Hill Country Rehab And Nursing Center

F-F689 Free from Accidents/ Hazards

Interventions:

1. DNS/Designee conducted a 100% Audit of all residents who reside in the community was conducted on 6/20/2024 to validate care plans and Kardex accuracy reflected the current care needed for each resident. 12 residents were identified during this process and care plan/Kardex was updated to reflect the current need of each resident identified.

Date commenced: 6/20/2024

Date completed: 6/21/2024

2. All 12 residents identified with care plan updates were assessed on 6/21/2024 with no negative outcomes.

Date completed: 6/21/2024

3. AdHoc meeting to address issue, correction, action plan and plan of removal with Administrator, Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Operations and Medical Director was conducted on 6/22/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 675536 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675536 B. Wing 06/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

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 0689 4. DNS/ADNS/Designee (Charge Nurse) will ensure all staff on leave/agency staff /PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an Level of Harm - Immediate assignment of patient care until they have passed skills validation of accessing the Kardex. Community will jeopardy to resident health or ensure administrative nursing staff in the community to provide in-service/education prior team members safety working their assigned shift. These trainings will also be conducted with new hires.

Residents Affected - Few In-services:

5. Regional Nurse (Director of Clinical Operations) re-educated the Director of Nursing on the following:

oImportance of nursing staff reviewing the Kardex before providing care to ensure proper level of care is provided according to the resident's need and adherence to the resident's plan of care. Staff should report any concerns or inaccuracies of the care plan/Kardex to the charge nurse/licensed nurse for direction prior to care being provided, so that the licensed nurse can evaluate the resident and determine the appropriate level of care necessary as well as monitoring the resident to ensure that the appropriate care is being provided in accordance to the resident's needs; thus, updating the care plan/Kardex as indicated.

The licensed nurse should ensure that the appropriate care needs are communicated across all shifts by reviewing the information with the on-coming shift nurse, in order to ensure that care provided is consistently provided in a safe manner until the plan of care/Kardex has been updated.

The IDT will review and update the plan of care with necessary changes within 24-72 hrs as per the RAI, which indicates that necessary changes to the plan of care should be within a reasonable period of time. Until the plan of care has been updated the charge nurses will continue to communicate necessary care to be provided during shift-to-shift report.

Preventing Accidents/Fall Prevention/Promoting a Safe Environment: identifying risk, reducing risks, and promoting an accident-free environment as indicated in the plan of care.

6. All Nursing Team Members were educated on providing care to residents were re-educated/re-trained by

the Director of Nursing or Designee.

Nursing staff reviewing the Kardex before providing care to ensure proper level of care is provided according to the resident's need and adherence to the resident's plan of care. Staff should report any concerns or inaccuracies of the care plan/Kardex to the charge nurse/licensed nurse for direction prior to care being provided, so that the licensed nurse can evaluate the resident and determine the appropriate level of care necessary as well as monitoring the resident to ensure that the appropriate care is being provided in accordance to the resident's needs; thus, updating the care plan/Kardex as indicated.

The licensed nurse should ensure that the appropriate care needs are communicated across all shifts by reviewing the information with the on-coming shift nurse, in order to ensure that care provided is consistently provided in a safe manner until the plan of care/Kardex has been updated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 675536 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675536 B. Wing 06/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

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 0689 The licensed nurse should ensure that the appropriate care needs are communicated across all shifts by reviewing the information with the on-coming shift nurse, in order to ensure that care provided is consistently Level of Harm - Immediate provided in a safe manner until the plan of care/Kardex has been updated. Education provided to all Nursing jeopardy to resident health or Department Preventing Accidents/Fall Prevention/Promoting a Safe: identifying risk, reducing risks, and safety promoting an accident-free environment indicated in the plan of care by DNS/Designee.

Residents Affected - Few The IDT will review and update the plan of care with necessary changes within 24-72 hrs as per the RAI, which indicates that necessary changes to the plan of care should be within a reasonable period of time. Until the plan of care has been updated the charge nurses will continue to communicate necessary care to be provided during shift-to-shift report.

DNS/ADNS/Designee conducted 100% audits of skills validation of accessing the Kardex by return demonstration; observing the direct care team member is has verified competency by return demonstration of accessing the Kardex to review the level of care to be provided.

Date commenced: 6/20/2024

Date completed: 6/22/2024

7. All licensed nurses were re-educated on the completion and accuracy of care plans to ensure they reflect

the current needs of each resident. Baseline Care plans must be completed within 48 hours of admission. Care plans must be updated as clinically indicated. Kardex must be initiated upon admission and updated as clinically indicated.

Date commenced: 6/20/2024.

Date completed: 6/22/2024.

Risk Response:

Residents who currently reside in community potentially can be affected by the deficient practice.

DNS/Designee conducted a 100% Audit of all residents who reside in the community was conducted on 6/20/2024 to validate care plans and Kardex accuracy reflects the current care needs for each resident. 12 residents were identified during the review process. Careplan/Kardex were updated to reflect the current need of each resident identified.

Date commenced: 6/20/2024.

Date completed: 6/21/2024

The DNS (Director of Nursing) will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. The DNS will ensure administrative nursing staff will provide in-service/education prior team members working their assigned shift.

These trainings will also be conducted with new hires.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 675536 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675536 B. Wing 06/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

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 0689 The Administrator is responsible for validating that all tasks assigned and monitoring efforts (as indicated on

this plan) has been achieved and that compliance is maintained. Level of Harm - Immediate jeopardy to resident health or Systemic Response: safety 100% Direct care educated on review of the Kardex before providing care to all residents assigned to them Residents Affected - Few to ensure proper assistance and interventions are utilized according to the resident's need and adherence to

the resident's plan of care. Reporting any concerns or inaccuracies to the charge nurse/licensed nurse for additional direction prior to care provided.

100 % Education provided to all Nursing Department Preventing Accidents/Fall Prevention/Promoting a Safe: identifying risk, reducing risks, and promoting an accident-free environment indicated in the plan of care by DNS/Designee.

100% care plans were reviewed for all residents with fall prevention interventions to ensure interventions on

the Kardex are in place.

100% validation of accessing the Kardex was conducted on all nursing department.

Date commenced: 6/20/2024

Date of completion: 6/22/2024

The Director of Nursing / Asst. Director of Nursing will ensure all staff on leave/agency/PRN staff are in serviced prior to working their shift. No licensed nurse, certified medication aide or certified nurse aide will assume an assignment of patient care until they have passed skills validation of accessing the Kardex. DNS will ensure administrative nursing staff will provide in-service/education prior team members working their assigned shift. These trainings will also be conducted with new hires.

The Administrator is responsible for validating that all tasks assigned and monitoring efforts (as indicated on

this plan) has been achieved and that compliance is maintained.

Monitoring Response:

The Administrator/ DNS/ designee will conduct weekly rounds to validate interventions related to fall prevention is in place 1-7 days a week for 2 months. The DNS/Designee will conduct random skills validations regarding Kardex use 3-7 days a week for 2 months to ensure direct staff is compliant with the use of the Kardex. Policies are followed to ensure the safety and wellbeing of our residents. Additional education will take place based on needs observed during this process. The Administrator is responsible for validating that all tasks assigned and monitoring efforts (as indicated on this plan) has been achieved and that compliance is maintained. All findings will be reported to the QAPI committee during monthly meeting until there is 100% compliance observed during observations.

On 06/22/24 and 06/23/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:

06/22/24:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 675536 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675536 B. Wing 06/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

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 0689 In an interview on 06/22/24 at 09:15 AM with the DON, she stated she had already sent out the care feed system (a system that communicated with all staff via text) in services facility wide to all staff related to Level of Harm - Immediate accessing Kardex, ANE, Fall Prevention and Care Plans. She stated that they have visually checked off staff jeopardy to resident health or prior to their shift to ensure they are able to access the Kardex system and training is ongoing and in safety progress. She stated Care plans were updated for the 12 residents of concern related to transfer status. Education will remain ongoing until 100% of staff are trained. Residents Affected - Few Staff education:

28 staff were educated on Kardex

30 staff were educated on ANE

28 staff were educated on Fall Prevention

9 (nurses) staff were educated on Care Plans

Record reviews were conducted by surveyor. 12 residents were identified during the review process by DON and RDCO. Care plans/Kardex were updated to reflect the current need of each resident identified. Surveyor verified updated care plans for 12 residents affected.

QAPI committee meeting to address issue, correction, action plan and plan of removal with Administrator, Director of Nursing Services, Assistant Director of Nursing Services, Director of Clinical Operations and Medical Director was conducted on 6/22/2024. Sign in sheet was obtained by surveyor.

An interview on 06/22/24 at 09:36 AM with RN G, she validated she knew where to find information on the care needs of the resident via the Kardex and POC. She verbalized examples of fall prevention and hazard free environment and demonstrated action to take in response to how to know about a change of condition.

An interview and observation on 06/22/24 at 09:40 AM with the ADON validated training on accessing the Kardex to determine the transfer needs of the resident by accessing the Kardex and POC. The ADON was observed in return demonstration via the computer. Prevention of falls to include gait belts, ensuring correct method of transfer. The ADON stated CNAs know to consult PT when transfer needs of the resident are in question.

An interview on 06/22/24 at 09:49 AM with PT H, he discussed how and when CNAs are trained and stated that they will routinely seek out PT for guidance on how best to transfer residents.

An interview on 06/22/24 at 09:51 AM with CNA E verbalized the need to access Kardex to know transfer status and care needs of the resident. She stated the prevention of falls includes interventions such as appropriate socks and shoes, gait belt, get help if needed with transfers.

An interview on 06/22/24 at 10:01 AM with CMA I, she confirmed recent training on Kardex and accessing information regarding the status of resident transfers. She stated she consistently assists with transfers as needed, especially in the use of the Hoyer Lift. Able to discuss various methods for fall/accident prevention: ie, appropriate shoes/socks, gait belt.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 675536 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675536 B. Wing 06/23/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522

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 0689 An interview on 06/22/24 at 10:13 AM with CNA F she stated that was her first day working there and she was able to verbalize the process to access the Kardex and POC. Level of Harm - Immediate jeopardy to resident health or An interview on 06/22/24 at 10:20 AM with LVN J she stated she had received training and then safety demonstrated knowledge on how to access the EMR and POC. She stated she takes that information into consideration but will also conduct her own nursing assessments. Residents Affected - Few

An interview on 06/22/24 at 10:45 AM with CMA K she confirmed she received training related to transfers and accessing the EMR and POC on 06/21/24. CMA K verbalized interventions for prevention of falls (low bed, making sure resident is toileted frequently, and making sure floors are clear of debris). CMA K confirmed that she also received training on 06/21/24 related to ANE and stated the ANE coordinator was

the ADM.

An interview on 06/22/24 at 10:54 AM with LVN L she confirmed recent training on how to locate information regarding resident transfer needs via Kardex and POC. She was able to verbalize methods of fall prevention (i.e., bed low, scoop mattress, check often, fall mat) in response to fall, nurse does the assessment. She confirmed recent training on ANE and stated the administrator was the ANE coordinator.

An interview on 06/22/24 at 10:59 AM with CNA M she confirmed training on access of Kardex/POC in order to identify resident needs for assistance with transfers. She stated prevention measures may include ensure appropriate toileting times, have call light in place, checking Kardex for transfer needs. CNA M confirmed recent ANE training and stated the ANE coordinator was the administrator.

An interview on 06/22/24 at 11:06 AM with LVN N she confirmed training on access of Kardex/POC to identify resident needs for assistance with transfers. She said in the event of a fall, she would first assess for

a change in condition, she would then check vitals, get a gait belt, and notify the Charge Nurse. She stated prevention could include assessing toileting needs and having call light in place. She confirmed recent ANE training and states the ANE coordinator is the administrator and said, that information is posted everywhere.

06/23/24:

Staff education remained ongoing [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 675536