Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillview Nursing & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to conduct neurological assessments on two residents after unwitnessed falls, despite policies requiring such evaluations. One resident with severe cognitive impairment fell and was found on the floor, but no neurological checks were done. Similarly, another resident with Alzheimer's disease experienced a fall without subsequent neurological assessment. Interviews revealed a lack of recent training on this protocol, and the facility's policies were not followed, resulting in deficiencies.
The facility failed to maintain food safety and sanitation standards in its kitchen. Dietary staff did not practice proper hand hygiene, touching contaminated surfaces and then handling clean dishes and utensils without washing their hands. Additionally, food items were not properly labeled, dated, or sealed, violating facility policies and FDA guidelines. These deficiencies could lead to foodborne illnesses among residents.
The facility failed to maintain a safe environment for 27 residents in the memory care unit by not addressing a loose handrail in the community bathroom. Despite the facility's policy requiring staff to report maintenance issues, no report was made for the handrail. The ADM was unaware of the issue until the survey, and the MNTD had not yet secured the handrail despite being informed by a CNA. The facility's Angel Round checklist did not include the bathroom, contributing to the deficiency.
The facility failed to provide adequate nail care for several residents, resulting in poor hygiene and potential health risks. Observations showed that residents had a blackish/brownish substance under their fingernails, indicating a lack of proper care. Despite the facility's policy on ADLs, there was no documentation of nail care in the residents' medical records, and staff interviews revealed inconsistencies in the execution of nail care responsibilities.
Three residents with prescribed mechanically altered diets received meals with unpeeled potatoes, contrary to their dietary needs. Staff interviews revealed a failure to ensure meal trays matched meal tickets, risking residents' ability to chew and swallow properly.
The facility failed to maintain an effective infection control program, as staff did not consistently perform hand hygiene or sanitize equipment between residents. A medication aide did not sanitize hands after glove removal, and CNAs moved a Hoyer lift between residents without cleaning it. Staff interviews confirmed non-compliance with facility policies, risking infection spread among residents with conditions like Alzheimer's and COPD.
The facility failed to provide two residents with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) when their Medicare Part A coverage ended. This oversight could lead to residents being unaware of potential financial liability for services not covered by Medicare. Interviews revealed a lack of training and safeguards for proper SNF ABN disbursement.
Two residents in a LTC facility shared a bathroom with a call light switch positioned 2.5 feet from the floor, lacking a string to extend to the floor, making it inaccessible if they fell. Resident #4, with schizophrenia and anxiety disorder, and Resident #50, with a traumatic brain injury, were both at risk due to this deficiency. Staff interviews revealed a lack of awareness and training about the requirement for the string, and the facility's Angel Rounds checklist did not specify checking for it.
A resident's medication, Ondansetron, was misappropriated by a CMA for personal use, despite existing accountability measures like medication counts and cameras. The resident, with Alzheimer's and heart disease, was at risk of not receiving prescribed medication. Staff interviews confirmed awareness of policies against misappropriation, but the incident was deemed isolated by the DON and ADM.
Failure to Conduct Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to conduct neurological assessments on two residents following their unwitnessed falls, which is a deviation from professional standards of practice. Resident #1, a male with severe cognitive impairment and a history of neurocognitive disorder with Lewy bodies, experienced an unwitnessed fall on 12/05/24. Despite being found on the floor, no neurological assessments were initiated or completed, as confirmed by the absence of such documentation in his records. The charge nurse, LVN A, used personal judgment to decide against initiating neurological checks, citing the resident's position and the presence of a fall mat. Similarly, Resident #2, a female with Alzheimer's disease and severe cognitive impairment, had an unwitnessed fall on 01/31/25. Although she was assessed for immediate injuries and her family and physician were notified, no neurological assessments were conducted post-fall. The facility's policies clearly state the necessity of such assessments following unwitnessed falls, yet these were not adhered to in either case. Interviews with the facility's administration and nursing staff revealed a lack of recent in-service training on neurological assessments and falls. Both the Administrator and the Director of Nursing acknowledged the importance of these assessments but were unaware of their omission until informed by the surveyor. The facility's policies, revised in 2010 and 2018, emphasize the need for neurological checks after unwitnessed falls, yet these protocols were not followed, leading to the identified deficiencies.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in its kitchen operations. Observations revealed that dietary staff did not practice proper hand hygiene and glove use. One dietary staff member was seen touching her shirt and a cleaning towel without washing or sanitizing her hands before putting on gloves and handling clean plates and utensils. Another dietary aide was observed touching her clothes multiple times without washing her hands before handling residents' napkins, dessert plates, and cups of tea. A dietary dishwasher aide also failed to wash her hands after handling her cellphone and then touched clean plates and forks. Additionally, the facility did not properly label, date, or seal food items in storage. Observations in the kitchen's food prep area showed tortillas in a non-sealed bag without a label or date, and hamburger meat and ice-covered chicken in clear bags without labels or dates. These items were not in their original packaging, which is against the facility's policy and the Food and Drug Administration Food Code. Interviews with the dietary manager and administrator confirmed that the staff were expected to wash their hands after touching anything considered contaminated, such as clothes or cellphones. The dietary manager acknowledged that improperly stored food could affect its quality and taste, and that it was her responsibility to ensure food was stored correctly. The facility's policies on sanitation and food handling, as well as storage, were not followed, leading to potential risks of foodborne illnesses for residents.
Failure to Maintain Safe Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for 27 residents in the memory care unit by not addressing a maintenance issue with a loose handrail in the community bathroom. Observations revealed that the handrail had 1 to 2 inches of vertical movement, which could have posed a risk of falls to the residents. Despite the facility's policy requiring staff to report maintenance issues in a maintenance book, no such report was made for the handrail. Interviews with staff, including a CNA and the ADM, indicated that the issue was known but not properly communicated or documented in the maintenance log. The ADM was unaware of the loose handrail until it was brought to her attention during the survey. The MNTD confirmed that he was informed of the issue by the CNA a day before the surveyor's observation but had not yet secured the handrail. The facility's Angel Round checklist, which is supposed to identify maintenance issues, did not include a line item for checking the memory care unit's community bathroom. The facility's Preventative Maintenance Policy, dated 2003, outlines the need for a comprehensive preventive maintenance program, but the lack of documentation and communication led to the deficiency.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not ensure that the fingernails of four residents were cleaned, which could place them at risk for poor hygiene, dignity issues, and decreased quality of life. Observations revealed that these residents had a blackish/brownish substance underneath their fingernails, indicating a lack of proper nail care. Resident #23, a female with moderate cognitive impairment and dementia, was observed with dirty fingernails. Despite requiring supervision with showers and being independent with personal hygiene, her care plan indicated she needed assistance with dressing, personal hygiene, and bathing. Similarly, Resident #29, a male with severe cognitive impairment and vision issues, was dependent on staff for personal hygiene and was also observed with dirty fingernails. Resident #104, a female with severe cognitive impairment and Parkinson's disease, required assistance with personal hygiene and was found with a similar substance under her nails. Interviews with staff, including the Director of Nurses and CNAs, revealed inconsistencies in the responsibility and execution of nail care. The facility's policy on ADLs emphasized the importance of nail care to prevent infections, yet there was no documentation in the residents' medical records regarding when nail care was provided or the condition of the nails. Staff acknowledged the potential health risks of the blackish substance, which could contain bacteria, but there was a lack of adherence to the facility's policy and procedures for nail care.
Failure to Provide Prescribed Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that therapeutic diets were prescribed by the attending physician and properly implemented for three residents who required mechanically altered diets. On the specified date, these residents were observed receiving meals that did not match their prescribed dietary requirements. Specifically, the residents were supposed to receive peeled roasted new potatoes as part of their mechanically soft diet, but the potatoes served had the skin intact, which was not suitable for their dietary needs. Resident #18, diagnosed with Alzheimer's Disease and diabetes mellitus type 2, was observed struggling with the potato skins due to a lack of teeth, which made it difficult for him to chew. Similarly, Resident #26, also diagnosed with Alzheimer's Disease and heart disease, was assisted by a CNA who cut the potatoes into small pieces but did not recall if the resident had difficulty eating them. Resident #30, with chronic obstructive pulmonary disease and diabetes mellitus type 2, removed the potato skins herself due to difficulty chewing and swallowing them. Interviews with staff revealed a breakdown in the process of ensuring meal trays matched the residents' meal tickets. LVN D admitted to not comparing meal tickets to meal trays, and LVN A confirmed that neither she nor other nursing staff checked the meal tickets for accuracy. The dietary manager and the Director of Nursing acknowledged the failure in the system, attributing it to misreading or not identifying discrepancies in meal tickets, which could lead to residents receiving incorrect meal textures.
Infection Control Deficiency Due to Improper Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and equipment sanitation. Observations revealed that a medication aide (MA) did not perform hand hygiene after removing gloves and before touching the medication cart and other items, potentially contaminating them. This occurred during medication administration to several residents, including one with Alzheimer's and another with COPD, both of whom have varying levels of cognitive impairment. Additionally, two certified nursing assistants (CNA-A and CNA-B) were observed moving a Hoyer lift between residents without sanitizing it, despite the equipment being touched by residents. This lack of sanitation was noted when transferring residents with conditions such as Parkinsonism and neurocognitive disorder, which could increase their vulnerability to infections. The CNAs did not clean the Hoyer lift between uses, contrary to the facility's policy, which requires cleaning and disinfecting reusable equipment between residents. Interviews with staff, including licensed vocational nurses (LVN-A and LVN-B), a certified nursing assistant (CNA-C), the director of nursing (DON), and the administrator (ADMIN), confirmed that the facility's policies on hand hygiene and equipment cleaning were not followed. The staff acknowledged the importance of these practices in preventing the spread of infections and the potential negative outcomes for residents if not adhered to. The facility's policies clearly state the necessity of hand hygiene before and after resident contact and the cleaning of reusable equipment between uses, yet these protocols were not consistently implemented.
Failure to Provide Advance Notice of Non-Coverage for Medicare Services
Penalty
Summary
The facility failed to provide advance notice of change in services and charges not covered under Medicare for two residents reviewed for Medicaid and Medicare Coverage Liability Notices. Specifically, the facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055 (SNF ABN) to Resident #27 and Resident #28 when they were discharged from Medicare Part A skilled nursing services. This oversight could place the residents or their representatives at risk of not being fully informed about services covered by Medicare Part A and unknowingly being charged for skilled nursing services. Resident #27, a man diagnosed with diabetes mellitus type 2 and vascular dementia, experienced a change in payer source from Texas Medicaid to Medicare Part A, which terminated on August 1, 2024. Similarly, Resident #28, diagnosed with a neurological disorder with Lewy Body and hypertension, had a payer source change from Texas Medicaid to Medicare Part A, which ended on May 1, 2024. Both residents remained in the facility after their Medicare Part A coverage ended, but neither received the required SNF ABN to inform them of potential financial liability for services not covered by Medicare. Interviews with the Business Office Manager (BOM) and the Administrator (ADMIN) revealed a lack of training and safeguards in place to ensure proper SNF ABN disbursement. The BOM was not provided with adequate resources or training to calculate when a resident should receive an SNF ABN, and the ADMIN acknowledged the responsibility for this failure. The facility's Resident Rights Policy and the Medicare Claims Processing Manual outline the requirement to inform residents of changes in services and charges, but these procedures were not followed, leading to the deficiency.
Inadequate Call System in Resident Bathroom
Penalty
Summary
The facility failed to provide an adequate call system in the shared bathroom of two residents, which could prevent them from calling for assistance if they fell. The call light switch in the bathroom was positioned approximately 2.5 feet from the floor and required a downward pull to activate. However, the switch lacked a string that extended to the floor, making it inaccessible to residents who might be lying on the floor. This deficiency was observed during a survey, and interviews with the residents confirmed their lack of awareness about the missing string and their potential inability to call for help in case of a fall. Resident #4, a man with schizophrenia, hypertension, and anxiety disorder, was independent in his mobility and toileting activities. Despite his independence, his care plan emphasized the importance of having the call light within reach. During an interview, he expressed that he would feel helpless and angry if he fell and could not reach the call light switch. Similarly, Resident #50, who had a traumatic brain injury and moderate cognitive impairment, required assistance with mobility and toileting. His care plan also highlighted the need for the call light to be accessible. Interviews revealed that he could transfer himself to the commode but had communication difficulties that limited his ability to elaborate on his needs. Interviews with staff, including a CNA and the Maintenance Director, revealed a lack of awareness and training regarding the requirement for the call light string to extend to the floor. The facility's Angel Rounds checklist, used for routine inspections, did not specify the need to check for the string's presence. The Director of Nursing acknowledged the oversight in staff training and the checklist, noting the potential risks to residents if they could not call for help. The Administrator also confirmed the deficiency, admitting that the Angel Rounds checklist did not include checking for the string, and she had not noticed the missing string during her inspections.
Misappropriation of Resident Medication by Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their medication, specifically Ondansetron, by a Certified Medication Aide (CMA-A). The resident, a male with Alzheimer's Disease, heart disease, and other comorbidities, was prescribed Ondansetron to manage nausea. However, CMA-A admitted to taking the medication for personal use due to feeling nauseated, which was documented in a written statement. Interviews with other staff members, including another CMA and a Licensed Vocational Nurse (LVN), revealed that they were unaware of any routine misappropriation of medications by staff. They confirmed that accountability measures, such as medication counts and the presence of cameras, were in place. The Director of Nursing (DON) and the Administrator (ADM) also confirmed these measures and stated that the incident was isolated, with appropriate disciplinary action taken against CMA-A. The facility's policies on resident rights and the reporting of abuse, neglect, and misappropriation were reviewed, indicating that employees are required to treat residents with respect and report any suspicions of misappropriation immediately. Despite these policies, the incident occurred, highlighting a lapse in adherence to the facility's procedures designed to protect residents from such occurrences.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Goldthwaite
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Goldthwaite Health & Rehab Center | 0.5 mi | — | 1 | 0 |
| San Saba Nursing & Rehabilitation | 20.5 mi | — | 0 | 0 |
| Cross Country Healthcare Center | 28.3 mi | — | 1 | 0 |
| Pecan Bayou Nursing And Rehabilitation | 29.6 mi | — | 0 | 0 |
| Oak Ridge Manor | 29.7 mi | — | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hillview Nursing & Rehabilitation.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.