Inspection visit

Health inspectionDecember 6, 2023

HILLSIDE HEIGHTS REHABILITATION SUITESCMS #6754986 citations on this visit

6 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 6 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #7) reviewed for incontinent care. - Facility failed to obtain order for foley catheter care for Resident #7. This deficient practice could place residents at risk by exposing them to care that could lead to infection, tissue breakdown, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: Record review of Resident #7's face sheet revealed that Resident #7 is a [AGE] year-old female with diagnoses of Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Neuromuscular dysfunction of bladder, unspecified, urinary tract infection, Alzheimer's disease, muscle wasting and atrophy, muscle weakness. Record review of Resident #7's last MDS, dated [DATE] revealed a BIMs of 03. MDS did not reflect the need for a foley catheter at the time of the assessment. Record review of Resident #7's care plan, dated 11/10/2023, did address Residents foley catheter. Record review of Resident #7's physicians orders, dated 12/05/2023 revealed that there was no order for residents foley catheter. Observation on 12/04/23 at 12:36 PM Resident #7 in dining room eating lunch. Resident was unable to answer questions. Foley Catheter was hanging in a privacy bag under resident's wheelchair. Interview on 12/05/2023 at 11:27 AM with DON stated she would find the foley catheter order. Record review of physicians order dated 11/09/2023, for the diagnosis of Neuromuscular dysfunction of bladder,indicated a discontinue date of 11/19/2023. Interview on 12/06/23 at 09:36 AM with LVN B was asked if she could find an order for catheter care for Resident #7. LVN could not find order. LVN stated that a negative outcome for not performing catheter care could lead to an infection. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 12 Event ID: 675498 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 12/06/23 at 09:47 AM DON brought an order dated 12/06/2023 for foley catheter care to be performed every shift by nursing assistant, she stated a previous order for catheter care was not in place before now. Interview on 12/06/23 at 02:48 PM during the exit conference DON stated the care plan would cover care for a resident's need for foley catheter care, and there didn't need to be an order for catheter care. Record review of facility provided policy titled Physicians Orders, revised 05/05/2023, revealed under the title Procedures 3. .C. Routine care orders to maintain or improve the Resident's functional abilities until staff can conduct a comprehensive assessment and develop an appropriate care plan. Record review of facility provided policy, named Lippincott Nursing Procedures, 9th Edition, undated revealed under title Implementation stated the following: Catheter care . .Review the necessity of continued urinary catheter use; remove the catheter (as ordered or according to facility protocol) as soon as it's no longer clinically indicated to reduce the risk of CAUTI. .Provide routine hygiene for meatal care; .Clean after each bowel movement; FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #26) of 4 residents reviewed for feeding tubes, in that: -The facility staff failed to raise the head of Resident #26's bed during his nutritional feeding This failure could affect residents in the facility receiving enteral feeding by placing them at risk of complication such as aspiration pneumonia, pneumothorax, perforations, empyema, bronchopleural fistula, and hospitalization. Finding include: Observation on 12/04/23 at 09:30 AM Resident #26 lying flat in bed, his tube feeding of Jevity was infusing at 76ml/hr. Resident 26's right hand and both legs were contractured. Resident #26 was not interviewable. Record review of Resident #26 medical records, dated 12/04/2023 revealed Resident #26 is a [AGE] year-old male with the diagnosis of Unspecified injury of head, gastro-esophageal reflux disease ( acid reflux) , muscle wasting (break down of muscle), muscle weakness, traumatic seizures, dysphagia (difficulty swallowing), Quadriplegia (paralysis of all four limbs, insomnia, contracture (hardening of muscles) of the knee and wrist, depression, anxiety, constipation and muscle spasms (a sudden involuntary muscular contraction or convulsive movement. Record review of Resident #26's MDS, dated [DATE], revealed Resident #26 has a BIMS of 00. Record review of Resident #26's physicians orders, dated 12/04/2023, revealed the following order for the following: Enteral Feeding: Elevate HOB 30- 45 degrees during Jevity feeding and one hour after. Every Shift First 06:00 - 18:00, Second 18:00 - 06:00 Observation on 12/04/23 at 2:45 PM Resident #26 observed was watching TV in bed, was lying flat in bed with tube feeding going. Observation on 12/05/23 at 09:25 AM Resident #26 was lying flat in bed with tube feeding running at 76ml/hr. Interview on 12/05/23 at 09:29 AM CNA E- stated Resident #26's bed was currently 30-45 degrees elevated at the head of the bed. CNA stated they (staff) estimate how many degrees the bed was elevated and there was no way to measure. CNA stated the negative outcome for Resident #26 was aspirating (inhaling) tube feeding liquid if the head of the bed was not elevated to the correct degrees. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 12/05/23 at 09:52 AM LVN B stated Resident #26 gets 60mL of water before and after any medication, and usually received that an estimated 4 times a day. LVN B stated residents head of the bed was currently estimated at 35 degrees elevated. LVN B stated that the negative outcome of the bed not being appropriately leveled is choking and can lead to death. Observation on 12/05/23 at 09:55 AM Resident #26's head of bed was not flat but unable to determine degree of elevation. Interview on 12/05/23 at 11:22 AM, with DON stated when Resident's receiving tube feeding the HOB should be elevated between 30-45 degree, but they (staff) verify the orders. The DON stated risk of the head of the bed not being elevated appropriately include various risk factors depending on the type of tube feeding. The DON stated beds are marked to where 30 degrees is pre-measured and lets the staff know when the resident is raised at least 30 degrees. The DON stated anyone who works with a resident who had a PEG tube should be trained. The DON stated her newer staff had not been trained and would be doing an in-service today. The DON stated staff was trained every couple of months and as needed. Observation on 12/05/23 at 11:26 AM DON demonstrated the black mark on the bed, but the mark was not visible. DON stated she would have maintenance remark them on the appropriate beds. Interview on 12/05/23 at 11:50 AM with Maintenance Director, stated he measured the head of bed elevation using a square level and mark the minimum degree of 30 degrees on the bed. He stated he does this monthly during his monthly inspections of the beds. Record review of maintenance logs did not indicate beds were inspected for markings for 30 degrees at the head of bed. Record review of facility provided policy, named Lippincott Nursing Procedures, 9th Edition, undated revealed under title Implementation stated the following: .Position the patient with the head of the bed elevated to at least 30 degrees or upright in a chair to prevent aspiration. If this position is contraindicated, consider a reverse Trendelenburg position. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 2 (Resident #13 and #17) of 6 residents reviewed for respiratory care. Residents Affected - Few The facility failed to obtain orders for Resident #13's oxygen therapy. The facility failed to obtain orders for Resident #17's oxygen therapy. This failure could place residents at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition. Findings include: Resident #13 Record review of Resident #13's face sheet revealed a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), pain, shortness of breath, acute respiratory failure (the inability of the respiratory system to meet the oxygenation, ventilation or metabolic requires of the patient), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Record review of Resident #13's MDS completed 9-28-2023 listed her with a BIMS of 13 indicating she was cognitively intact, and she had a functionality of requiring one-person assistance with most of her activities of daily living. Section O-Special Treatments, Procedures, and Programs-Respiratory Programs: Oxygen Therapy-Resident #13 was marked not having oxygen while a resident. Record review of Resident #13's Physician Orders created 12-6-2023 with active orders for December-2023 revealed no orders for oxygen therapy. Record review of Resident #13's care plan last review date of 11-1-2023 revealed no care plans for oxygen therapy. Record review of Resident #13's Vital Signs: O2 Saturation created 12-6-2023 revealed the following: O2 saturations checked from 5-1-2023 to 9-19-2023 were never below 90%. Resident #13's O2 saturation was not checked after 9-19-2023. During an observation and interview on 12-04-2023 at 09:44 AM, Resident #13 was sitting up in her recliner. Noted was an oxygen concentrator on the opposite side of her bed that was on, set at 2liters per minute, and her oxygen tubing and nasal cannula was laying on Resident #13's bed. Resident #13 reported that she wears her O2 most of the time during the day and night when she feels she needs it but that she does not require it all the time. That she will sometimes go to the bathroom and forget to put it back on. She reported that she has used oxygen in this facility for about a year. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 12-04-2023 at 12:21 PM, Resident #13 was in her room sitting in her recliner. Resident #13 was wearing her oxygen via her nasal cannula. Resident #13 was eating her lunch. During an interview on 12-6-2023 at 09:41 AM, the DON reported that she reviewed Resident #13 clinical record and found no orders and no care plans for her oxygen therapy. The DON reported that LVN B (the nurse responsible for Resident #13 this shift) was a new nurse and was to nervous to answer questions asked by this surveyor. Resident #17 Record review of Resident #17's face sheet revealed a [AGE] year-old female resident admitted to the facility originally on 8-10-2023 and readmitted on [DATE] with diagnoses to include chronic obstructive pulmonary disease(a group of lung diseases that block airflow and make it difficult to breath), chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), pain, congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it should), and chronic kidney disease (longstanding disease of the kidneys leading to kidney failure). Record review of Resident #17's clinical record revealed her last MDS was a quarterly completed 11-14-2023 listing her with a BIMS of 8 indicating she was moderately cognitively impaired, and she had a functionality of requiring substantial assistance with most of her activities of daily living. Section O-Special Treatments, Procedures, and Programs-Respiratory Programs: Oxygen Therapy-Resident #17 was marked not having oxygen while a resident. . Record review of Resident #17's Physician Orders created 12-6-2023 with active orders for December-2023 revealed no orders for oxygen therapy. Record review of Resident #17's care plan revealed the following: Resident requires oxygen therapy R/T COPD Start Date: 12-6-2023. No other care plans noted related to oxygen therapy. Record review of Resident #17's Vital Signs: O2 Saturation created 12-6-2023 revealed the following: O2 saturations checked from 8-10-2023 to 12-6-2023 were never below 90%. During an observation on 12-05-2023 at 11:12 AM, Resident #17 was in her room sitting in her wheelchair. Resident #17 was receiving her nose spay treatment from the floor nurse. After the treatment the nurse placed Resident #17's oxygen nasal canula back in her nose. The nasal canula was attached to the oxygen tank on the back of her wheelchair and was set a 3 liter per minute. During an observation on 12-06-2023 at 08:45 AM, Resident #17 was in the hallway with her oxygen nasal cannula in her nose. The nasal cannula was attached to the oxygen tank on her wheelchair. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0695 oxygen tank was set at 3 liters/min. Level of Harm - Minimal harm or potential for actual harm During an interview on 12-06-2023 09:00 AM, ADON A was asked if she could find any orders or care plans for Resident #17 concerning her oxygen therapy. ADON A reviewed Resident #17's chart and reported that she could not find 02 orders or find anything in Resident #17's care plan for 02 therapy. ADON A reported that a negative outcome for not having oxygen order or care plans for oxygen therapy would be that the nurse taking care of the resident would not be able to see that resident needs 02 for their condition especially Resident #17's COPD. Residents Affected - Few During an interview on 12-06-2023 at 10:32 AM, the DON verified that orders for Oxygen therapy should be in a resident's chart along with notification in the CNA section of the resident's chart to address the care they provide. The DON reported that it is the responsibility of the entire care team to ensure that each resident has the orders they need in their chart to ensure their care is provided. The DON reported that all resident on respiratory therapy to include oxygen should have that therapy included in their care plans and orders if needed, and that if that care is not addressed in the care plans and/or orders that there will not be continuity of care between the team members providing care and the resident could be affected in a negative way. Record review of the facility provided policy titled Physician Orders revised 5-5-2023 revealed the following: 3. Upon admission, the facility has physician orders for the resident immediate care to include but not limited to: B. Medications MEDICATION/TREATMENT: 1. The facility should not administer medication or biological except upon the order of a physician/prescriber lawfully authorized to prescribe them. Record review of the facility provided policy titled FMC Long-Term Care Standing Orders updated 5-16-2023, revealed the following: Respiratory: If Spo2<90%-Apply NC at 2-3 L to maintain >90% FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 medication carts (Hall 300 medication cart and Hall 200 medication cart) and 1 of 1 medication rooms. Reviewed for expired medications. 1. The 300 Hall medication cart had 4 loos pills and 2 bottles of expired medications. 2. The 200 Hall medication cart #2 had 1 bottle of expired medication on the cart. These failures could place residents at risk for drug diversion, exposure to expired drugs, and accidental administration to the wrong resident. Findings include: Observation on 12/04/23 at 1:56 PM of the Medication cart on the 300 hall with MA C revealed 1 bottle of Ibuprofen with no expiration on bottle; 1 bottle of Sodium bicarbonate that had an expiration date of 10/2023; 4 unidentifiable loose pills found in medication cart. Interview on 12/04/23 at 02:01 PM, with MA C was asked what a negative outcome was of having expired medications in cart. MA C never answered questions. MA C stated that loose pills would be placed in in drug buster and disgarded. MA C asked if there was anything further. Observation on 12/04/23 at 02:23 PM of Medication cart #2 with MA D revealed. 1. a bottle of Aspirin with an expiration date of 06/2022. Interview on 12/04/23 at 02:26 PM, MA D stated that the negative outcome would be for giving expired medication. MA C stated that the medication would not be effective. Interview on 12/04/23 at 2:52 PM with the DON, stated that a negative outcome to giving expired medications would be that the medication would lose it's efficacy and not provide a therapeutic effect to the resident. Record review of facility provided policy named Medication Management Program, revised on 05/05/2023 stated under title Administering the Medication Pass 3. Prior to administering medications, the nurse is responsible for: . .D. Checking for expiration dates and removing any expired products. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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 in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. This failure could put/ place residents at risk for foodborne illness or cross contamination. Findings Included: Observation of refrigerated foods on 12/04/2023 at 8:27 am revealed the following: 1. Container of chicken broth in refrigerator 1 with no label or date. 2. Box of oranges in refrigerator 1 with no label or date. 3. Whipping cream in refrigerator 2 with no label or date. 4. Bowel of individual packets of butter in refrigerator 2 with no label or date. 5. 3 boxes of creamy wheat on counter with no label or date. 6. 3 cans of evaporated milk on counter with no label or date. 7. 1 plastic container of chicken broth on counter with no label or date. 8. 1 plastic bin of 2 tartar sauce packs in storage room with no date. 9. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0812 1 bin of individual packs of mustard with no label or date. Level of Harm - Minimal harm or potential for actual harm 10. 1 bin of individual packs syrup with no label or date. Residents Affected - Many 11. 1 bin of individual packs Italian dressing with no label or date. 12. 1 bin of individual packs of ketchup with no label or date. 13. 1 bin of individual packs mayo with no label or date. 14. 1 bin of individual packs of sugar with no label or date. 15. 1 bin of individual packs of creamer with no label or date. 16. 1 tub of onions on table with no label or date. An interview on 12/5/2023 at 9:24 am the Dietary Manager said that all kitchen staff are responsible for safe food storage per their policy. The Dietary Manager stated that she would go to the policy to see what the policy stated concerning food storage. The Dietary Manager said that the negative outcome for not practicing food storage would be food poisoning and residents could get sick. Record review of in-service dated 8/10/23, training contained proper labeling and storage procedure. Record review of Dietary Services Nutrition Policy & Procedure Manual dated 8/1/2020 stating that open packages of food are stored in closed air-tight containers or sealed plastic bags. Each container must be labeled with name of food item and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 as is possible for 1 of 1 medication room. Residents Affected - Few The facility failed to ensure expired needles were not available for use in the medication room. These failures could place residents at risk of injury. The findings include: Observation on [DATE] at 02:39 PM of the medication room and 2 needles were observed to be expired with an expiration date of 09/2019. Interview on [DATE] at 02:41 PM with MA #2 stated that the needles were used for blood draws if the local lab could not make it to facility to perform lab draw. MA #2 stated that the negative outcome could possibly be that the needle could possibly cause harm to resident. Interview on [DATE] at 2:52 PM with DON, stated that a negative outcome of using expired equipment such as needles could cause undue injury. Interview on [DATE] at 10:27 AM with ADM, was asked what a negative outcome would be for using expired needles. ADM stated that the staff didn't even like using those needles and stated, I am not medical I don't know what those needles are used for. Record review of facility provided policy named Medication Management Program, revised on [DATE] stated under title Administering the Medication Pass 3. Prior to administering medications, the nurse is responsible for: . .D. Checking for expiration dates and removing any expired products. Record review of the University of Texas Medical Branch on-line documentation, dated [DATE], states the following, Sterility of a packaged item is event related and depends on the quality of the wrapper material, the storage conditions, the conditions during transport, and the amount of handling. Any item that has a torn wrapper, has been compressed, appears wet, or has been dropped on the floor should not be used. Items purchased as sterile should be used according to the manufacturer's directions. This may be either a designated expiration date, or a day-to day expiration date such as a sterile unless the integrity of the package is compromised. Record review of the Medline website, with the entry of the reference number as well as the lot number of the syringe did not produce a result secondary to the needle being obsolete. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675498 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/06/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hillside Heights Rehabilitation Suites 6650 South Soncy Road Amarillo, TX 79119 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 0880 No other policy provided by facility regarding expired equipment. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675498 If continuation sheet Page 12 of 12

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

6 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the December 6, 2023 survey of HILLSIDE HEIGHTS REHABILITATION SUITES?

This was a inspection survey of HILLSIDE HEIGHTS REHABILITATION SUITES on December 6, 2023. The surveyor cited 6 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at HILLSIDE HEIGHTS REHABILITATION SUITES on December 6, 2023?

Yes, 6 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, an..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·December 6, 2023