Hallettsville Nursing and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF689Jun 28, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents reviewed for accidents (Resident #1). CNA A failed to use a gait belt while performing a sliding board transfer for Resident #1 resulting in Resident #1 being improperly lowered to the ground and receiving a fracture of the proximal tibia and fibula (a fracture or break in the shinbone just below the knee). This deficient practice could affect residents at the facility who required a gait belt while receiving sliding board transfers by contributing to injury. […]

• Actual harm, isolatedF689May 23, 2022

  Based on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accident hazards/supervision, in that: CNA A performed the 2-person mechanical lift by herself without requesting assistance from another staff member, resulting in Resident #1 slipping from the mechanical lift. Resident #1 was sent to a local ER and was diagnosed with a subdural hemorrhage (bleeding in the brain), and subarachnoid hemorrhage (bleeding in the brain). […]

• No harm, potential for more than minimal, widespreadF812Aug 25, 2023

  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, in that: 1. There were storage containers of food in the reach in cooler that were not properly sealed. 2. Cook E wore jewelry on both hands while engaged in food preparation in the kitchen. 3. Cook E portioned food onto plates in an unsanitary manner during the lunch meal service on 08/24/2023. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 08/22/2023 at 10:20 a.m. in the reach in cooler revealed a clear, plastic 2-quart container filled with sliced American cheese. […]

• No harm, potential for more than minimal, patternF578Jan 16, 2026

  Based on interview and record review, the facility failed to ensure the resident's right to formulate an advance directive for one (Resident #12) of twenty-five residents reviewed, in that:Resident #12's OOH-DNR was witnessed by two unqualified witnesses and was therefore invalid. This deficient practice could place residents at risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.The findings were:Record review of Resident #12's facesheet, dated [DATE], revealed the resident was admitted to the facility on [DATE] with diagnoses including: unspecified dementia, acute kidney failure, and generalized anxiety disorder.Record review of Resident #12's Quarterly MDS, dated [DATE], revealed a BIMS score of 3 which indicated severe cognitive… […]

• No harm, potential for more than minimal, patternF759Jan 16, 2026

  Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater. A total of 6 errors out of 36 opportunities were observed, resulting in a 16.67% error rate for 1 of 3 residents (Resident #33) reviewed during medication pass, in that: Medication Aide E failed to administer Resident #33's medications at the correct time. These deficient practices could place residents at risk for not receiving the intended therapeutic benefits of their medications and exacerbation of their medical conditions.The findings were: Record review of Resident #33's face sheet, dated 01/15/2026, revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included: Type 2 diabetes… […]