Lone Star Ranch Rehabilitation and Healthcare Cent

In the surveyor’s words

From the most serious findings on record at Lone Star Ranch Rehabilitation and Healthcare Cent, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 7, 2022

  Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 (Resident #1) of 5 residents reviewed for supervision. The facility did not implement interventions to prevent Resident #1 from eloping from the facility. Resident #1 exited the facility undetected and was missing 2.5 hours before the facility initiated a search and located Resident#1 two miles from the facility. This failure resulted in an identification of a past non-compliance Immediate Jeopardy at 1:00 p.m. on 10/07/22. The noncompliance was identified as PNC. The IJ began on 08/20/22 and ended on 08/24/22. […]

• Actual harm, isolatedF689Sep 18, 2023

  Based on interview and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1 of 1 resident (R#2) reviewed for accidents. The facility failed to provide R #2 with adequate supervision, resulting in falls on 08/13/23 and 08/17/23. This failure could lead to the injury of residents that are at risk of falls. The findings included: Record review of R #2 's file reflected a [AGE] year-old female, with an original admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Apr 25, 2024

  Based 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 for sanitation in that: 1. The facility failed to ensure dry goods were sealed 2. The facility failed to ensure dry goods were labeled and dated 3. The facility failed to ensure equipment was clean and sanitized 4. The facility failed to refrain from having personal items in the prep areas 5. The facility failed to label and date items in the walk-in refrigerator 6. The facility failed to label and date items in the walk-in freezer 7. The facility failed to maintain temperature logs for refrigerators and the freezer 8. […]

• No harm, potential for more than minimal, widespreadF925Jun 11, 2022

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of ants for 10 residents of 45 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) reviewed for pest control in that: Each reviewed resident had ants in their bedcovers. Resident #8 pointed out a stream of ants on the wall that this surveyor observed. These failures could place residents at risk for illness and infection due to the nature of pathogens ants are known to carry. Findings include: Observation of 45 beds on 6/11/22 beginning at 11:00 am revealed ants found in the bedcovers of Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, and Resident #10. […]

• No harm, potential for more than minimal, patternF880Aug 12, 2026

  Based 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 for 2 (Resident #40 and Resident #2) of 5 residents reviewed for infection control practices. The facility failed to ensure Resident #40 received proper or adequate incontinent care on 08/11/2026 at 8:22 AM. […]