F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and
comfortable environment for residents, staff, and the public on 1 of 3 resident hallways (Hallway 100), and 1
of 1 kitchen reviewed for environmental concerns, in that:
1. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired 3 and
5 foot wall scrapes near bed-A and had removed dust and lint from the bathroom ceiling vent.
2. The facility failed to ensure resident room [ROOM NUMBER], located on hallway 100, had repaired a 3x3
inch bathroom door penetration and had repaired an unsecured bathroom wall vent.
3. There was a 4.5- foot piece of floor baseboard molding under the prep table on the right side of the main
kitchen that was missing.
4. There was a 7.0- foot piece of floor baseboard molding behind the ice machine and juice bar on the left
side of the main kitchen that was not attached to the wall.
5. There were 2 broken 1x1 ft floor tiles in the main kitchen area that were cracked.
6. There were 2 eight- foot florescent ceiling lights in the main kitchen area that did not have protective
sleeve covers.
7. There were 4 three- foot florescent ceiling lights in the dry storage room that did not have protective
sleeve covers.
These failures could place residents at risk of a diminished quality of life due to exposure to an environment
that is unpleasant, unsanitary, and unsafe.
Findings included:
1. During observation rounds with the Maintenance Director and Administrator on 03/7/25 from 12:50 pm 12:55 pm revealed the following:
a. In room [ROOM NUMBER] on hallway 100 there were two wall scrapes near Bed-A with one scrape
measuring 3 ft in length and the other measuring 5 foot in length.
b. In room [ROOM NUMBER] on hallway 100 there was a bathroom ceiling vent that was covered with
(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
03/07/2025
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 0921
dust and lint.
Level of Harm - Minimal harm
or potential for actual harm
c. In room [ROOM NUMBER] on hallway 100 there was a 3x3 inch penetration on the bathroom door.
Residents Affected - Some
d. In room [ROOM NUMBER] on hallway 100 there was a bathroom ceiling vent was not fully attached to
the ceiling wall surface.
2. During observation rounds in the kitchen with the Administrator and Maintenance Director on 3/5/25 from
1:40 pm -2:00 pm the following was noted
a. There was a 4.5- foot piece of floor baseboard molding under the prep table on the right side of the main
kitchen that was missing.
b. There was a 7.0-foot piece of floor baseboard molding behind the ice machine and juice bar on the left
side of the main kitchen that was not attached to the wall.
c. There were 2 broken 1x1 ft floor tiles in the main kitchen area that were cracked.
d. There were 2 eight- foot florescent ceiling lights in the main kitchen area that did not have protective
sleeve covers.
e. There were 4 three- foot florescent ceiling lights in the dry storage room that did not have protective
sleeve covers.
During an interview with the Maintenance Director and Administrator on 3/7/25 at 1:00 pm the Maintenance
Director stated that he makes monthly rounds on all of the resident rooms. He stated that staff
communicate the need for repairs on the work order TELS system and he was not aware of the needed
repairs in rooms [ROOM NUMBERS]. The Administrator stated that making the noted repairs would
improve the homelike environment for the residents. The Maintenance Director further stated that he made
monthly rounds in the kitchen and was aware of the noted areas needing repaired. The Maintenance
Director stated the kitchen light bulbs without sleeves could allow glass spillage onto the kitchen floor if the
ceiling light bulbs break. The Administrator stated that all of the noted areas needing repair in the kitchen
could affect employee safety and general food preparation.
Record review of the undated TELS weekly, bi-weekly, and monthly maintenance task form revealed that
there was not a resident room inspection task listed, and there was not a kitchen inspection task listed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675226
If continuation sheet
Page 2 of 2
