Vape Use and Inadequate Smoking Assessment
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision related to electronic vape use for 3 of 15 residents reviewed. Resident #2, who had severe cognitive impairment with a BIMS score of 07, was dependent with transfers and most or all ADLs, and had a care plan identifying him as a smoker and vaper with a goal to smoke only in designated areas without injury. His safe smoking assessment noted limited upper extremity range of motion, finger dexterity problems, direct supervision while smoking, and that all smoking materials should be kept at the nurse's station. During observation, Resident #2 was found in bed with an electronic vape device secured to his right first finger with a hair tie and tape. He stated he used it that way because he had trouble holding things with his fingers and said he could use it in the room because it was not a cigarette and did not have cigarette smoke. A CNA stated staff charged his vape pen, removed it from his finger to recharge it, and then put it back on for him, and that they charged it in his room. Resident #16, who had COPD, type 2 diabetes, and bipolar disorder, had a BIMS score of 12 and required supervision or touching assistance for some ADLs. His care plan dated 3/30/26 identified him as a smoker and vape user, but there was no record of a smoking assessment prior to that date. He was observed in his room with 2 vape pens in his drawer and stated he smoked outside and did not require supervision to vape. Resident #17, who was cognitively intact with a BIMS score of 13 and required minimal assistance with most or all ADLs, had a care plan and safe smoking assessment indicating she was a safe smoker. She was observed sitting in her room with an electronic vape device on the table next to her recliner and stated she stayed in her room all the time and used the vape in her room.
Medication Not Dated After Opening
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in the nurse medication cart for Hall C/D. During observation on 3/31/2026 at 8:26 a.m., an insulin flex pen for Resident #38 was found in the cart with a prescription fill date of 3/25/2026, but there was no open date on the label or on the plastic bag. The report states that pharmacy directions required the medication to be discarded 28 days after the open date, and the facility policy required opened or accessed multi-dose vials to be dated and discarded within 28 days unless the manufacturer specified otherwise. Resident #38 was admitted with diagnoses including hypertension, type 2 diabetes, and iron deficiency anemia, and had an active order for insulin glargine 35 units subcutaneously at bedtime. Her MDS indicated she had no impairment in thinking and received insulin injections during the look-back period. In interview, LVN A stated insulin should be dated when opened and discarded 28 to 30 days later depending on the type, and said the pen should have been discarded if it did not have an open date. The DON and Administrator also stated staff should place an open date on medications when used and that staff should check carts for labeling and expiration dates.
Improper Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. During an inspection, it was found that multiple food items in the freezer were not labeled, dated, or sealed, including a 15-pound box of bacon, packages of chili, sweet potato fries, hashbrowns, curly fries, Italian breaded zucchini sticks, zucchini squash, yellow squash, and a box of cheese sticks. Additionally, a dented can of tomato sauce was not separated from non-dented cans in the pantry. These lapses in food storage practices were confirmed through interviews with various staff members, who acknowledged that food items should be checked, labeled, and stored properly upon delivery. The facility's Food Storage Policy and an in-service training document both emphasize the importance of labeling, dating, and properly storing food items to prevent foodborne illness and contamination. Despite these guidelines, the facility's practices did not align with the policy, as evidenced by the observations and staff interviews. The Administrator and other staff members recognized the risks associated with improper food storage, including the potential for serving expired or contaminated food to residents, which could lead to foodborne illnesses.
Infection Control Lapses in Hand Hygiene and Equipment Handling
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in hand hygiene and the improper handling of medical equipment. CNA A did not wash or sanitize her hands between handling meal trays for different residents, nor did she perform hand hygiene between glove changes during incontinent care for a resident. This oversight occurred despite the CNA having completed training on infection control and hand hygiene. The CNA admitted to forgetting to use hand sanitizer, which she had in her pocket, and acknowledged the potential risk of infection to residents due to these lapses. Additionally, the facility did not ensure that a Yaunker suction tip used for a resident was stored properly. The suction tip was left uncovered and unbagged on the bedside table, which could pose an infection risk. The staff, including an LVN and the ADON, acknowledged that the suction tip should not have been left open and that it should be replaced regularly to prevent infection. The facility also failed to implement enhanced barrier precautions for a resident with an indwelling medical device. CNAs providing care did not wear the appropriate PPE, and there was no indication outside the resident's room that enhanced barrier precautions were required. The ADON and Administrator admitted to misinterpreting guidelines regarding the need for enhanced barrier precautions for residents with indwelling medical devices, which could increase the risk of infection.
Failure to Develop Comprehensive Care Plans for Bed Rail Use
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents regarding the use of bed rails. Resident #16, who was admitted with diagnoses including diastolic congestive heart failure, dementia, breast cancer, and type 2 diabetes, did not have a care plan addressing the use of bed rails despite observations of all four rails being up while she was in bed. The resident's care plan did not include any assessments for bed rails, and there were no physician orders for their use. Observations confirmed the use of bed rails, which were not documented in the care plan, potentially affecting the resident's care and safety. Similarly, Resident #34, diagnosed with multiple sclerosis, also lacked a care plan for the use of bed rails, despite using them to assist with bed mobility. The resident's MDS assessment did not code the use of physical restraints for bed rails, and there were no physician orders for their use. Observations noted the presence of a half rail on the left side of the bed, which the resident used for assistance. The absence of a care plan for the bed rails could lead to inadequate care and safety measures for the resident. Interviews with staff, including a CNA, the DON, RN H, and the Administrator, revealed a lack of awareness and documentation regarding the use of bed rails in the care plans. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, which were not followed in these cases. The deficiency in care planning could result in residents not receiving the necessary care or services tailored to their needs.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to attempt appropriate alternatives before installing bed rails and did not assess two residents for the risk of entrapment from bed rails prior to their installation. Resident #16 had full bed rails on both sides of her bed without an order or assessment for their use. She was admitted with diagnoses including diastolic congestive heart failure, dementia, breast cancer, and type 2 diabetes. Observations showed that all four bed rails were up while she was in bed, which was not care planned or assessed, and staff were unaware of the need for an order or assessment. Resident #34 had a 1/2 rail on the left side of his bed without an order or assessment. He was admitted with a diagnosis of multiple sclerosis and had no cognitive impairment. He used the rail to assist with turning in bed, but there was no documentation or assessment for its use. The facility's staff, including CNAs and LVNs, were not aware of the need for assessments or orders for bed rails, and the DON admitted that assessments were not documented. Interviews with staff revealed a lack of awareness and documentation regarding the use of bed rails, with some staff believing that having all four rails up constituted a form of restraint. The facility's policy required assessments and documentation for the use of side rails as assistive devices, but these were not followed. The Maintenance Supervisor conducted quarterly checks on bed rails, but there was no evidence of assessments being completed for the residents involved.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as evidenced by the presence of Caladryl lotion at the bedside of a resident. The resident, who was cognitively intact with a BIMS score of 14, was not care planned to self-administer medications and did not have a physician's order for Caladryl lotion. Despite this, the lotion was observed on the resident's bedside table, and the resident admitted to self-applying it for a rash on his lower back. The lotion remained accessible in the room during multiple observations. Interviews with facility staff, including an LVN, ADON, DON, and the Administrator, revealed that the lotion was brought in by the resident's family without notifying the facility. Staff acknowledged that medications should not be left unattended in residents' rooms due to the risk of misuse by other residents, especially those with dementia. The facility's policy mandates that all medications be stored in locked compartments, accessible only to authorized personnel, which was not adhered to in this instance.
Failure to Maintain Current Nursing Licenses
Penalty
Summary
The facility failed to ensure that two of its licensed nursing staff, the Assistant Director of Nursing (ADON) and a Registered Nurse (RN A), maintained current nursing licenses in accordance with state laws. The ADON's license expired between specified dates, and RN A's license expired on a particular date without subsequent verification by the facility. These lapses were discovered during a review of personnel files and license verifications from the Texas Board of Nursing. Interviews revealed that the Administrator had been responsible for checking nursing licenses annually until August 2023, after which the responsibility was transferred to the Business Office Manager (BOM). However, the BOM was not adequately trained to include license verification in her checks, leading to the oversight. The DON was aware of the ADON's expired license but did not report it to the Administrator, while RN A was unaware of her license expiration until notified by the facility. The facility's policy required nursing personnel to present verification of their licenses upon employment and annually. However, the policy was not effectively implemented, as evidenced by the expired licenses. The Administrator acknowledged the oversight and the need for better training and systems to prevent future occurrences. The BOM and DON also recognized the potential risks to residents from being cared for by unlicensed nurses, although RN A did not perceive any risks.
Resident Abuse Incident Involving CNA
Penalty
Summary
The facility failed to ensure that residents were free from abuse, as evidenced by an incident involving a certified nursing assistant (CNA) and a resident. On the specified date, CNA A was reported to have purposefully tossed water onto a resident, who was sitting at a dining table in a locked unit. This resident had a history of severe cognitive impairment and physical behavioral symptoms directed toward others. Witnesses reported that CNA A walked by the resident and tossed water from a Styrofoam cup onto the blanket the resident was wrapped in, with some water splashing on her face. The incident was reported by Witness B, who observed CNA A's actions and informed the Director of Nursing (DON). The DON conducted a head-to-toe assessment of the resident and confirmed the incident with another witness, Witness C. The facility's investigation corroborated the accounts of the witnesses, confirming that CNA A had indeed tossed water on the resident. The resident's care plan was updated to reflect the risk to her psychosocial well-being related to the incident. The facility's policy on abuse and neglect clearly states that residents have the right to be free from abuse, including physical and mental abuse. Despite this policy, the incident occurred, indicating a lapse in adherence to the facility's standards for resident care and dignity. The report highlights the failure to protect the resident from abuse, which was identified as a deficiency by the surveyors.
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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 San Augustine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At San Augustine | 1.6 mi | ★★★★★ | 4 | 0 |
| Colonial Pines Healthcare Center | 1.7 mi | ★★★★★ | 9 | 0 |
| Avir At Center | 18.6 mi | ★★★★★ | 0 | 0 |
| Pine Grove Nursing Center | 18.6 mi | ★★★★★ | 3 | 0 |
| Focused Care Of Center | 19.2 mi | ★★★★★ | 3 | 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.