Lone Star Rehabilitation & Wellness Center

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 4 of 16 employees (SW, ADMN, CNA C and CNA D) reviewed for employability. The facility failed to ensure record of criminal history check and/or an EMR/NAR check prior to hire were maintained for the SW.The facility failed to ensure record of annual EMR/NAR checks were maintained for the (SW, ADMN, CNA C and CNA D). These findings placed residents at risk of receiving care by someone that was unemployable.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident received food that was palatable, attractive and at a safe and appetizing temperature of 1 of 1 lunch meal in 1 of 1 kitchen tested for nutritive value, flavor, and appearance. The facility failed to provide palatable food served at an appetizing temperature to residents, during lunch on 09/03/2025. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of meals served.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents receive meals at regular times comparable to normal mealtimes in the community, for 1 of 1 meal observed for meal service. The facility failed to ensure meals were consistently served at posted mealtimes (lunch meal on 09/02/2025). Posted meal times: Breakfast-Assisted dining room [ROOM NUMBER]:00 PM, Main Dining room [ROOM NUMBER]:05 PM, Hall Trays 12:40 PM This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, unplanned weight loss, and side effects from medication given without food, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate residents' needs, preferences and accommodation of needs, for 1 (Resident #6) of 19 residents reviewed for dignity. The facility failed to ensure Resident #6's call light was within reach while he was in bed on 09/02/2025 and 09/03/2025. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for 1 (Resident #1) of 3 residents reviewed for infection control practice. CNA A and CNA B failed to perform hand hygiene and change their gloves while providing incontinence care for Resident #1. These failures placed residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow menus for 1 of 1 lunch meal reviewed. This facility failed to follow the menu when preparing lunch meal on 08/27/2024. This failure could place residents at risk for a decline in health status due to inadequate or inappropriate nutritional intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident received food that was palatable, attractive and at a safe and appetizing temperature of 1 of 1 lunch meal in 1 of 1 kitchen tested for nutritive value, flavor, and appearance. The facility failed to provide palatable food served at an appetizing temperature to residents, during lunch on 08/27/2024. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of meals served.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 3 (Resident #80, Resident #63, and Resident #46) of 12 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness to ensure Resident #80, Resident #63, and Resident #46 received adequate end-of-life care. The facility failed to have physicians' orders for Hospice Care for Resident #80, Resident #63, and Resident #46. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 5.88% based on 2 errors out of 34 opportunities, which involved 2 of 7 residents (Resident #24 & Resident #39) reviewed for medication errors. 1. The facility failed to ensure LVN B administered potassium chloride liquid diluted with 4-6 oz (ounces) of water prior to administration given for hypokalemia (low potassium) to Resident #24 according to physician orders. 2. The facility failed to ensure MA A administered the correct dose of Ferrous gluconate (iron) given for anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) to Resident #39 according to physician orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 (cart #1) of 8 medication carts reviewed for medication storage in that: The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident group meetings were held as scheduled, the residents were made aware of upcoming meetings, and resident group concerns were promptly acted upon for reviewed resident group meeting minutes, in that: 1. The facility failed to ensure Resident Council Meetings that were scheduled during May 2023 and June 2023 were held as scheduled. 2. The facility failed to ensure there was documented evidence that residents' concerns, as noted in the Resident Council Minutes dated 4/18/23, regarding not knowing how to use the remote controls for the new televisions in their rooms had been addressed or resolved. [...]

Inspectors wroteBased on interview and record review, the facility failed to make information on how to file a grievance or complaint available to the residents, including notifying residents individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed for reviewed for resident rights, in that: 1. The facility failed to ensure residents knew how to file a grievance, as expressed during the Resident Council group meeting held 6/28/23. 2. The facility failed to ensure residents knew who was responsible for addressing and investigating any complaints or concerns they may have regarding life in the facility. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to ensure that the daily nurse staffing was posted as required for 2 of 3 days (06/27/23 and 06/28/23) reviewed for nursing services and postings. The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.