Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Stephenville Nursing And Rehabilitation during CMS and state inspections, most recent first.
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.
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 | — | 0 | 0 |
| Avir At Stephenville | 1.2 mi | — | 1 | 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 August 2026) and official state health department websites.