Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lone Star Ranch Rehabilitaion And Healthcare Cente during CMS and state inspections, most recent first.
A resident with a history of aggressive behavior and severe cognitive impairment physically struck another cognitively impaired resident in the memory care unit. Despite prior incidents and interventions such as one-to-one monitoring and behavioral health referrals, the aggressive resident continued to have outbursts, and staff were unable to prevent further abuse. The facility's inability to protect residents from repeated aggression resulted in a deficiency related to resident rights and abuse prevention.
A main treatment cart assigned to an RN was found unlocked and unattended in a hallway, with residents present in the area. The cart contained treatment supplies and medications, including scissors, needles, and liquids, and could be fully accessed due to the disengaged lock. The RN responsible was not available for interview, and both the DON and Administrator confirmed that facility policy requires carts to be locked when not in use.
Two residents with severe cognitive impairment were involved in a verbal and physical altercation, but nursing staff failed to document the incident and subsequent injury assessments in a timely manner. Documentation was delayed or omitted in the medical records, contrary to facility policy requiring prompt and complete entries after such events.
Surveyors identified multiple failures in food service sanitation and storage, including unclean equipment such as the ice machine and juice gun, improperly sealed and unlabeled food items, and the presence of personal items in food storage areas. Staff interviews and record reviews revealed inconsistent cleaning, incomplete temperature and chemical logs, and a lack of adherence to facility policies for food safety and sanitation.
A medication error rate above 5% was identified when an LVN failed to administer the correct dose of folic acid to a resident with anemia and withheld hydrochlorothiazide from another resident with hypertension and edema, despite clear physician orders. These errors were observed during medication passes and confirmed by facility staff interviews.
Surveyors observed that two opened multidose insulin vials for two residents with Type 2 Diabetes Mellitus were stored in a nurse cart without the required opened-on date, contrary to facility policy and professional standards. Nursing staff confirmed the absence of the opened-on date and acknowledged the expectation to document it on the vials.
Two residents with severe cognitive impairment were subjected to physical abuse by another resident with a known history of aggression and behavioral issues. The aggressor slapped one resident in the face and another on the arm during separate incidents, despite documented risks and care plans noting the potential for physical aggression. Staff were aware of the behavioral risks, but the facility did not prevent these incidents, resulting in a failure to protect residents from abuse.
A medication cart was left unlocked and unattended by an RN, contrary to facility policy, which requires carts to be locked when not in use or out of sight. The incident involved Medication cart #1, which was left outside a resident's room, potentially allowing access to non-narcotic medications. Interviews with the DON and Administrator confirmed the policy breach, emphasizing the importance of securing medication carts to prevent unauthorized access.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed unsealed, unlabeled, and undated dry goods, crusted steam table wells, personal items in prep areas, and lack of temperature logs. Interviews with staff indicated a lack of awareness and adherence to food safety protocols, leading to potential risks of foodborne illnesses for residents.
The facility failed to date the oxygen tubing for three residents as per physician's orders, despite observations and interviews confirming that the tubing was changed weekly. This oversight could lead to uncertainty about when the tubing was last replaced.
The facility failed to provide separately locked and permanently affixed compartments for Schedule II-V medications in two medication rooms. Observations revealed that emergency use narcotic boxes in both B and C wings were not permanently affixed and could be easily removed. Interviews with the ADON and DON confirmed that the practice had been ongoing for years without correction.
The facility failed to maintain an effective infection control program, as staff did not follow proper hand hygiene and glove-changing protocols during peri care for two residents with severe cognitive impairments. Staff admitted to not following procedures and could not recall recent training on infection control.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of behavioral symptoms was physically struck twice on the right arm by another resident, who also had severe cognitive impairment and a documented history of aggression toward others. The incident took place in the memory care unit, where both residents resided. The staff member on duty, an LVN, heard yelling and witnessed the physical contact, after which the residents were separated and assessed for injuries. No injuries, redness, or swelling were noted, and neither resident was able to recall the incident during subsequent interviews. The resident who initiated the physical contact had a documented pattern of aggressive behavior, including multiple prior altercations with other residents. His care plan reflected these behaviors, with interventions such as one-to-one monitoring and behavioral health referrals following previous incidents. Despite these interventions, the resident continued to exhibit aggressive outbursts, and staff were unable to identify consistent triggers for his behavior. The facility had attempted to find alternative placements for this resident due to his ongoing aggression, but these efforts were unsuccessful as other facilities declined to accept him. The facility's abuse prohibition policy states that each resident has the right to be free from abuse, mistreatment, and neglect. However, the repeated incidents of aggression by one resident toward others, culminating in the observed physical abuse, demonstrate a failure to protect residents from abuse as required. The actions and inactions leading to the deficiency include the inability to prevent further aggressive incidents despite known behavioral risks and prior occurrences, as well as the lack of effective interventions to ensure the safety of all residents in the memory care unit.
Unattended Unlocked Treatment Cart with Medications and Supplies
Penalty
Summary
A deficiency occurred when a main treatment cart, assigned to an RN, was observed unlocked and unattended in a hallway. The RN was in a resident's room at the time, and there were residents ambulating in the area. The cart's lock was disengaged, allowing all drawers to be opened and accessed. The cart contained various treatment supplies and medications, including scissors, needles, multiple containers of liquids, and a medication cup filled with a thick, white substance with a wooden spoon. No staff were present to supervise the cart during this time. Attempts to interview the responsible RN were unsuccessful, as she left work early and did not respond to follow-up calls or texts. The DON confirmed that the RN was responsible for the cart and acknowledged that facility policy requires all treatment and medication carts to be locked when not in use. The Administrator also confirmed that nurses are responsible for securing their carts to prevent resident access to medications and supplies.
Failure to Timely Document Resident Altercation and Injury Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two residents involved in a verbal and physical altercation. Specifically, LVN A did not document the altercation in a timely manner in either resident's progress notes, and both LVN B and RN C failed to document injury assessments for one of the residents in a timely fashion. The documentation of the incident and subsequent assessments was delayed, with some entries being made several days after the events occurred, and in some cases, only after being reminded by other staff members. The residents involved had significant cognitive impairments, as evidenced by their BIMS scores of 4, and relevant diagnoses including dementia with agitation, mood disorder, and cognitive communication deficits. The altercation involved one resident striking another with a walker, resulting in visible redness and pain for the affected resident. Despite the incident, documentation of injury assessments and follow-up was not completed as required by facility policy, which mandates follow-up documentation every shift for 72 hours after such incidents. Interviews with staff revealed that documentation was sometimes delayed due to waiting for supervisory review or simply being forgotten. Staff acknowledged the importance of timely and accurate documentation for ensuring appropriate care, and facility policy required pertinent documentation in nurse progress notes and follow-up entries. However, the failure to document the incident and injury assessments promptly resulted in incomplete medical records for both residents.
Widespread Food Service Sanitation and Storage Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by multiple sanitation and storage deficiencies observed in the kitchen and nutrition rooms. During inspections, surveyors found the ice machine chute and juice gun nozzle contaminated with removable substances, including what staff identified as possible mold. The steam table wells contained a thick, yellowish substance, and the underside of a shelf above the range was covered in a gritty, brownish-red residue. Food storage practices were also deficient, with open containers of spices, improperly sealed bags of cereal and seasoning, and unlabeled or undated food items in both refrigerators and freezers. Personal items, such as a cup from a fast-food establishment and a purse, were found in food storage areas, contrary to facility policy. Staff interviews revealed a lack of understanding and adherence to cleaning schedules, temperature logs, and sanitation procedures. The dietary aide and dietary supervisor were unaware of the proper cleaning frequency for equipment and did not consistently monitor or document sanitation levels, such as the chemical concentration in the dishwasher. Logs for cleaning, temperature, and chemical levels were incomplete or missing for several months, and staff admitted to not following established protocols for labeling, dating, and sealing food items. The maintenance staff and regional dietician also indicated gaps in accountability and follow-up regarding cleaning and sanitation responsibilities. Facility policy required all food to be sealed, labeled, and dated, and for equipment to be cleaned and sanitized according to manufacturer instructions. However, record reviews showed that these policies were not consistently followed. Cleaning checklists were marked as completed despite evidence to the contrary, and temperature and chemical logs were often missing or incomplete. The lack of adherence to these standards and procedures resulted in unsanitary conditions and improper food storage, as directly observed and documented by surveyors.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by a 7.41% error rate identified during a survey. Specifically, LVN C did not administer medications as ordered for two residents. For one resident with an active order for 800 mcg of folic acid daily via G tube for anemia, LVN C only administered one 400 mcg tablet, citing the absence of 0.8 mg tablets in the medication cart. For another resident with an active order for 12.5 mg of hydrochlorothiazide daily for hypertension and edema, LVN C withheld the medication without a physician's order to do so, based on her assessment of the resident's blood pressure and the presence of hold parameters on other antihypertensive medications. Interviews with facility staff confirmed that the orders for both medications were clear and did not include parameters for withholding doses. The facility's policy required medications to be administered as prescribed and for staff to verify the correct medication, dose, and administration method. The failures were observed directly by the surveyor during medication passes and were acknowledged by both LVN C and supervisory staff during interviews.
Failure to Date Opened Insulin Vials in Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure all drugs and biologicals were labeled in accordance with professional standards, specifically by not recording the opened-on date on two multidose insulin vials stored in a medication cart. During an observation, two opened vials of insulin—one Lantus vial for a female resident with Type 2 Diabetes Mellitus and one Lispro vial for another female resident with the same diagnosis—were found in the 100-hall nurse cart without the required opened-on date written on either the vial or its box. Both residents had received multiple insulin injections in the past week, and the facility's policy required the date of opening to be recorded on multidose containers. Interviews with nursing staff and clinical supervisors confirmed that the standard practice was to write the opened-on date on insulin vials and check expiration dates before administration. However, the staff were unable to locate any opened-on dates on the vials in question. The facility's policy, as reviewed by surveyors, also specified that the date of opening must be recorded on multidose containers, and this was not followed in these instances.
Failure to Prevent Resident-to-Resident Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect two residents from abuse by another resident in the memory care unit. One resident, who had a history of severe cognitive impairment, physical aggression, and behavioral symptoms related to dementia and depression, slapped another resident in the face twice after an altercation over a napkin. On a separate occasion, the same resident grabbed a different resident's arm and slapped it multiple times while speaking to her. Both incidents involved physical contact initiated by the resident with a known history of aggression. The residents involved in the incidents all had severe cognitive impairment and resided in the memory care locked unit. The aggressor had a documented history of behavioral problems, including yelling, hitting, and using abusive language, and required varying levels of assistance with daily activities. The other two residents also had significant cognitive and physical impairments, with one being an elopement risk and the other on palliative care for end-stage Alzheimer's disease. At the time of the incidents, the aggressor was not consistently on 1:1 supervision, and the facility's care plan noted the potential for physical aggression but did not prevent the altercations from occurring. Staff interviews and record reviews confirmed that the aggressive resident had a pattern of physical outbursts and that staff were aware of her behavioral risks. Despite this knowledge, the facility did not prevent the incidents of abuse, and both affected residents were exposed to physical harm. The report notes that neither of the abused residents appeared to recall the incidents or showed signs of distress afterward, but the facility's failure to ensure their right to be free from abuse constituted a deficiency.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments, as observed with one of the four medication carts. Specifically, Medication cart #1 was left unlocked and unattended outside a resident's room by RN A. This incident was observed on 11/7/2024, at 8:39 a.m., when the cart remained unlocked for five minutes until RN A was questioned about it. RN A acknowledged that she forgot to lock the cart after administering medication and admitted that it was against the proper process, which requires the cart to be locked when not in view or use. She confirmed that while narcotics were secured in a double-locked drawer, other medications were accessible. Interviews with the Director of Nursing (DON) and the Administrator confirmed that the facility's policy mandates medication carts to be locked when not in use or out of sight of the staff member responsible for them. The DON emphasized that an unlocked cart could allow residents to access medications not prescribed to them. The facility's Administering Medication policy, dated 07/08/2024, specifies that medication carts must be closed and locked when out of sight, with no medications kept on top of the cart. This policy aims to prevent unauthorized access to medications by residents or others passing by.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation and initial tour of the kitchen, it was found that dry goods were not sealed, labeled, or dated. Equipment such as steam table wells were heavily crusted with a flaking, yellow-whitish substance, and there were no covers on the plate warmers. Personal items were found in the prep areas, including a large purse, a personal phone, and a purple personal cup of ice. Additionally, items in the walk-in refrigerator and freezer were not labeled or dated, and there was a lack of proper lighting and a broken door latch in the walk-in freezer. Temperature logs for refrigerators, the freezer, and the 3-compartment sink were not maintained, and the facility failed to ensure proper sanitization of equipment and surfaces. Interviews with the Food Service Manager (FSM) and dietary aides revealed a lack of awareness and adherence to food safety protocols. The FSM admitted that the bucket of rice should have been covered, spices should have been closed, and expired bread and buns should have been discarded. The FSM also acknowledged that the steam table wells should be cleaned nightly and that the lack of plate covers could lead to contamination. The FSM was unaware of the broken freezer latch, the dim light in the walk-in refrigerator, and the presence of personal items in the prep areas. The dietary aides also admitted to placing personal items on prep tables, which could lead to cross-contamination. The FSM and dietary aides were not following proper labeling, dating, and sealing procedures for items in the walk-in refrigerator and freezer. Further observations revealed that the facility did not have temperature logs for the milk refrigerator, walk-ins, or the 3-compartment sink. The FSM stated that he did not know he was supposed to have logbooks for temperatures and had not informed the administrator about the issues with the milk refrigerator or plate warmer covers. The FSM also admitted to not being aware of his responsibilities as a food service manager and not following the facility's policies regarding kitchen operations. The maintenance supervisor was also unaware of the broken latch on the walk-in freezer and had not taken steps to address the issue. The facility's policies on food preparation, storage, and sanitization were not being followed, leading to potential risks of foodborne illnesses for the residents.
Failure to Date Oxygen Tubing for Residents
Penalty
Summary
The facility failed to ensure that respiratory care was provided consistent with professional standards of practice for three residents who required oxygen therapy. Specifically, the facility did not date the oxygen tubing for Resident #21, Resident #23, and Resident #170 as per the physician's orders. Observations on multiple occasions revealed that the oxygen tubing in use for these residents was not dated, despite physician orders requiring weekly changes, labeling, and dating of the tubing. Interviews with the residents and staff confirmed that the tubing was changed weekly, but the dating was not consistently performed, which could lead to uncertainty about when the tubing was last replaced. Resident #21, a cognitively intact female with diagnoses including heart failure, type two diabetes, and chronic obstructive pulmonary disease (COPD), had undated oxygen tubing observed on two separate occasions. Resident #23, a male with heart failure, atrial fibrillation, and cerebral infarction, also had undated oxygen tubing observed on two occasions and was unable to answer questions appropriately. Resident #170, a cognitively intact female with COPD, type two diabetes, and heart disease, had undated oxygen tubing observed on two occasions as well. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the responsibility for dating the tubing lay with the charge nurses, and the DON acknowledged the need for an immediate in-service on the procedure.
Failure to Securely Affix Narcotic Boxes
Penalty
Summary
The facility failed to provide separately locked and permanently affixed compartments for Schedule II-V medications and other medications subject to abuse in two medication rooms (B and C wing). During observations, it was noted that the emergency use narcotic boxes in both wings were not permanently affixed and could be easily carried out of the rooms. Specifically, in the C wing medication room, a red metal box with a numbered keypad was found sitting on top of a mini refrigerator and could be picked up without difficulty. Similarly, in the B wing medication room, another red metal box with a numbered keypad was also found on top of a mini refrigerator and could be easily removed from the room. Interviews with the ADON and DON revealed that the facility's practice was to double lock the narcotics and ensure they were logged and checked for expiration dates. However, the red boxes provided by the pharmacy were not permanently affixed, and this practice had been ongoing for years without any notification from the pharmacist that the boxes needed to be permanently affixed. The facility's Medication Labeling and Storage Policy, revised in February 2023, stated that controlled substances and other drugs subject to abuse should be separately locked in permanently affixed compartments, which was not being followed in this case.
Infection Control Deficiencies During Peri Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of staff members during peri care for two residents. Specifically, CNA C and CNA D did not change their gloves after removing a soiled brief from Resident #2 and proceeded to place a clean brief using contaminated gloves. Additionally, they performed hand hygiene for only approximately 15 seconds. Resident #2, a [AGE] year-old female with severe cognitive impairment, chronic obstructive pulmonary disease, type two diabetes, and heart failure, was always incontinent and required total dependence for care. Both CNAs admitted to not following proper hand hygiene protocols and could not recall recent in-service training on infection control practices. Similarly, CNA E and Hospitality Aide F did not perform hand hygiene before peri care for Resident #122 and failed to change contaminated gloves after removing a soiled brief. They also touched various surfaces in the resident's room with contaminated gloves and did not perform adequate hand hygiene afterward. Resident #122, an [AGE] year-old female with severe cognitive impairment, cerebrovascular disease, cognitive communication deficit, and hypertension, required partial to moderate assistance and was always incontinent. Both staff members acknowledged their mistakes and mentioned that the last infection control in-service was conducted within the past month. Interviews with the DON and ADON confirmed that proper hand hygiene should last at least 20 seconds and that gloves should be changed between dirty and clean procedures to prevent the spread of infections. The facility's policies on hand hygiene and infection control were reviewed, indicating that hand hygiene is the primary means to prevent the spread of infections and that gloves do not replace hand washing. Despite these policies, the observed deficiencies in hand hygiene and glove use during peri care for the two residents highlight lapses in adherence to infection control protocols.
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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 Kingsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kingsville Nursing And Rehabilitation Center | 1 mi | — | 5 | 0 |
| The Premier Snf Of Alice | 21.6 mi | — | 9 | 0 |
| Windsor Nursing And Rehabilitation Center Of Alice | 21.6 mi | — | 11 | 0 |
| Meridian Care Of Alice | 21.8 mi | — | 9 | 4 |
| Robstown Nursing And Rehabilitation Center | 24.9 mi | — | 6 | 0 |
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