Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Rehabilitation & Wellness Center during CMS and state inspections, most recent first.
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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 15 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | — | 1 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Lone Star Rehabilitation & Wellness Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.