Hill Country Heights

Inspectors wroteBased 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 one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (ensuring trash receptacles were securely covered, ensuring kitchen floors were free from debris, ensuring kitchen utensils were free of dried debris, ensuring kitchen utility cart was debris free, and ensuring kitchen shelving was debris free)2. The facility failed to label and date all food items in the kitchen. These failures could place residents at risk of foodborne illness. During an observation on 5/19/26 at 6:13 am, of the facility's kitchen revealed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 resident (Resident #20) of 6 residents reviewed for care plans. The facility failed to ensure Resident #20 received her divided plate and small 4 oz. cups with a straw at mealtimes and was included in her care plan. These failures could affect residents and put them at risk of not receiving care and services to meet their needs. Record review of Resident #20's face sheet dated 05/20/2026, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 of 1 resident (Resident #7) reviewed for tracheostomy care. The facility failed to ensure ADNS LVN used aseptic technique (a procedure that healthcare providers use to prevent the spread of germs that cause infection) during tracheostomy care and tracheostomy suctioning for Resident #7 by not performing hand hygiene, placing barriers, performing proper suction depth procedures or using sterile equipment during care on 05/20/2026. This failure could place residents at risk for respiratory infections and respiratory distress.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide special eating equipment and cups with straws for resident who need them for 1 of 6 (Residents #20) residents reviewed for special eating equipment. The facility failed to provide Resident #20's physician ordered divided plate and 4 oz cup with straw with lid for drinking on 05/20/2026. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem. Record review of Resident #20's face sheet dated 05/20/2026, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's health status (that is, a deterioration in health status in either life-threatening conditions or clinical complications), and need to alter treatment significantly for one (Resident #1) of six residents reviewed for notification of changes. The facility failed to notify the wound care provider when Resident #1's sacral region continued to develop new areas of MASD from 07/08/2025 to 08/22/2025. This failure could result in decreased continuity of care, and a delay in the treatment and services needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all assistive devices were maintained and free of hazards for four (Residents #13, #21, 48 and #221) of fifteen residents reviewed for essential equipment. The facility failed to properly maintain wheelchairs for Residents #13, #21, #48 and #221. These failures could place residents at risk for equipment that is in unsafe operating condition, which could cause injury.

Inspectors wroteBased on observation, interview, and record review 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 1 of 2 (MA A) staff members and 2 of 4 residents (Residents #47, and #221) reviewed for infection control procedures. MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #47 and #221. This failure could place residents at risk for cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the third quarter (April 1, 2024, to June 30, 2024) reviewed for Administration. The facility failed to submit complete PBJ staffing information to CMS for April 1, 2024, to April 30, 2024. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: Record review of the Casper3 PBJ report revealed the facility had four areas triggered on the FY Quarter 3 (April1- June30) report. The areas were One Star Staffing Rating, Excessively low Weekend Staffing, No Rn hours, and Failed to have Licensed Nursing Coverage 24 hours/day. [...]

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and received adequate supervision and assistance devices to prevent accidents for 1 of 13 residents (Resident #1) reviewed for transfers in that: CNA A failed to provide adequate supervision and transfer assistance for Resident #1 in the shower resulting in Resident #1 falling and having an open right ankle fracture with bleeding. Resident #1 had to be hospitalized and required surgical intervention. The facility failed to update the Kardex and POC to reflect current safe transfer status requirements for Resident #1 and 12 other residents. The facility failed to ensure CNAs were knowledgeable on how to locate the Kardex to determine if 1 or 2 staff were required to safely transfer/assist a resident. An IJ was identified on 06/21/24. [...]

Inspectors wroteBased on observation and interviews , the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: 1. The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food was unidentifiable and did not taste good. 2. The test tray of the lunch meal foods were dry, bland, and cold. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.

Inspectors wroteBased 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 reviewed for food and nutrition services. 1. The facility failed to ensure dry storage food was properly labeled and dated. 2. The facility failed to ensure dry storage items were sealed properly. 3. The facility failed to properly label and date items in the refrigerator and freezer. 4. The facility failed to ensure expired food was discarded. 5. The facility failed to ensure kitchen staff practiced proper hand hygiene and glove use. 6. The facility failed to ensure hairnets were worn while in the kitchen. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of their quality of life for two (Resident #3 and Resident #39) of six residents reviewed for rights. 1. The facility failed to ensure Resident #3 catheter bag was covered when out of room. 2. The facility failed to provide dignity and respect for Resident #39 by not aiding a resident that required assistance in dressing. These failures placed the residents at risk of a decline of their sense of dignity, level of satisfaction with life, and feelings of self-worth.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission that included instructions for providing effective person-centered care for the resident and met professional standards of quality of care for 1 of 4 residents (Resident # 58) reviewed for care plans, in that: The facility failed to develop and implement a baseline care plan for Resident #58. This failure placed residents at risk of not having their immediate care needs met or not receiving continuity of care.

Inspectors wroteBased on, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 3 (Resident # 3, 52 and 55) 16 residents reviewed for care plans. 1. The facility failed to ensure Resident # 3's Catheter was addressed on her care plan. 2. The Facility failed to ensure Resident # 52's care plan was updated by removing isolation when the resident no longer medically required it. 3. The facility failed to ensure Resident # 55's Fluid restriction and noncompliance with restrictions was on the care plan. This failure placed the resident at risk for not having their individual needs met in a timely manner and communicated to provide and could result in injury and a decline in physical well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 11 and Resident # 16) reviewed for quality of life. 1. The facility failed to ensure Resident #11's nails were trimmed. 2. The facility failed to ensure Resident #16's nails were cleaned. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 (Resident # 6 and Resident # 22) of 8 reviewed for Quality of care. The facility failed to maintain the drainage bag to Resident # 6's surgical wound in a position that it could drain. The facility failed to obtain a physician's order for finger sticks for Resident # 22 who was on sliding-scale insulin. These Failures could put the residents at risk for infection, and risk for medical decline.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 resident ( Resident # 57) of 8 reviewed for accurate weights. The facility failed to establish a consistent method of weighing residents to ensure the accuracy of weight. for 1 resident (Resident # 57) of 8 reviewed for accurate weights. This failure put the residents at risk for undetected weight loss, malnutrition, medical complications poor quality of life.

Inspectors wroteBased on interviews and record review , the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident reviewed for pain management (Resident #27), in that: RN C failed to assess and evaluate Resident# 27's existing pain and cause for pain in the administration of an opioid (narcotic). RN C failed to verify last administered dose of an opioid (narcotic) and available PRN pain medications putting the resident at risk for overmedication causing oversedation hypoxia oversedation respiratory failure. This failure placed Resident# 7 residents at risk for continued pain and adverse drug consequences. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders for two (Resident #1 and Resident #2) of two residents reviewed for parenteral fluids. 1. The facility failed to ensure RN A and LVN B stopped administration of TPN (nutrition administered intravenously through a large vein near the heart) which could cause tissue damage, while performing a sterile dressing change for Resident #1. 2. The facility failed to ensure Resident #1 and Resident #2 had their central lines maintained per professional standards, physician's order, or facility policy. These failures could place the residents with central lines at risk for serious infection, impaired nutrition, and hospitalization.

Inspectors wroteBased on observation, interview, and record revies, the facility failed to have sufficient nursing staff with appropriate competencies and skills sets to provide nursing services to assure resident safety and maintain the highest practicable, physical, well-being of the resident for two (Resident #1 and Resident #2) of two residents and three (RN A, RN C, and LVN D) of four staff reviewed for competent nursing. 1. The facility failed to ensure RN A and LVN B stopped administration of TPN (nutrition administered intravenously through a large vein near the heart) which could cause tissue damage while performing a sterile dressing change for Resident #1. 2. The facility failed to ensure nursing staff (RN A, RN C, and LVN D) who cared for residents with central lines (Resident #1 and Resident #2) were competent in providing care following physician orders and facility policy. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet his or her preferences, goals, and address his or her medical, physical, mental, and psychosocial needs for 2 of 7 residents (Residents #1 and #2) reviewed for care plans in that: 1. Resident #1 did not have a comprehensive person-centered care plan that addressed her falls on 09/09/2023, 09/13/2023, and 09/24/2023. 2. Resident #2 had a comprehensive person-centered care plan that was started on 08/22/2023 with no completion date. These failures could place residents are risk of not having their preferences, goals, and needs met.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that each resident received treatment and care in accordance with professional standards of practice for 1 of 7 residents (Resident #1) reviewed for quality of care in that: Staff did not monitor, assess, and document neurological checks on Resident #1 after her falls on 09/09/2023, 09/13/2023, and 09/24/2023. This failure could place residents at risk of pain, mental anguish, emotional distress, physical harm, diminished quality of life, and death.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the resident environment remained free of accidents and hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and hazards in that: The facility failed to supervise Resident #1, who fell once on 09/09/2023, twice on 09/13/2023, and once on 09/24/2023. This failure could place residents at risk for further falls, pain, and/or injury.