Cycle 1
Health 2024-10-04 · Fire 2024-10-04
4 health deficiencies
Top issue: Environmental (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Hallettsville, TX
Hallettsville Nursing And Rehabilitation
3-star overall rating with 4-star inspections with $8,824 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
825 W Fairwinds, Hallettsville, TX
(361) 798-3268
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
119
Certified beds
Average residents
77
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Wellsential Health
Operator or chain grouping
Approved since
1992-10-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
67 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
0.17
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.10
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.03
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.17
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,438
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.68% · Performance 21.90% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.35
Baseline 9.22% · Performance 7.17% · Measure score 4.35 · Achievement 2.22 · Improvement 4.35
Total nurse turnover
6.35
Baseline 38.60% · Performance 37.74% · Measure score 6.35 · Achievement 6.35 · Improvement 0.13
Adjusted total nurse staffing
0
Baseline 3.23 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.25% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 7.58% · Lower 95% interval 6.34% |
| Discharge to community | 46.45% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 40.82% · Lower 95% interval 37.71% |
| Medicare spending per beneficiary | 1.29 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 95.83% |
95.27%
0.6 pts better
|
Numerator 46 · Denominator 48 |
| Falls with major injury | 6.25% |
0.77%
5.5 pts worse
|
Numerator 3 · Denominator 48 |
| Discharge self-care score | 19.35% |
53.69%
34.3 pts worse
|
Numerator 6 · Denominator 31 |
| Discharge mobility score | 16.13% |
50.94%
34.8 pts worse
|
Numerator 5 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 48 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.17% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 46 · Observed rate 6.52% · Lower 95% interval 3.31% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 90 |
| Staff flu vaccination coverage | 94.55% |
42%
52.5 pts better
|
Numerator 104 · Denominator 110 |
| Discharge function score | 16.13% |
56.45%
40.3 pts worse
|
Numerator 5 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 45.45% |
25.2%
20.3 pts better
|
Numerator 10 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.2 |
2.1
1.1 pts worse
|
1.9
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 2.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.1
1.4 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.4% |
3.3%
3.1 pts worse
|
3.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.8% · Q3 7.5% · Q4 5.6% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 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 who lose too much weight | 4.3% |
3.3%
1 pts worse
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.2% · Q3 3.6% · Q4 3.4% · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
18.9%
0.9 pts worse
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 23.3% · Q3 21.1% · Q4 15.0% · 4Q avg 19.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.3% |
10.8%
6.5 pts better
|
16.7%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 4.1% · Q3 2.2% · Q4 4.3% · 4Q avg 4.3% · 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 | 11.9% |
15.4%
3.5 pts better
|
16.3%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 16.9% · Q3 11.2% · Q4 4.6% · 4Q avg 11.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.2% |
16.1%
5.1 pts worse
|
14.9%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 25.9% · Q3 28.3% · Q4 19.0% · 4Q avg 21.2% · 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 | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.4% |
15.0%
7.6 pts better
|
19.8%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 6.6% · Q3 8.3% · Q4 3.9% · 4Q avg 7.4% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
4.2%
2.3 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 1.5% · Q4 3.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
89.7%
9 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.8% · Q4 97.1% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
12.0%
4 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 8.3% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.9% |
1.5%
5.4 pts worse
|
1.6%
5.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.0% · Q3 7.7% · Q4 13.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
88.0%
9.1 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.0% |
25.9%
9.1 pts worse
|
23.9%
11.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.0% · Observed 36.1% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-25 · Fire 2023-08-25
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-07-08 · Fire 2022-07-08
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-01
F · Potential for more than minimal harm
2024-10-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-10-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-01
E · Potential for more than minimal harm
2023-08-25
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 2023-09-19
D · Potential for more than minimal harm
2022-07-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
E · Potential for more than minimal harm
2024-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-22
E · Potential for more than minimal harm
2024-10-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-10-22
D · Potential for more than minimal harm
2024-10-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-22
G · Actual harm
2024-06-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-02
F · Potential for more than minimal harm
2023-08-25
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-08-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-08-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-08-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-08-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-08-28
D · Potential for more than minimal harm
2023-08-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-28
D · Potential for more than minimal harm
2022-07-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-07-18
Penalties and ownership
What sits behind the stars
$8,824
2024-06-28
Fine
Fine · fine $8,824
Fine
Ownership
Winnie-Stowell Hospital District
5% Or Greater Direct Ownership Interest · Organization
825 Fairwinds Street LLC
Operational/Managerial Control · Organization
Baird, Daniel
Operational/Managerial Control · Individual
Clapp, Barbara
Operational/Managerial Control · Individual
Cortese, Daren
Operational/Managerial Control · Individual
Csv Rhea Management Holdco, LLC
Operational/Managerial Control · Organization
Dekowski, Donovan
Operational/Managerial Control · Individual
Dwd Tx Holdings LLC
Operational/Managerial Control · Organization
Gibson, Patricia
Operational/Managerial Control · Individual
Jack And Nancy Dwyer Workforce Development Center Inc
Operational/Managerial Control · Organization
Kainer, Keeley
Operational/Managerial Control · Individual
Kutac, Melissa
Operational/Managerial Control · Individual
Murrell, Edward
Corporate Officer · Individual
Olveda, Leah
Operational/Managerial Control · Individual
Reg Bridge Opco LLC
Operational/Managerial Control · Organization
Reg Hg Opco LLC
Operational/Managerial Control · Organization
Reg Operator Holdco LLC
Operational/Managerial Control · Organization
Regency Ihs Clinical Consulting, LLC
Operational/Managerial Control · Organization
Regency Ihs Of Fairwinds Hallettsville LLC
Operational/Managerial Control · Organization
Regency Ihs Rehab LLC
Operational/Managerial Control · Organization
Regency Integrated Health Services LLC
Operational/Managerial Control · Organization
Regency Texas Holdings LLC
Operational/Managerial Control · Organization
Rollo, Jeffery
Corporate Officer · Individual
Selzer, Kody
Operational/Managerial Control · Individual
Stramecki, Anthony
Corporate Officer · Individual
Vratis, Kacey
Corporate Officer · Individual
Way, George
Corporate Officer · Individual
Winnie-Stowell Hospital District
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Stevens Nursing And Rehabilitation Center Of Halle
Hallettsville, TX
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Shiner Nursing And Rehabilitation Center Inc
Shiner, TX
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Yoakum Nursing And Rehabilitation Center
Yoakum, TX
4-star overall rating with 4-star inspections with $13,627 in total fines with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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