Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hallettsville Nursing And Rehabilitation during CMS and state inspections, most recent first.
Invalid OOH-DNR Witnessing: A resident with dementia and severe cognitive impairment had an OOH-DNR form witnessed by the facility’s HR Director and Business Office Director. The DON and Administrator confirmed both witnesses were facility employees and acknowledged they were not qualified witnesses, making the DNR form improperly completed.
A medication pass observation found a 16.67% error rate, with 6 errors in 36 opportunities. A resident with DM, HTN, CKD, dementia, hyperlipidemia, and hemiplegia had six scheduled meds, including carvedilol, metformin, sertraline, buspirone, docusate, and hydroxyzine, given more than 2 hours late instead of within the required 1-hour window. The med aide confirmed the late administration, and the DON stated meds must be given within 1 hour before or after the ordered time.
Kitchen and food service areas were not maintained in accordance with sanitation standards. Surveyors observed dust and dirt in ceiling air vents in the main kitchen, food storage room, employee bathroom, dish-room, and Dietary Manager's office, along with several areas of missing paint in the food storage room and an overhead light in the main kitchen that did not work. The Dietary Manager stated no work order had been placed for the needed cleaning or repairs, and the Administrator stated dust and dirt could affect food prep surfaces.
Environmental Maintenance Deficiencies: Surveyors observed a bathroom sink light that did not turn on in a resident room, a dirty ceiling vent and missing ceiling paint in one shower room, a nonfunctioning sink overhead light in another shower room, and a dirty ceiling vent plus a nonfunctioning ceiling light in the laundry room. The MDS stated repairs were tracked through the TELS work order system but said he had not been notified of the issues, and record review showed the observed items were not listed on work orders.
Care plans for two residents were incomplete. One resident with moderate cognitive impairment had a physician-ordered pureed diet with regular liquids, but the diet was not addressed in the care plan. Another resident with dementia and type 2 DM had an order for Lantus 25 units SQ, but the ongoing care plan did not document insulin use. Staff confirmed both omissions during interview.
Care plan included incorrect diet information. A resident with dysphagia, convulsions, and intellectual disabilities had an active NPO order and received nutrition and fluids via feeding tube, but the care plan still included a discontinued oral diet with pureed texture, nectar-thick liquids, and other mealtime instructions. The LVN MDS confirmed the outdated oral diet information should not have remained in the care plan.
Improper Perineal Care During Incontinent Care: A resident with dementia and frequent bowel and bladder incontinence received incontinent care from a CNA who wiped the buttocks in a back-to-front motion instead of front to back. The CNA said she thought she was using the correct motion and had received recent incontinent care and infection control training. The DON confirmed that front-to-back cleansing is required, and the facility policy also directs staff to cleanse the buttocks and anus front to back.
Hand Hygiene Not Performed Before Incontinent Care: A CNA provided incontinent care to a resident with dementia, a BIMS score of 0, and frequent bowel and bladder incontinence after touching the resident's bed and bed remote with bare hands, then putting on gloves without sanitizing her hands first. The CNA acknowledged she did not sanitize before gloving, and the DON stated the area around the resident was considered contaminated and hand hygiene should be performed before care; the facility policy also stated gloves do not replace hand hygiene.
A resident with severe cognitive impairment and no designated POA or guardianship was denied the ability to discharge with a family member of his choice, despite expressing this wish. Facility staff instead followed the preferences of another family member without legal authority, citing unsubstantiated allegations and concerns, and barred the chosen family member from contact. The facility did not follow its own discharge policies or respect the resident's right to self-determination.
A LTC facility failed to maintain an effective infection prevention and control program, with staff not following proper hand hygiene and barrier precautions. A CNA did not sanitize her hands after coughing and wiping her nose while feeding a resident. Another CNA did not change gloves during incontinent care, risking cross-contamination. An LVN failed to wear a gown for a resident with a G-tube, and another LVN did not sanitize hands between medication administrations.
The facility failed to maintain a safe and functional kitchen environment, with multiple fluorescent lights lacking covers and several bulbs not operating in the main kitchen and dish machine room. Additionally, a panel light and a refrigerator light strip were not functioning, and the employee bathroom light was out. Interviews revealed that no work order was submitted for repairs, contrary to the facility's safety guidelines.
The facility failed to maintain a safe environment in the 100 hall, where an unlocked shower room contained an accessible disinfectant labeled 'Danger, Keep Out of Reach of Children.' This was confirmed by an LVN and the Administrator, violating the facility's housekeeping policies.
A resident with paraplegia and high fall risk was injured during a transfer when a CNA failed to use a gait belt, contrary to facility protocol. The resident was being transferred using a sliding board when they pushed against the wheelchair, causing it to move. The CNA attempted to prevent a forward fall by turning the resident, resulting in the resident's legs becoming tangled and leading to fractures. Interviews confirmed the CNA was trained to use a gait belt, which was not utilized during the incident.
Invalid OOH-DNR Witnessing
Penalty
Summary
The facility failed to ensure one resident’s right to formulate an advance directive when Resident #12’s Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was witnessed by two facility employees who were not qualified witnesses. Resident #12 was admitted with diagnoses including unspecified dementia, acute kidney failure, and generalized anxiety disorder, and the quarterly MDS documented a BIMS score of 3, indicating severe cognitive impairment. The care plan identified the resident as DNR. Review of the OOH-DNR form showed Witness #1 was the facility’s Director of Human Resources and Witness #2 was the facility’s Business Office Director. During interview, the DON and Administrator confirmed these were the witnesses on the form and acknowledged that neither was considered a qualified witness. Review of the Texas Health and Human Services guidance and Texas Health and Safety Code showed that the form must be properly completed and that certain facility officers and business office employees may not serve as witnesses.
Medication pass error rate exceeded 5% due to late administration
Penalty
Summary
The facility failed to ensure it was free of a medication error rate of 5% or greater. During medication pass observation, 6 errors were identified out of 36 opportunities, resulting in a 16.67% error rate for 1 of 3 residents reviewed. The deficiency involved Resident #33, whose record showed diagnoses including type 2 diabetes mellitus, hyperlipidemia, dementia, chronic kidney disease, hypertension, and hemiplegia. Resident #33 had physician orders for carvedilol, docusate sodium, metformin, sertraline, buspirone, and hydroxyzine, all scheduled for 8:30 a.m. Observation showed Medication Aide E administered all 6 medications at 11:50 a.m., more than 2 hours late. During interview, the Medication Aide confirmed the medications were given at 11:50 a.m. and stated they were 2 hours late and outside the one hour before or after time frame. The DON stated medications must be administered within one hour before or after the prescribed time, and the facility policy stated medications should be administered within 60 minutes prior to or after the scheduled time unless otherwise ordered.
Kitchen and Food Service Areas Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for sanitation. During observation with the Dietary Manager, an approximate 2x2 ft ceiling air vent in the main kitchen area had dust and dirt in the vent slots, an overhead light in the main kitchen area did not turn on, an approximate 6x5 inch ceiling air vent in the food storage room had dust and dirt in the vent slots, and several areas of missing paint were observed on the ceiling in the food storage room. Additional observations identified an approximate 1x1 ft ceiling air vent with dust and dirt in the vent slots in the employee bathroom and an approximate 1 ft perimeter ceiling air vent with dust and dirt in the vent slots in the Dietary Manager's office. During interview, the Dietary Manager stated she had not placed a work order for the observed areas that needed cleaning or repair. The Administrator stated that dust and dirt could affect the food preparation surfaces in the kitchen. Record review showed the facility policy required the food service area to be maintained in a clean and sanitary manner, and other policies required floors, walls, and ceilings to be free of dirt, litter, and moisture, non-food-contact surfaces to be kept free of dust, dirt, and food particles, and equipment to be kept in working order and malfunctioning equipment reported to Maintenance.
Environmental Maintenance Deficiencies
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment on one resident hallway, two shower rooms, and the laundry room. During observation rounds with the Administrator and Maintenance Director, surveyors found that a bathroom sink light in one resident room on Hallway 500 did not turn on, a 6-inch ceiling vent in the shower room on Hallway 100 had dust and dirt on the vents, and there was an approximate 6x2 inch section of missing ceiling paint in that same shower room. Surveyors also observed a sink overhead light that did not turn on in the shower room on Hallway 200. In the laundry room, surveyors observed an approximate 10-inch ceiling vent with dust and dirt on the vents and an approximate 10x2 inch ceiling light that did not turn on. During interview, the Maintenance Director stated the facility used the TELS work order system to notify him of needed repairs and said he had not been notified of the observed areas needing repair. The Administrator stated that completing the repairs of the observed areas would be necessary for general maintenance of the facility. Record review of work orders dated 12/15/25-1/15/25 showed the observed areas needing repair were not included, and the facility document titled What is TELS described a protocol for staff to create work orders for facility maintenance purposes.
Care Plans Did Not Address Ordered Diet or Insulin Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #8 by not including the resident’s diet in the care plan. Resident #8 was admitted with diagnoses including unspecified fracture of the right femur, unspecified atrial fibrillation, and essential primary hypertension, and the admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment. The record also showed a diet order dated 12/10/2025 for a regular diet with pureed texture and regular liquids, but the care plan as of 01/15/2026 did not address the resident’s diet. During interview, the LVN MDS A confirmed the diet order should have been addressed in the care plan so the resident would receive the correct diet as ordered by the physician. The facility also failed to revise Resident #64’s care plan to address insulin use. Resident #64 was an [AGE]-year-old male admitted on 5/16/25 with diagnoses including unspecified dementia, primary hypertension, and type 2 diabetes, and the quarterly MDS dated 11/2/25 showed a BIMS score of 8, indicating moderate cognitive impairment. Physician’s orders initiated on 9/22/25 and revised on 11/14/25 included Lantus subcutaneous solution, 25 units subcutaneously, but the ongoing care plan initiated on 5/16/25 did not document the resident’s insulin use. During interview, MDS LVN A and RN B stated the insulin use was not documented on the current care plan and that having it on the care plan was important for staff awareness of the resident’s care needs.
Care Plan Included Incorrect Diet Information
Penalty
Summary
The facility failed to review and revise a comprehensive person-centered care plan for Resident #4 that was consistent with the resident’s rights and included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. The deficiency involved the resident’s care plan incorrectly noting that the resident received tube feeding as well as food by mouth. Resident #4 was admitted with diagnoses including dysphagia, unspecified convulsions, and unspecified intellectual disabilities. The resident’s Significant Change MDS indicated the resident was rarely or never understood, had both long- and short-term memory problems, and had a feeding tube. The order summary showed an active NPO diet order, and the clinical record showed a discontinued diet order for food in bowls from 02/20/2025 to 11/19/2025. The care plan, revised 12/04/2025, stated the resident required tube feeding related to dysphagia, but also included a revision dated 09/29/2025 for a regular diet with pureed texture, nectar thickened liquids, food in bowls, maroon spoon, 1/2 teaspoon, no straws, double handled cup with lid for all liquids, and a preference for the plate to be left on the serving tray while eating. During interview, the LVN MDS A confirmed the resident’s current diet order was nothing by mouth, that all liquids and nutrition were provided via tube feeding, and that the discontinued diet order should not have continued to be included in the care plan.
Improper Perineal Care During Incontinent Care
Penalty
Summary
The facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for Resident #22. Resident #22 had diagnoses including dementia, hyperlipidemia, and hypertension, and the quarterly MDS dated 01/06/2026 indicated a BIMS score of 0, showing severe cognitive impairment, with the resident frequently incontinent of bowel and bladder. During observation on 01/15/2026 at 10:10 a.m., while CNA C was providing incontinent care, the CNA used a back to front motion to wipe the resident's buttocks. In interview, CNA C stated she used a back to front motion and thought she was using the right motion, and stated she had received incontinent care and infection control training within the year. The DON confirmed that staff must use a front to back motion during incontinent care to clean the resident and prevent fecal matter entering the urinary stream and prevent urinary infection. The facility's CNA/NA competency skills checklist dated 02/04/2025 showed CNA C met competency for infection control and incontinent care, and the facility policy titled Perineal care directed staff to cleanse the buttocks and anus front to back.
Hand Hygiene Not Performed Before Incontinent Care
Penalty
Summary
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 one resident. Resident #22 had diagnoses including dementia, hyperlipidemia, and hypertension, had a BIMS score of 0 on the quarterly MDS, required extensive assistance with activities of daily living, and was frequently incontinent of bowel and bladder. The care plan identified bowel incontinence related to immobility and directed staff to provide pericare after each incontinent episode. During observation of incontinent care for Resident #22, CNA D washed her hands, then touched the resident's bed and bed remote with bare hands. CNA D then put on gloves but did not sanitize her hands before beginning care for the resident. In interview, CNA D stated she did not sanitize her hands before putting on gloves and did not think about the bed and bed remote being possibly contaminated. The DON stated the environment around a resident was considered contaminated and staff should wash or sanitize their hands prior to providing care to prevent cross contamination and infection. The facility policy on hand hygiene stated that gloves do not replace hand hygiene and that hand hygiene should be performed prior to donning gloves and immediately after removing gloves.
Failure to Honor Resident's Discharge Rights and Follow Policy
Penalty
Summary
The facility failed to honor a resident's right to self-determination and to follow its own policies regarding discharge and decision-making when no power of attorney (POA) or guardianship was in place. The resident, an elderly male with severe cognitive impairment and multiple diagnoses including dementia and major depressive disorder, was his own responsible party with no legal documentation granting decision-making authority to any family member. Despite this, the facility did not allow the resident to discharge with a family member (FM A) as he wished, and instead followed the wishes of another family member (FM B) who had no legal authority. On the day of the incident, FM A arrived at the facility to facilitate the resident's discharge, which the resident verbally supported. Facility staff, including the interim administrator and DON, denied the discharge, citing concerns about FM A's behavior and vehicle condition, as well as unsubstantiated allegations of past mistreatment presented by FM B. The facility then barred FM A from the property and from having contact with the resident, despite the lack of any substantiated evidence or legal documentation restricting her involvement. The resident expressed a desire to leave with FM A and reported no safety concerns about living with her. Interviews with facility staff, the ombudsman, and both family members confirmed that there was no active POA or guardianship, and that the facility's actions were based on unsubstantiated allegations and the preferences of FM B rather than the resident's expressed wishes or established policy. The facility's own discharge policy required informing the resident and family of risks, notifying the physician, and documenting the process, none of which were followed in this case. The failure to adhere to policy and to respect the resident's rights resulted in the resident being denied the ability to discharge as he wished.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies involving staff members and residents. One incident involved a Certified Nursing Assistant (CNA) who did not sanitize her hands after blowing her nose, wiping her nose with her finger, and coughing into her hand while feeding a resident. This resident, who had severe cognitive impairment and required assistance with eating, was at risk of infection due to the CNA's failure to follow proper hand hygiene protocols. Another deficiency was observed during the provision of incontinent care to a resident with moderate cognitive impairment and total dependence in bed mobility and toileting. The CNA providing care did not change gloves or sanitize his hands when transitioning from cleaning the resident's peri area to repositioning him and changing his brief. This oversight could lead to cross-contamination and the spread of infection among residents. Additionally, a Licensed Vocational Nurse (LVN) failed to adhere to Enhanced Barrier Precautions (EBP) by not wearing a gown while administering medications via a gastrostomy tube to a resident. The LVN did not notice the EBP sign and was unaware that a gown was required for residents with feeding tubes. Furthermore, another LVN did not sanitize his hands between administering medications to different residents and after picking up dropped pills from the floor, which could result in the spread of germs.
Deficient Lighting and Safety in Kitchen Area
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the kitchen area, as observed during a survey. Specifically, the main kitchen and dish machine room had multiple double fluorescent lights without lid covers, and several light bulbs were not operating. Additionally, a panel light in the main kitchen area and the light strip inside the refrigerator in the kitchen storage room were not functioning properly. The overhead ceiling light in the employee bathroom was also not operating. These deficiencies were identified during a kitchen tour with the Dietary Manager. Interviews with the Dietary Manager and the Administrator revealed that the lack of functioning light bulbs and covers in the kitchen could compromise the safety of kitchen operations. The Dietary Manager admitted to not having completed a work order request for the necessary repairs. A review of the facility's General Kitchen Safety Guidelines policy indicated that the facility is required to keep all equipment in working order and report any malfunctions to the Maintenance Department. However, this procedure was not followed, leading to the identified deficiencies.
Unlocked Shower Room with Hazardous Disinfectant
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and provided adequate supervision to prevent accidents in the 100 hall. During an observation, it was found that the shower room on this hall was unlocked, and a supply cabinet within the room was also unlocked with both doors open. Inside the cabinet, a 16-ounce spray bottle of disinfectant labeled 'Danger, Keep Out of Reach of Children' was accessible. This situation was confirmed by LVN A, who acknowledged that the disinfectant should not have been accessible to residents. The Administrator also confirmed that the disinfectant cleaner should not be accessible to residents, as per the facility's General Housekeeping Policies, which require maintaining a safe environment.
Failure to Use Gait Belt During Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices during a transfer for a resident, leading to an accident. The resident, who had a history of paraplegia and was categorized as a high fall risk, required substantial assistance with transfers. During a sliding board transfer, a CNA did not use a gait belt, which was against the facility's protocol. The resident was improperly lowered to the ground, resulting in fractures to the proximal tibia and fibula. The incident occurred when the CNA was assisting the resident with a sliding board transfer from the bed to a wheelchair. The CNA reported that the resident became anxious and pushed against the wheelchair, causing it to move. In an attempt to prevent the resident from falling forward, the CNA turned the resident's upper torso, which led to the resident's legs becoming tangled under the wheelchair. This action potentially contributed to the fractures sustained by the resident. Interviews with facility staff, including the PT and DON, confirmed that the CNA was trained to use a gait belt during transfers and that the facility required its use. The PT indicated that the resident was capable of performing a sliding board transfer with one-person assistance. The DON emphasized that the proper procedure for lowering a resident to the ground involves using a gait belt and following the direction of the fall, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hallettsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stevens Nursing And Rehabilitation Center Of Halle | 0.7 mi | ★★★★★ | 11 | 0 |
| Shiner Nursing And Rehabilitation Center Inc | 13 mi | ★★★★★ | 13 | 0 |
| Yoakum Nursing And Rehabilitation Center | 13.8 mi | ★★★★★ | 5 | 0 |
| Shady Oak Nursing And Rehabilitation | 14.9 mi | ★★★★★ | 10 | 0 |
| Paradigm At Stevens | 15.7 mi | ★★★★★ | 3 | 0 |
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