Cycle 1
Health 2025-09-04 · Fire 2025-09-04
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Stephenville, TX
Lone Star Rehabilitation & Wellness Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2601 Northwest Loop, Stephenville, TX
(254) 968-4649
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hmg Healthcare
Operator or chain grouping
Approved since
1990-12-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.58
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.08
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.73
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,858
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.78
Baseline 21.15% · Performance 21.07% · Measure score 0.78 · Achievement 0.78 · Improvement 0
Healthcare-associated infections
0
Baseline 7.55% · Performance 9.62% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.21
Baseline 49.23% · Performance 42.37% · Measure score 5.21 · Achievement 5.21 · Improvement 2.31
Adjusted total nurse staffing
0
Baseline 3.18 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.8% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 157 · Observed rate 11.46% · Lower 95% interval 8.52% |
| Discharge to community | 56.91% |
50.57%
6.3 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 57.04% · Lower 95% interval 49.9% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 121 · Denominator 121 |
| Falls with major injury | 2.48% |
0.77%
1.7 pts worse
|
Numerator 3 · Denominator 121 |
| Discharge self-care score | 62% |
53.69%
8.3 pts better
|
Numerator 31 · Denominator 50 |
| Discharge mobility score | 28% |
50.94%
22.9 pts worse
|
Numerator 14 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 2.48% |
2.29%
0.2 pts worse
|
Numerator 3 · Denominator 121 · Adjusted rate 2.59% |
| Healthcare-associated infections requiring hospitalization | 9.62% |
7.12%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 11.54% · Lower 95% interval 6.19% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 83 |
| Staff flu vaccination coverage | 31.63% |
42%
10.4 pts worse
|
Numerator 31 · Denominator 98 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 25 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 98.53% |
96.28%
2.2 pts better
|
Numerator 67 · Denominator 68 |
| Resident COVID-19 vaccinations up to date | 2.67% |
25.2%
22.5 pts worse
|
Numerator 2 · Denominator 75 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
2.1
0.3 pts better
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
97.1%
1.9 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 98.6% · Q4 98.5% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
97.9%
0.4 pts worse
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.3%
3.3 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.7% · Q3 7.1% · Q4 8.8% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.4% |
2.7%
3.7 pts worse
|
11.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.0% · Q3 7.7% · Q4 6.2% · 4Q avg 6.4% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
3.3%
0.5 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 3.9% · Q4 3.8% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.6% |
18.9%
11.7 pts worse
|
19.6%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 29.3% · Q3 34.0% · Q4 28.3% · 4Q avg 30.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
10.8%
2.1 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 4.5% · Q3 13.3% · Q4 8.7% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.8% |
15.4%
7.6 pts better
|
16.3%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
16.1%
5.7 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 9.4% · Q3 10.2% · Q4 14.3% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.7% |
15.0%
3.3 pts better
|
19.8%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 11.4% · Q3 11.4% · Q4 13.5% · 4Q avg 11.7% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
4.2%
1.1 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.2% · Q3 2.8% · Q4 1.3% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
89.7%
3.6 pts better
|
81.7%
11.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.3% · Q2 93.5% · Q3 92.1% · Q4 96.4% · 4Q avg 93.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.0% |
12.0%
13 pts worse
|
12.0%
13 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 22.4% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.5% |
88.0%
0.5 pts better
|
79.7%
8.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.8% |
25.9%
5.9 pts worse
|
23.9%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.8% · Observed 28.0% · Expected 21.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2024-08-29
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-29 · Fire 2023-06-29
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-31
E · Potential for more than minimal harm
2025-09-04
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-12-31
E · Potential for more than minimal harm
2025-09-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-31
E · Potential for more than minimal harm
2025-09-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-31
E · Potential for more than minimal harm
2025-09-04
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-12-31
F · Potential for more than minimal harm
2024-08-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-16
F · Potential for more than minimal harm
2024-08-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-29
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-23
E · Potential for more than minimal harm
2024-08-29
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-09-24
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-09-05
E · Potential for more than minimal harm
2025-09-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-05
E · Potential for more than minimal harm
2025-09-04
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-09-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-01-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-14
E · Potential for more than minimal harm
2024-08-29
F803 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-09-16
E · Potential for more than minimal harm
2024-08-29
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-17
E · Potential for more than minimal harm
2024-08-29
F849 · Administration Deficiencies
Health
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.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-08-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-09-23
D · Potential for more than minimal harm
2024-08-29
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-09-16
E · Potential for more than minimal harm
2023-06-29
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-06-29
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-06-30
C · Minimal harm
2023-06-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-06-30
Penalties and ownership
What sits behind the stars
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
Prince, Derek
5% Or Greater Indirect Ownership Interest · Individual
Culp, Roland
Operational/Managerial Control · Individual
Daspit, Laurence
Operational/Managerial Control · Individual
Hmg Park Manor Of Stephenville, LLC
Operational/Managerial Control · Organization
Murrell, Edward
Corporate Officer · Individual
Pico, Ana
Operational/Managerial Control · Individual
Prince, Derek
Operational/Managerial Control · Individual
Rollo, Jeffery
Operational/Managerial Control · Individual
Rollo, Jeffery
Corporate Officer · Individual
Sanders, Jana
Operational/Managerial Control · Individual
Stramecki, Anthony
Operational/Managerial Control · Individual
Stramecki, Anthony
Corporate Director · Individual
Vratis, Kacey
Operational/Managerial Control · Individual
Vratis, Kacey
Corporate Director · Individual
Way, George
Operational/Managerial Control · Individual
Way, George
Corporate Director · Individual
Way, George
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Stephenville Nursing And Rehabilitation
Stephenville, TX
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Avir At Stephenville
Stephenville, TX
2-star overall rating with 2-star inspections with $204,614 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Deleon Nursing And Rehabilitation
De Leon, TX
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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