Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillside Medical Lodge during CMS and state inspections, most recent first.
MDS assessments for three residents did not accurately reflect ordered CPAP or BiPAP use. One resident had CPAP orders and a care plan for sleep apnea, another had a BiPAP order, and a third had CPAP orders, but none of the MDS assessments coded the devices. Observations found the CPAP/BiPAP machines in the residents’ rooms, and interviews with the residents and LVN staff confirmed ongoing use. The MDS Nurse said she was responsible for the assessments but did not know the residents were using the devices.
Respiratory masks were left unbagged when not in use for three residents using BiPAP, nebulizer treatment equipment, or CPAP. A resident with OSA, a resident with respiratory failure, and another resident with OSA all had their masks observed on bedside tables attached to the equipment and not stored in bags. Staff stated the masks should be bagged to keep them clean and prevent infection, but the masks were not properly stored at the time of observation.
A resident with muscle weakness, hemiplegia, hemiparesis, and severe cognitive impairment was found in bed with the call light placed on a side table under wheelchair leg rests instead of within reach. Staff interviews showed the resident had been transferred after breakfast and the call light was not left accessible after the transfer, despite the care plan and facility policy requiring it to remain within reach before staff leave the room.
An LVN disclosed a resident’s blood sugar check to the resident’s roommate while providing care. The resident had DM, severe cognitive impairment, and was receiving insulin and fingerstick blood sugar monitoring. The LVN stated she should not have answered the roommate, and the DON and ADON confirmed the roommate was not the resident’s responsible party and that the information should not have been shared.
A facility failed to include BiPAP and CPAP therapy in the care plans for two cognitively intact residents with obstructive sleep apnea, even though both had physician orders for nighttime use with daily checks of placement, settings, and functioning. Staff confirmed the residents were using the devices, but the MDS Nurse acknowledged the care plans were missing and said it was an oversight. The DON and Administrator stated residents should be care planned for the care and services they receive, and the facility policy required measurable objectives and time frames in the comprehensive care plan.
A resident with dysphagia, severe cognitive impairment, and a PEG tube did not receive g-tube medication administration as ordered. An LVN administered two medications via the tube without flushing before the first medication and then flushed a total of 120 ml of water, exceeding the ordered amounts. The LVN, ADON, and DON all acknowledged that the ordered flush amounts were important for proper tube patency and medication delivery, and the facility policy required flushing before medication administration.
A resident with severe cognitive impairment and an order for arginine supplement twice daily had a cup of the supplement left in her room on an overbed table. An MA admitted leaving it there instead of waiting for the resident to take it, and an LVN later identified and discarded the liquid. The ADON, DON, and Administrator stated medications and supplements should not be left for unsupervised administration.
The facility failed to maintain infection control for two residents. One resident with a g-tube and enhanced barrier precautions was transferred by two CNAs who began the lift without gowns or gloves, despite a room sign and PPE cart indicating required precautions. Another resident receiving IV vancomycin through a PICC line had an LVN reconnect the IV after touching a trash can and changing gloves without sanitizing her hands first.
A medication aide in an LTC facility administered non-prescribed Buspirone and Magnesium Oxide to a resident due to a failure to confirm the 5 rights of medication administration. The resident, with moderate cognitive impairment and a heart condition, was monitored after the error and showed no significant adverse effects. The incident was attributed to communication and human error.
The facility failed to ensure that five out of nine dietary staff members had current food handler's certificates, potentially risking foodborne illness for residents. The Dietary Manager and Administrator relied on Relias training, mistakenly believing it was accredited. No records of in-service training or dietary new hire training policy were available.
A dietary aide in an LTC facility was observed using bare hands to handle ready-to-eat foods, violating food safety standards. Despite receiving training on proper food handling, the aide did not use gloves or utensils, and the ADON did not intervene. The facility's policy requires the use of utensils or gloves to prevent cross-contamination.
MDS Assessments Did Not Reflect CPAP or BiPAP Use
Penalty
Summary
The facility failed to ensure that the Comprehensive MDS assessments accurately reflected the use of CPAP or BiPAP for three residents. Resident #16 had a diagnosis of obstructive sleep apnea, a care plan that included assisting with CPAP equipment, and physician orders directing CPAP use at bedtime, but the Comprehensive MDS dated 10/24/2025 did not indicate CPAP use. Resident #28 had a diagnosis of obstructive sleep apnea and a physician order for BiPAP at night, but the Comprehensive MDS dated 09/22/2025 did not indicate BiPAP use and the care plan did not include BiPAP. Resident #91 had a diagnosis of obstructive sleep apnea and a physician order for CPAP at night, but the Comprehensive MDS dated 10/24/2025 did not indicate CPAP use and the care plan did not include CPAP. During observations, a CPAP machine was seen behind Resident #16’s recliner chair, a BiPAP machine was seen at Resident #28’s side table, and a CPAP machine was seen on top of Resident #91’s side table. In interviews, Resident #16 stated she had been using CPAP for about five to six months and used it every night. Resident #28 stated he had been using BiPAP for months, and Resident #91 stated she had been using CPAP since June if she was not mistaken. LVN staff confirmed that Resident #16 and Resident #28 had been using their devices for months. The MDS Nurse stated she was responsible for completing the residents’ MDS assessments and said she did not know the residents were using CPAPs and a BiPAP. She reviewed the orders and confirmed that Resident #28 had a BiPAP order and Residents #16 and #91 had CPAP orders, but the MDS assessments were not coded for those devices. She stated she could not click CPAP and BiPAP because they were grayed out and said she would correct and resubmit the MDS. The DON and Administrator stated that if residents were using CPAPs or a BiPAP, the MDS should reflect it, and the DON stated the MDS could be the basis for what is included in the care plan.
Respiratory Masks Not Properly Stored When Not in Use
Penalty
Summary
The facility failed to ensure that respiratory equipment was properly stored when not in use for three residents who used BiPAP, nebulizer treatment equipment, or CPAP. Resident #28 had a physician order to wear BiPAP at night, and the resident was cognitively intact with a BIMS score of 15. On 12/09/2025, the resident was not in the room and the BiPAP machine was observed on the bedside table with the mask attached and not bagged. The resident stated nurses applied and removed the BiPAP and that he never told staff not to bag the mask. LVN B stated the mask should be bagged to prevent respiratory infection. Resident #46 was diagnosed with respiratory failure and had a physician order for Ipratropium-Albuterol nebulizer treatments three times daily. On 12/09/2025, the resident was observed awake in bed with a nebulizer machine on the side table and a breathing mask attached, but the mask was not bagged. The resident stated the nurse put the treatment on every morning and also took it off. LVN B stated she administered the treatment, placed the mask on top of the nebulizer without bagging it, and said it should be bagged to keep it clean. Resident #91 had obstructive sleep apnea, was cognitively intact with a BIMS score of 15, and had a physician order to wear CPAP at night. On 12/10/2025, the resident was not in the room and the CPAP machine was observed on the side table with the mask attached and not bagged. The resident stated she sometimes took it off and that nobody told her to put it inside a bag. ADON L, LVN E, the DON, and the Administrator all stated the CPAP, BiPAP, and breathing masks should be bagged when not in use to prevent infection and cross contamination, and that staff were responsible for bagging the masks.
Call Light Not Left Within Resident’s Reach
Penalty
Summary
The facility failed to ensure the call light system in Resident #80’s room was positioned within the resident’s reach. Resident #80 was a female admitted to the facility with diagnoses including muscle weakness, hemiplegia, and hemiparesis. Her MDS assessment reflected severe cognitive impairment with a BIMS score of 05, and the quarterly MDS indicated she required maximal assistance for showering, dressing, bed mobility, and transfers. Her care plan identified her as at risk for falls and included an intervention to keep the call light within reach. During an observation, Resident #80 was in bed awake, and her call light was observed on top of her side table beneath her wheelchair leg rests rather than within her reach. When asked where her call light was, the resident looked to her side and shrugged. Staff interviews showed the resident had been transferred to bed after breakfast, and the call light was not left accessible after the transfer. The LVN later placed the call light where the resident could reach it. Interviews with the CNA staff, ADON, DON, and Administrator confirmed that call lights were expected to remain within residents’ reach and that staff were responsible for ensuring this before leaving the room. The facility policy also stated that the call light must always be within the resident’s reach before staff leave the room.
Disclosure of Resident Blood Sugar Treatment to Roommate
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when an LVN disclosed a resident’s blood sugar check to the resident’s roommate. Resident #84 was a [AGE]-year-old female admitted to the facility with diabetes mellitus and severe cognitive impairment, with a BIMS score of 00. Her record showed she was receiving insulin, including Humalog 3 units subcutaneously before meals, and had an order for fingerstick blood sugar monitoring. During an observation, the LVN entered the room to check Resident #84’s blood sugar, pulled the privacy curtain, and when the roommate asked what she was doing, the LVN replied that she was getting the resident’s blood sugar. The LVN did not ask Resident #84 for permission before answering the roommate’s question. In interview, the LVN stated she should not have answered because blood sugar testing is medical treatment and should not be disclosed to someone not involved in the resident’s care. The ADON and DON stated the roommate was not the resident’s responsible party and that staff should not have told her what treatment was being provided. The Administrator also stated staff should not disclose medical information to another resident or other individuals not involved in care. The facility policy stated staff are responsible for safeguarding resident health information and must use and disclose protected health information only as authorized and conduct oral discussions in a manner that limits inadvertent disclosures.
Incomplete Care Plans for BiPAP and CPAP Therapy
Penalty
Summary
The facility failed to develop complete care plans for two residents with sleep apnea who had physician orders for nighttime positive airway pressure therapy. Resident #28, a cognitively intact male with obstructive sleep apnea, had a physician order for BiPAP at night set at 14/7 with instructions to check placement, setting, and functioning daily on every night shift, but his comprehensive care plan did not include BiPAP. On observation, the resident was not in his room and his BiPAP machine was seen on top of his bedside table. The resident stated he had been using the BiPAP for months, and an LVN stated he had been using it for almost six months. Resident #91, a cognitively intact female with obstructive sleep apnea, had a physician order for CPAP at night with instructions to check placement, setting, and functioning daily on every night shift, but her comprehensive care plan did not include CPAP. On observation, the resident was not in her room and a CPAP machine was seen on top of her side table. The resident stated she had been using CPAP since June if she was not mistaken. The MDS Nurse stated she was responsible for care plans, confirmed both residents had orders for BiPAP and CPAP, and acknowledged the residents were not care planned for those therapies, stating it was an oversight on her part. The DON and Administrator stated residents should be care planned for the care and services they receive, and the facility policy reflected that a comprehensive person-centered care plan is to include measurable short-term and long-term objectives and time frames to meet the resident's identified needs.
Improper G-Tube Medication Administration
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one resident with a g-tube. Resident #8 was a male resident with dysphagia, severe cognitive impairment, and a feeding tube noted on the MDS assessment. His care plan reflected that he required a PEG tube and that one goal was for him not to experience adverse effects. The physician order for g-tube medication administration required flushing with 30 cc of water before medications, flushing between each medication with 5 to 30 ml of water, and flushing with 30 cc after medication administration. During an observation of medication administration via g-tube, LVN D prepared two medications for the resident and administered them through the tube. She crushed one medication and opened a capsule for the other, then placed the medications on a tray with water. She connected a 60 ml syringe to the g-tube, checked placement and residual, and then administered the first medication without flushing the tube beforehand. She flushed each medication with 15 ml of water, then flushed the tube four additional times with 30 ml each, totaling 120 ml of water. She stated she was supposed to flush the tube before medication administration to make sure it was not clogged and acknowledged she had forgotten to do so. The ADON and DON stated that flushing the g-tube before medication administration and using the ordered amount of water were important to prevent clogging and to ensure medications went through properly. They also stated that using more or less than the ordered amount of water could affect the resident, and that too much water could cause fluid overload, vomiting, and aspiration. The facility policy for tube medication administration also required flushing the tube with water prior to medication administration.
Unsupervised Supplement Left in Resident Room
Penalty
Summary
The facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for one resident. Resident #100 was a female admitted with hyponatremia, severe cognitive impairment with a BIMS score of 00, and a care plan that included administering a supplement as ordered for potential weight loss. Her physician ordered Arginine Supplement Powder twice daily, mixed in water, for risk of protein-calorie malnutrition and to promote wound healing. During observation, a cup of colored liquid was seen on the resident’s overbed table in her room. An LVN identified the liquid as the protein supplement and stated it should not have been left in the room because another resident could consume it or the resident could have an allergic reaction. The LVN discarded the liquid. The MA stated she was the one who left the arginine supplement in the room and acknowledged she should have waited for the resident to drink it before leaving so she could confirm the resident took it and monitor for refusal or swallowing difficulty. The ADON and DON stated medications or supplements should never be left in a resident’s room for unsupervised administration, and the Administrator stated the same expectation.
Infection Control Lapses During Resident Transfer and IV Administration
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents. One resident had dysphagia, severe cognitive impairment with a BIMS score of 00, a feeding tube, and was dependent on staff for transfers. The resident’s care plan required a PEG tube and transfer via mechanical lift, and the resident’s room had a sign indicating enhanced barrier precautions and a PPE cart inside. On 12/10/2025, CNA F and CNA G were observed preparing to transfer the resident from bed to wheelchair via mechanical lift. Although both CNAs sanitized their hands before entering the room, neither put on gowns or gloves before beginning the transfer. They went to the resident’s bedside, rolled the resident, and placed the sling under the resident while already having contact with the resident. Lead CNA N stopped the transfer and stated the CNAs should have been wearing gloves and gowns because the resident had a g-tube and was on enhanced barrier precautions. CNA F and CNA G each stated they should have worn PPE because the resident had a g-tube and the room sign indicated PPE was required. A second resident had severe cognitive impairment with a BIMS score of 00 and was receiving IV vancomycin for an infected left hip prosthesis through a PICC line. During observation of IV preparation and connection, LVN B washed her hands and donned gloves and a gown, but after touching a trash can and removing her gloves, she put on a new pair of gloves without sanitizing her hands first. She then proceeded to connect the IV. LVN B stated hands should be sanitized before putting on a new pair of gloves, especially after touching the trash can. The ADON and DON stated hand hygiene should be performed before donning new gloves and that staff should wear gowns and gloves when transferring a resident with a g-tube.
Medication Error Due to Non-Compliance with 5 Rights
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in a medication error. A medication aide (MA A) administered 5 mg of Buspirone and 400 mg of Magnesium Oxide to a resident without a prescription. This incident occurred when the medication aide, who was not being supervised by a trainer at the time, mistakenly gave the medications to the wrong resident. The error was attributed to the failure to confirm the 5 rights of medication administration, which include the right person, right time, right dose, right medication, and right route. The resident involved in the incident was an elderly woman with a diagnosis of Paroxysmal Atrial Fibrillation and moderate cognitive impairment, as indicated by a BIMS score of 12. Following the administration of the non-prescribed medications, a telehealth visit was conducted, during which the resident was found to be non-distressed, alert, and oriented, with stable vital signs. The physician advised monitoring the resident's vitals and holding her usual doses of Remeron and Melatonin due to potential sedation effects from the Buspirone and Magnesium Oxide. The medication error was documented in a facility-generated Medication Error Report, which noted that the error occurred because the medication aide did not follow the 5 rights of medication administration. The aide had recently been issued a medication aide permit and had completed a medication administration check-off form the day before the incident, indicating that she met the required tasks. Interviews with other medication aides and the Director of Nursing (DON) confirmed that training and safeguards were in place to prevent such errors, but the incident was attributed to communication and human error.
Deficiency in Dietary Staff Certification
Penalty
Summary
The facility failed to provide sufficient support personnel with the appropriate competencies and skills to carry out the functions of the food and nutrition service. Specifically, five out of nine dietary staff members did not possess a current food handler's certificate from the date of hire until August 13, 2024. This deficiency was identified through observations, interviews, and record reviews. The absence of these certificates could place all residents consuming food prepared in the kitchen at risk of foodborne illness. Interviews revealed that the Dietary Manager (DM) acknowledged the requirement for all dietary staff to have an accredited food handler's certificate before working in the kitchen. However, the DM stated that the staff underwent training through Relias, a computer-based education system, and on-the-job training. The Administrator also believed that Relias was accredited based on guidance from the corporate office, but this was not the case. The Relias customer service confirmed that they were not affiliated with any state-level accreditation programs. Furthermore, the facility failed to provide records of in-service training for dietary staff, and the policy for dietary new hire training was unavailable.
Failure to Follow Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a lunch service on the 200 hall bistros. Dietary Aide C was seen using her bare hands to pick up pickles and onions, placing them into residents' sandwiches without wearing gloves or using utensils. This action was witnessed by the Assistant Director of Nursing (ADON), who did not intervene or correct the behavior. Dietary Aide C later acknowledged that she should have used utensils or gloves to prevent cross-contamination, as per facility policy. Interviews with facility staff revealed that the Dietary Manager (DM) was responsible for training new kitchen staff on proper food handling and serving procedures, although she did not maintain documentation of this training. The Director of Nursing (DON) confirmed that dietary staff received specific training from their manager, separate from nursing staff. The Administrator stated that new dietary personnel underwent general facility orientation, job-specific training through RELIAS, and on-the-job training with the dietary supervisor. Despite these training protocols, the incident occurred, indicating a lapse in adherence to the established food safety policies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gatesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coryell Health Rehab Living At The Meadows | 3.9 mi | ★★★★★ | 9 | 0 |
| Mcgregor Wellness & Rehabilitation | 17.5 mi | ★★★★★ | 6 | 0 |
| St. Joseph's Care Center | 17.5 mi | — | 2 | 0 |
| Avir At Killeen | 20.8 mi | ★★★★★ | 13 | 0 |
| Rosewood Heights | 21 mi | ★★★★★ | 5 | 0 |
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