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Deficiency Records for Stephenville Rehabilitation and Wellness Center

A list of the most recent deficiencies for Stephenville Rehabilitation and Wellness Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Stephenville Rehabilitation and Wellness Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Ensure medication error rates are not 5 percent or greater. Health 2024-08-29 2024-09-23 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2024-08-29 2024-09-17 Y
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2024-08-29 2024-09-16 Y
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Health 2024-08-29 2024-09-16 Y
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Health 2024-08-29 2024-09-16 Y
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2023-06-29 2023-06-30 N
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Health 2023-06-29 2023-06-30 N
Post nurse staffing information every day. Health 2023-06-29 2023-06-30 N
Establish roles under a Waiver declared by secretary. Fire Safety 2022-12-21 2023-01-27 N
Have an alternate power supply for its alarm system. Fire Safety 2022-12-21 2023-01-27 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-12-21 2023-01-27 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-12-21 2023-01-27 N
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Health 2022-05-05 2022-05-27 Y
Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. Health 2022-05-05 2022-05-27 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-05-05 2022-05-27 Y
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2022-05-05 2022-05-25 Y
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2022-05-05 2022-05-25 Y
Ensure that residents are free from significant medication errors. Health 2022-05-05 2022-05-09 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-03-08 2022-03-09 Y
Conduct testing and exercise requirements. Fire Safety 2024-09-11 Not Fixed N
Meet other general requirements that are deficient. Fire Safety 2024-09-11 Not Fixed N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-09-11 Not Fixed N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-09-11 Not Fixed N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2024-09-11 Not Fixed N
Have simulated fire drills held at unexpected times. Fire Safety 2024-09-11 Not Fixed N

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