Stephenville Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food items out of original containers were dated and labeled. The facility failed to ensure the Vegetable Freezer and the Meat Freezer's temperatures were taken and recorded on 09/20/2025, 09/21/2025, 09/22/2025 and 09/23/2025. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview 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 and infections reviewed for 2 of 2 residents (Resident #13 and Resident #25) and 2 of 2 staff (CNA A and CNA B) reviewed for infection control. The facility failed to ensure proper infection prevention techniques were used by CNA A when providing peri-care by not performing hand hygiene before and after peri-care for Resident #13. The facility failed to ensure proper infection prevention techniques were used by CNA A when providing peri-care by utilizing the same soiled wipe several times to clean the peri area for Resident #13. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent survey of the facility including any plans of correction without identifying information about complainants or residents reviewed for resident rights affecting 40 residents. The facility failed to ensure the three preceding years of any surveys, certifications, and complaint investigations with plans of correction were posted for residents, family members, and visitors to review without identifying information about complainants or residents. This failure could place residents at risk for not reviewing the findings from State surveys and investigations conducted in the facility without asking to review the reports.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. 1. The floors were soiled with food particles and grease beneath the appliances and stainless-steel shelf units throughout the kitchen. This failure could place residents that received meals prepared in the facility kitchen at risk for foodborne illness and a decline in health status.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (ID #20) reviewed for comprehensive care plans. 1. Resident #20 had an indwelling urinary catheter in place when he was admitted to the facility and the indication for use, care, and monitoring of input and output were not included in the comprehensive care plan. 2. Resident #20 had an admission order for the antidepressant medication of Cymbalta 60 mg by mouth daily, and it was not included in the comprehensive care plan. 3. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1(Resident #21) of 8 residents reviewed for infection control, in that: LVN A and LVN B failed to follow EBP (enhanced barrier precautions) signage instructions for Resident #21 by not donning a gown when providing incontinent care, and while performing wound care to Resident #21. This failure could affect residents and place them at risk for cross contamination and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #11, Resident #30, and Resident #2) of 13 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of a bolster (long padded cushion with sides) on the bed for safety and positioning for Resident #11. 2. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of a bed alarm in the bed and the use of a geri-chair for safety and positioning for Resident #30. 3. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 4 of 5 months reviewed. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 5 (11/27/2022, 12/11/2022, 01/07/2023, 03/11/2023 and 03/19/2023) of 151 days. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure kitchen staff followed proper hand hygiene during meal preparations. The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled. These failures could place residents at risk for food borne illness and cross-contamination.