F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to 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 disease and infection for 1 of 3 residents (Resident #1)
reviewed for infection control, in that:
Residents Affected - Few
CNA A did not wash or sanitize her hands between change of gloves during incontinent care for Resident
#1.
These deficient practices could place residents at-risk for infection due to improper care practices.
The findings include:
1 .Record review of Resident 1's face sheet, dated 11/28/2023, revealed an admission date of 11/26/2016
and, a readmission date of 08/21/2023, with diagnoses which included: Dementia (decline in cognitive
abilities), Anemia (Blood disorder in which the blood has a reduced ability to carry oxygen), Hypothyroidism
(under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Major depressive
disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), Hypertension
(High blood pressure) and, Bipolar disorder (Mental disorder characterized by periods of depression and
periods of abnormally elevated mood).
Record review of Resident #1's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of
99, she was coded as having severe impairment and memory problems. Resident #1 required extensive
assistance and was always incontinent of bowel and bladder.
Review of Resident #1's care plan dated 08/19/2021 revealed a problem of Resident #1 has FUNCTIONAL
bladder incontinence r/t (related to) impaired cognition and impaired mobility with an intervention of
Monitor/document for s/sx (signs and symptoms)UTI: pain, burning, blood tinged urine, cloudiness, no
output, deepening of urine color, increased pulse,increased temp, Urinary frequency, foul smelling urine,
fever, chills, altered mental status, change in behavior, change in eating patterns.
Observation on 11/30.2023 at 1:15 p.m. revealed, while providing incontinent care for Resident #1, CNA A,
after cleaning the genital area and front of Resident #1, changed her gloves but did not sanitize or wash her
hands before putting new gloves on. CNA A changed her gloves after she finished cleaning the resident's
buttocks but did not sanitize or wash her hands.
During an interview with CNA A on 11/30/2023 at 1:30 p.m., CNA A verbally confirmed she should have
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
675226
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675226
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/30/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Stevens Nursing and Rehabilitation Center of Halle
106 Kahn St
Hallettsville, TX 77964
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
washed or sanitized her hands between change of gloves but forgot. She confirmed the staff received
infection control training.
Review of CNA A's CNA orientation skills checklist, dated 01/11/2023, revealed she met proficiency in
infection control and incontinent care.
Residents Affected - Few
During an interview with the DON on 11/30/2023 at 5:30 p.m., the DON confirmed the staff should have
washed or sanitized her hands between change of gloves. The DON confirmed the staff received training
on infection control. The facility did annual skill checklists with the staff. The ADON did spot checks on
different staff to check their knowledge and skills.
Review of the facility policy titled, Perineal care, dated 10/24/2022, revealed 16. Remove gloves and
discard. Perform hand hygiene.
Review of the facility's Incontinent care proficiency checklist, undated, revealed Use hand gel between
glove changes. If heavily soiled, wash hands with soap and water.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675226
If continuation sheet
Page 2 of 2
