Lone Star Rehabilitation & Wellness Center

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

assistance. During an interview on 09/03/2025 at 4:07 p.m., the DON stated her expectation would be that call lights were in reach of residents when they were in bed. She stated that Resident #6 was not able to exit the bed to reach the call light if the call light was hanging on the cable where it exits the wall behind the head of his bed. She stated not having the call light in reach could interfere with residents calling for assistance. She stated the CNAs were responsible for call lights being in reach and the charge nurse was to monitor that call lights were in reach. During an interview on 09/04/2025 at 12:32 p.m., the ADMN stated

it was her expectation that call lights were in reach of residents lying in bed. She stated Resident #6 could not get out of the bed safely to reach a call light if it was handing on the wall behind the head of his bed.

She stated Resident #6 would not use his call light and would yell out if he needed assistance but even so,

she expected for him to have access to his call light. The ADMN stated the CNAs were responsible for making sure call lights were in residents' reach. She stated the charge nurses were who monitored the CNAs were keeping call lights in reach. She stated the department heads rounded the halls daily during the week to monitor nursing staff. The ADMN added the department head that was assigned to the hall where Resident #6 resided was on vacation and could have led to failure of call light not being in reach. Review of facility document titled Strategies for Reducing the Risk of Falls revised on date December 2007 revealed: Transfer and Ambulation: Remind the resident and family to call as needed for assistance with transfer and ambulation.Room: call light within reach. Review of facility policy titled Answering the Call Light revised date March 2021 revealed: Upon admission and periodically as needed, explain and demonstrate use of the call light to the resident. Ask the resident to return the demonstration.When a resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Lone Star Rehabilitation & Wellness Center

2601 Northwest Loop Stephenville, TX 76401

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Minimal harm or potential for actual harm

Based 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.The findings included:Record review of the SW's employee file revealed a hire date of 03/28/2022 and no evidence of a criminal history or an EMR/NAR check were completed prior to hire.

Further review revealed no evidence of annual EMR/NAR check was completed annually. Record review of

the ADMN's employee file revealed a hire date of 02/07/2023 and no evidence of an annual EMR/NAR check completed annually. Record review of the CNA C's employee file revealed a hire date of 03/30/2023 and no evidence of an annual EMR/NAR check completed annually.Record review of the CNA D's employee file revealed a hire date of 11/11/2022 and no evidence of an annual EMR/NAR check completed annually.During an interview on 09/04/2025 at 1:10 PM Payroll E stated she had only been in the position since March 2025. Payroll E stated she was responsible for completing criminal history and EMR/NAR checks. Payroll E stated criminal history checks and EMR/NAR checks were supposed to be completed prior to hire and EMR/NAR checks were supposed to be completed annually. Payroll E stated she had been working since March 2025 and that when she started at the facility, she was told to upload employee files to electronic files. Payroll E stated she uploaded all the documents could find. During an interview on 09/04/2025 at 1:45 PM the ADMN stated her expectation was criminal history checks and EMR/NAR checks were supposed to be ran prior to hire and EMR/NAR check should have been ran annually at date of hire. The ADMN stated Payroll was responsible for ensuring Criminal/EMR NAR checks were to be completed prior to hire and EMR/NAR checks were to be ran annually upon anniversary date. The ADMN stated she was ultimately responsible to ensure checks were completed. The ADMN stated residents could have been affected by being exposed to staff who should not have been hired. The ADMN stated what led to failure was turnover in the payroll in position. The ADMN stated she felt they were completed but the facility had started having employee files uploaded electronically and documents may have been misplaced. Record review of facility policy titled, Personnel Records dated 2/17/2023 revealed: A separate confidential folder will be maintained in conjunction with the personnel contents of payroll record folder and will contain the following confidential information: .a. Criminal History Check (completed prior to hire) . d.

Misconduct Registry and Nurse Aide Registry Checks (completed prior to hire and annually)

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

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If continuation sheet

Federal health inspectors cited LONE STAR REHABILITATION & WELLNESS CENTER in STEPHENVILLE, TX for a deficiency under regulatory tag F-F0804 during a standard health inspection conducted on 2025-09-04.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 4 deficiencies cited during this inspection of LONE STAR REHABILITATION & WELLNESS CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-14.

Federal health inspectors cited LONE STAR REHABILITATION & WELLNESS CENTER in STEPHENVILLE, TX for a deficiency under regulatory tag F-F0809 during a standard health inspection conducted on 2025-09-04.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 4 deficiencies cited during this inspection of LONE STAR REHABILITATION & WELLNESS CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-14.