Stephenville Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Stephenville Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Dec 9, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF880Dec 9, 2025

  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 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. […]

• No harm, potential for more than minimal, patternF812Jul 31, 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 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. The findings included: Observation on 07/29/2024 at 9:25 AM revealed food particles on the floor in the dry storage area and grease on the floor beneath the appliances and stainless-steel shelf units throughout the kitchen. […]

• No harm, potential for more than minimal, patternF656May 17, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF727May 17, 2023

  Based 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. […]