Inspection visit
Inspection
16 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 16 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0583
Keep residents' personal and medical records private and confidential.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure residents have a right to
personal privacy for 1 of 5 residents (Resident #27) observed for nursing care and 8 of (Resident #36,
Resident #41, Resident #56, Resident #58, Resident #66, Resident #80, Resident #91, and Resident #105)
of 25 residents reviewed for privacy, in that:
Residents Affected - Some
1. The Treatment nurse did not close Resident #27's window curtain while providing wound care for the
resident.
2. Shower sheets for Resident #27, Resident #36, Resident #41, Resident #56, Resident #58, Resident
#66, Resident #80, Resident #91, and Resident #105 with the residents' names and details about their
medical were found on a table on the 200 hallway.
This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.
The findings include:
1. Record review of Resident #27's face sheet, dated 03/21/2024, revealed an admission date of
11/29/2023 and, a readmission date of 03/28/2024, with diagnoses which included: Depression(mood
disorder that causes a persistent feeling of sadness and loss of interest), Sarcoidosis (disease involving
abnormal collections of inflammatory cells that form lumps known as granulomata), Type 2 diabetes
mellitus (high level of sugar in the blood), Hypertension (High blood pressure), Chronic kidney disease
(gradual loss of kidney function).
Record review of Resident #27's 5 days MDS assessment, dated 04/01/2024, revealed the resident had a
BIMS score of 11, indicating he was mildly impaired. Resident #27 had an indwelling catheter and, was
always incontinent of bowel. Resident #27 had a stage 3 pressure ulcer.
Review of Resident #27's care plan dated 03/18/2024, revealed a problem of [ .] has diabetic ulcer of the
left heel and, an goal of [ .] will have no complications related to ulcer through review date.
Observation on 04/18/24 at 2:45 p.m. revealed the Treatment nurse did not close the window curtain while
providing wound care for Resident #27. Resident #27's bed was by the window and could be seen from the
window. The window had a full view of the parking lot.
During an interview with the Treatment nurse on 04/18/2024 at 3:25 p.m., she confirmed the window curtain
was not closed while she provided care for Resident #27 but it should have been. She confirmed privacy
must be provided during nursing care. She confirmed receiving training about resident
(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 15
Event ID:
676114
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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 0583
rights within the year.
Level of Harm - Minimal harm
or potential for actual harm
During an interview with the DON on 04/19/24 at 12:15 p.m., the DON confirmed privacy must be provided
during nursing care and Resident #27's window curtains should have been closed completely. She
confirmed she provided training to the staff for resident's right.
Residents Affected - Some
2. Observation on 04/18/2204 at 9:57 a.m. revealed shower sheets for Resident #36, Resident #41,
Resident #56, Resident #58, Resident #66, Resident #80, Resident #91, and Resident #105 were found on
a side table in the facility's 200 hallway. Further observation revealed the papers contained each resident's
name and details about their medical condition including ability to bathe or shower themselves.
Further observation on 04/18/2204 between 9:57 a.m. and 10:13 a.m. revealed residents, staff, and visitors
on hallway near the papers.
During an observation on 04/18/2204 at 10:13 a.m., CNA G noticed the shower sheets.
During an interview with CNA G, at the same time as the observation, CNA G stated, These shouldn't be
here in reference to the pages and confirmed they contained protected medical information.
During an interview with the DON and ADON on 04/19/2024 at 11:47 a.m., the DON and ADON confirmed
that protected medical information should be kept private.
Review of the facility's policy titled Dignity, dated February 2021, revealed, Staff promotes, maintain and
protect resident privacy, including bodily privacy during assistance with personal care and during treatment
procedures.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 2 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the assessment accurately reflected the resident's
status for 1 of 26 residents (Resident #13) whose assessments were reviewed, in that:
Residents Affected - Few
Resident #13's Quarterly MDS assessment incorrectly documented the resident as not receiving an
antidepressant.
This failure could place residents at-risk for inadequate care due to inaccurate assessments.
The findings were:
1. Record review of Resident #13's face sheet, dated 04/18/2024, revealed an admission date of
09/21/2018 and, a readmission date of 02/21/2024, with diagnoses that included: Multiple sclerosis
(autoimmune disease affecting the nervous system), Type 2 diabetes mellitus(high level of sugar in the
blood), Schizophrenia (mental disorder characterized by abnormal thought processes and an unstable
mood), Depression(mood disorder that causes a persistent feeling of sadness and loss of interest), Anxiety
disorder(A group of mental illnesses that cause constant fear and worry), Hyperlipidemia(Elevated level of
any or all lipids(fat) in the blood) , Dementia(decline in cognitive abilities).
Review of Resident #13's physician orders, dated February 2024. revealed an order for Sertraline HCl Oral
Tablet 25 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for depression. with a start date of
10/30/2023.
Record review of Resident #13's Quarterly MDS, dated [DATE], revealed the assessment indicated
Resident #13 was not receiving an antidepressant.
During an interview with the MDS Coordinator A on 04/19/24 at 9:30 a.m., the MDS Coordinator confirmed
he had completed the MDS. The MDS Coordinator confirmed Resident #13's Quarterly MDS was coded as
the resident having not received antidepressant medications. The MDS Coordinator confirmed that
Resident's 13 was receiving an antidepressant medication. The MDS Coordinator revealed the RAI was
used as reference for the MDS and he had access electronically to the RAI on his computer.
During an interview with the DON on 04/19/2024 at 12:30 p.m., the DON confirmed Resident #13 was
receiving and antidepressant medication and should have been coded as receiving anti depressant
medications in the Quarterly MDS assessment. The DON revealed the inaccuracy of the MDS assessment
could negatively impact the care received
Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version
1.18.11, October 2023, revealed, N0415C1. Antidepressant: Check if an antidepressant medication was
taken by the resident at any time during the 7-day look-back period (or since admission/entry or
reentry if less than 7 days).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 3 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to develop and implement a comprehensive
person-centered care plan for each resident, consistent with the resident rights that included measurable
objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that
were identified in the comprehensive assessment for 1 of 5 (Resident #73) residents reviewed for
comprehensive assessments.
The facility failed to ensure that Resident #73's care plan documented interventions for the resident's
weight loss of 13 pounds.
This deficient practice could place residents at risk of not receiving proper care and services .
The findings were:
Record review of Resident #73's face sheet, dated 04/18/2024, reflected a [AGE] year-old female admitted
to the facility on [DATE]. Resident #73 had diagnoses which included:
Acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your
blood), Schizoaffective disorder (is a chronic mental health condition characterized primarily by symptoms
of hallucinations or delusions), and Bi-Polar Disorder ( a mental illness that causes unusual shifts in a
person's mood, energy, activity levels, and concentration).
Record review of Resident # 73's Care Plan , dated 4/18/24 , reflected no specific listing to address weight
loss .
Record review of weights for Resident # 73 from December 2023 to March 2024 , reflected a 13 pond
weight loss .
Record review of Resident # 73's Quarterly MDS, dated [DATE], revealed that Resident # 73 had a BIMS
score of 11, which indicated mild impairment.
Interview with the MDS nurse on 4/18/24 at 2:20 p.m., revealed, she was responsible for updating the care
plans .The MDS nurse stated she did not know why Resident # 73's weight loss was not care planned. She
added that by her not updating the care plan, Resident # 73 risked not having all team members on same
page .
Interview with the DON on 4/18/24 at 3:35 p.m. revealed Resident # 73 had recent weight loss of 13 pounds
that was not care planned , and it was her expectation the care provided is care planned accordingly to
ensure all team members are on the same page when providing care. The DON stated the nurse managers
were responsible for ensuring that care plans are completed, and she currently monitors this monthly
intermittently which is why this was missed.
Record review of facility policy titled Care Plans, Comprehensive Person - Centered, dated 2001, revised
March 2022, revealed Assessments of residents are ongoing and care plans are revised as information
about the residents and residents change in condition change .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 4 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the resident was not given a psychotropic drug
unless the medication was necessary to treat a specific condition as diagnosed and documented in the
clinical record for 1 (Resident #102) of 7 residents reviewed for unnecessary medications, in that:
Resident #102 was prescribed a psychotropic drug for anxiety without a documented diagnosis of anxiety
in the clinical record.
This deficient practice could place residents at risk of receiving unnecessary psychotropic medications.
The findings were:
Record review of Resident #102's facesheet, dated 04/18/2024, revealed the resident was admitted to the
facility on [DATE] with diagnoses including: End Stage Renal Disease, Cerebral Infarction, and
Hyperlipidemia. Further review revealed the listed diagnoses did not include Anxiety.
Record review of Resident #102's Quarterly MDS, dated [DATE], revealed a BIMS score of 10 which
indicated moderate cognitive decline.
Record review of Resident #102's care plan, dated 4/19/2024, revealed the care plan did not indicate that
the resident had a diagnosis of Anxiety.
Record review of Resident #102's order summary, dated 04/18/2024, revealed an order, LORazepam Oral
Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours as needed for anxiety for 14 Days.
During an interview with the DON and ADON on 04/19/2024 at 11:47 a.m., the DON and ADON confirmed
Resident #102 had been prescribed a psychotropic drug for anxiety without a documented diagnosis of
anxiety in the clinical record and that a diagnosis should have been listed in the resident's record. The DON
confirmed that nursing staff were responsible for ensuring the residents' records were correct and that the
deficient practice was an oversight.
Record review of Antipsychotic Medication Use Policy, dated 04/2017, revealed .antipsychotic medication
therapy shall be used only when it is necessary to treat a specific condition for which they are indicated and
effective .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 5 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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 0759
Ensure medication error rates are not 5 percent or greater.
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 a medication error rate was not 5% or
greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities, which
involved (Resident # 15) and 1 of 2 staff (CMA D) reviewed for medication errors.
Residents Affected - Few
The facility failed to ensure CMA D administered medications according to the physician's orders and per
professional standards, which resulted in an 8% medication administration error rate.
This deficient practice could place residents at risk of not receiving the therapeutic effects of their
medications and possible adverse reactions.
The findings were:
Record review of Resident # 15's face sheet dated 4/17/24 revealed an [AGE] year-old female admitted to
the facility on [DATE] with the diagnosis that included: Anxiety ( feeling of unease, such as worry or fear) ,
Dysphagia (medical term for difficulty swallowing) and Alzheimer's Disease (type of dementia that affects
memory, thinking and behavior).
Record review of Resident #15's Quarterly MDS assessment dated , 4/1/23 , revealed a BIMS score 03 ,
which indicated severe cognitive impairment.
Record review of Resident #15 order summary report for April 2024 revealed the following orders at 9:00
a.m.
Lactase: give one tablet by mouth daily for bowel maintenance.
Probiotic: give one tablet by mouth daily for probiotics.
Observation and Interview during the medication pass on 4/17/24 at 9:05 a.m. CMA D prepared Resident
#15's medications. The surveyor asked CMA D if she knew the dose ordered for both medications, she was
about to administer to Resident #15. CMA D responded, Whatever is on the bottle. This is what I will
administer
Surveyor observed CMA D administer one tablet of Lactase and one tablet of Probiotc to Resident # 15.
CMA D referred surveyor to Charge Nurse LVN E for any questions as she simply only administered
medications .
During an Interview with LVN E , on 4/17/24 at 10:08 am, she stated she was the charge nurse for Resident
#15 and that CMA D , shouldn't have administered medications to Resident #15 this morning if the order on
the EMAR did not have a dose as the orders may need to be clarified with the physician to ensure the
correct dose was administered. LVN E did not know why Resident #15's morning medication did not have a
dosage listed on orders, but she would correct this right away to ensure Resident # 15 received the correct
dose of medication moving forward. LVN E stated Resident # 15 risked
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 6 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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 0759
possibly not receiving the correct dose of medication ordered, if no dose was listed on the EMAR
Level of Harm - Minimal harm
or potential for actual harm
During an interview with the DON on 4/17/24 at 10:20 am, The DON stated that CMA D shouldn't have
administered medications to Resident #15 this morning if the order on the EMAR did not have a dose listed
, as the medication orders may have to be clarified with the physician to ensure the correct dose was
administered.
Residents Affected - Few
The DON stated Resident # 15 risked possibly not receiving the correct dose of medication ordered, if no
dose was listed on the EMAR. The DON stated the Nurse Managers were responsible for overseeing
physician orders were entered into the EMAR contained a dose . This is monitored by Nurse Managers
pulling order listing reports daily .
The DON stated she was responsible for overseeing this process and was only conducting spot checks,
which is why this might have occurred.
Record review of facility policy undated, titled Documentation of medication administration, Documentation
must include, at a minimum, the Name and strength of the drug.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 7 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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 0801
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the
food and nutrition service, including a qualified dietician.
Based on interview and record review, the facility failed to employ staff with the appropriate competencies
and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager
reviewed for qualified dietary staff.
The facility failed to employ a certified dietary manager as required.
This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of
food borne illness and not receiving adequate nutrition.
The findings were:
Record Review of the Employee Service List, undated, revealed the Dietary Manager with a hire date of
04/17/2023.
During an interview on 04/17/24 at 10:45 a.m., with the Dietary Director he revealed he had not taken a
Dietary Manager Certification course and was unaware that he needed to complete this course He stated
that his current position as a Dietary Manager was the only Dietary Manager position he had held. He
stated that all of his previous positions working in kitchens, had been working in the capacity of a cook.
During an interview with the Human Resources Director on 04/18/24 at 9:45am she stated that she was not
aware the Dietary Director had to have completed a certified Dietary manager course. She stated that she
along with the Administrator would have been responsible for ensuring the department heads met their
certification requirements.
During an interview on 04/18/24 at 10:00a.m., with the Administrator he stated that he was not aware the
Dietary Director had to have completed a dietary manager certification course. He stated that completion of
a certification course would help the Dietary Manager to better run the kitchen if there was a leadership
component as part of the course instruction.
Record review of the facility's employee handbook that was undated stated on page 6 if you are in a
position that requires being professionally licensed, registered, or certified, it is your responsibility at the
employee's expense to maintain current, active credentials while employed by this facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 8 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and
serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that:
Residents Affected - Many
1. The overhead light in the kitchen storage room was not working.
2. A bag of 2 dozen hard boiled eggs in the refrigerator was not labeled or dated.
3. A bag of shredded cheese in the refrigerator was not labeled or dated.
4. A bag of 30 ham slices in the refrigerator was not labeled or dated
5. The temperature test strips for the dish machine were wet and could not be used.
6. The ceiling vent across from the dish machine had mold around the edges of the vent.
7. The grill vent above the dish machine hood cover was covered with dirt and grease.
These deficient practices could place residents who received meals and snacks from the kitchen at risk for
food borne illness from improper infection control, from a lack of food label date monitoring, from a lack of
equipment maintenance, and improper sanitation in the kitchen area.
The findings included:
Observation on 04/16/24 from 10:00 a.m. to 10:35 a.m. during the kitchen tour with the Dietary Manager
revealed the following:
a. One of the overhead light in the kitchen store room which measured approximately 4x1 foot was not
working.
b. There was a bag of 2 dozen hard boiled eggs inside of the refrigerator that were not dated or labeled.
c. There was a bag of shredded cheese inside the refrigerator that was not dated or labeled.
d. There was a bag of 30 Hillshire Honey ham slices inside the refrigerator that were not labeled or dated.
e. The dish machine temperature test strips were wet and could not be used for a temperature check.
f. The ceiling vent across from the dish machine had mold around the edges of the vent.
g. The ceiling grill vent that was above the dish machine cover and measured approximately 1 foot square
had visible dirt particles and grease of the vent slats.
During an interview with the Dietary Manager on 04/16/24 at 10:40 a.m., he stated that he was not
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 9 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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
aware how long the light in the store room was not working. He stated that having the light working was
important for employee safety. The Dietary Manager stated that having food inside the refrigerator dated
and labeled was important to monitor for food expiration dates. He stated that having functional dish
machine test strips was important to maintain proper cleaning of the dishes. The Dietary Manager stated
having the dish machine grill vent kept clean was important for kitchen sanitation.
Residents Affected - Many
During an interview with the Administrator on 04/18/24 at 10:00a.m., he stated that having the food labeled
and dated was important to know how old the food was that was being used. He stated that having viable
dish machine temperature test strips was important to determine if the dish machine was working properly.
Record review of facility Nutrition and Foodservice policy for Food Storage number 03.003 dated 2018
stated that all refrigerated foods should be labeled and dated.
Record review of the facility's Nutrition and Foodservice policy for General Kitchen Safety Guidelines
05.001 dated 2018 stated the facility will follow basic safety guidelines to reduce the risk or accidents and
ensure the safety of employees.
Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS,
revealed 4-601.11 Equipment, Food-Contact Surfaces, Non-food-Contact Surfaces, and Utensils. (A)
EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The
FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease
deposits and other soil accumulations. (C) Non-FOOD-CONTACT SURFACES of EQUIPMENT shall be
kept free of an accumulation of dust, dirt, FOOD residue, and other debris.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 10 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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 0813
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
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 maintain and ensure safe and sanitary
storage of residents' food items for 2 (refrigerators in resident room [ROOM NUMBER] and room [ROOM
NUMBER]) of 5 residents' personal refrigerators reviewed, in that:
Residents Affected - Few
The personal refrigerators in two residents' rooms contained food items which were unlabeled and undated.
This deficient practice could place residents at risk of foodborne illness due to consuming foods which are
spoiled.
The findings were:
Observation on 04/16/2024 at 10:02 a.m. revealed the personal refrigerator in resident room [ROOM
NUMBER] contained a sandwich which was unlabeled and undated.
Further observation on 04/17/2024 at 10:32 a.m. revealed the sandwich was still present.
During an interview with CNA F on 04/17/2024 at 10:35 a.m., CNA F confirmed that the personal
refrigerator in resident room [ROOM NUMBER] contained a sandwich which was unlabeled and undated.
Observation on 04/16/2024 at 10:12 a.m. revealed the personal refrigerator in resident room [ROOM
NUMBER] contained a frozen meal which had thawed and was unlabeled and undated.
Further observation on 04/17/2024 at 10:34 a.m. revealed the frozen meal which had thawed was still
present.
During an interview with CNA F on 04/17/2024 at 10:35 a.m., CNA F confirmed that the personal
refrigerator in resident room [ROOM NUMBER] contained a frozen meal which had thawed and was
unlabeled and undated.
During an interview with the DON and ADON on 04/19/2024 at 11:47 a.m., the DON and ADON confirmed
that perishable food and drinks in residents' personal refrigerators should be labeled and dated to prevent
residents from consuming spoiled foods.
Record review of the facility policy, Foods Brought by Family/Visitors, revised October 2017, revealed,
.Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident
choice and a homelike environment with the nutritional and safety needs of residents. 8. The nursing staff
will discard perishable foods on or before the use by date .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 11 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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 0849
Level of Harm - Minimal harm
or potential for actual harm
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will
arrange for the provision of hospice services.
Based on interview and record review, the facility failed to designate an interdisciplinary team member
responsible for collaborating and communicating with hospice representatives.
Residents Affected - Some
This deficient practice could place residents who receive hospice services at risk of receiving substandard
care due to miscommunication between their hospice and facility caregivers.
The findings were:
During an interview with the Social Worker on 04/18/2024 at 3:20 p.m., the Social Worker stated she was
not the hospice liaison and did not know which facility staff member had been designated liaison.
During an interview with the Medical Records Director on 04/18/2024 at 3:25 p.m., the Medical Records
Director stated he was not the hospice liaison and did not know which facility staff member had been
designated liaison.
During an interview with the ADON on 04/18/2024 at 3:30 p.m., the ADON stated she was not the hospice
liaison and did not know which facility staff member had been designated liaison.
During an interview with the MDS Coordinator on 04/18/2024 at 3:35 p.m., the MDS Coordinator stated she
was not the hospice liaison and did not know which facility staff member had been designated liaison.
During an interview with the DON and ADON on 04/19/2024 at 11:47 a.m., the DON and ADON confirmed
that no specific facility staff member had been designated as hospice liaison and the DON stated the facility
would, tighten the hospice system.
Record review of the facility's policy titled, Residents with Hospice Services, revised 7/2018, revealed, The
facility will work closely with Hospice personnel .Coordinate services provided to the resident with the
Hospice personnel. The facility Administrator will follow state regulation with regards to retaining a resident
on Hospice services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 12 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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
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 infection for 1 of 5 residents
(Resident #28) reviewed for infection control, in that:
Residents Affected - Some
CNA B and CNA C failed to wash or sanitize their hands or change their gloves after touching the trash can
and the privacy curtain before starting incontinent care.
This deficient practice could place residents at-risk for infection due to improper care practices.
The findings included:
Record review of Resident #28's face sheet, dated 04/18/2024, revealed an admission date of 01/29/2024
with diagnoses which included: Parkinson's (Chronic degeneration of the central nervous system),
Hypothyroidism (under active thyroid), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood),
Hypertension (High blood pressure), Raynaud's syndrome (spasm of small arteries causes episodes of
reduced blood flow to end arterioles), Chronic kidney disease (gradual loss of kidney function).
Record review of Resident #18's Annual MDS assessment, dated 02/15/2024, revealed Resident #18 had a
BIMS score of 9, indicating moderate cognitive impairment and, was always incontinent of bowel and
bladder.
Record review of Resident #28's care plan, dated 02/12/2024, revealed a problem of has episodes of
incontinence of bowel and bladder., with a goal of will be clean, dry and odor free through next review date.
Observation on 04/18/24 at 10:58 a.m. revealed while providing incontinent care for Resident #28, CNA B
washed her hands and put on gloves. CNA B touched the resident's trash can with her gloved hands, then
without changing gloves or sanitizing her hands started providing care for the resident. CNA C washed his
hands and touched the trash can and the privacy curtain. Then, without washing or sanitizing his hands he
put on his gloves and started to provide care to Resident #28.
During an interview on 04/18/2024 at 11:09 a.m. both CNA B and CNA C confirmed the trash can and
privacy curtain were considered dirty and they should have changed gloves and wash their hands prior to
touch the resident and start care, they understood it was a risk for cross contamination and confirmed they
received infection control training within the year.
During an interview with the DON on 04/19/24 at 12:15 p.m., the DON confirmed the CNA should have
change their gloves and sanitized their hands after touching the trash can and curtain and before starting
care. There a risk for cross contamination. She provided training to the staff yearly and as needed if
infection control concerns were noted.
Record review of the annual skills check for CNA B and CNA C revealed both CNAs passed competency
for infection control on 03/15/2024.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 13 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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
Record review of the facility policy, titled Hand washing/Hand hygiene, dated 10/2023, revealed Hand
hygiene is indicated [ .] d. after touching the resident's environment.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 14 of 15
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
676114
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
River Hills Health and Rehabilitation Center
2091 Bandera Hwy
Kerrville, TX 78028
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on observation, interview, and record review, the facility failed to provide a safe, clean, and
comfortable environment for residents, staff, and visitors, in that:
Residents Affected - Some
Two containers of cleaning fluids with hazardous material warning labels were found within the shower
room of the facility's 200 hallway.
This deficient practice could place residents at risk of coming into contact with hazardous materials.
The findings were:
Observation on 04/17/2024 at 10:42 a.m. revealed the resident shower room on the 200 hallway was not in
use and was unlocked. Further observation revealed a container of cleaning wipes labeled, Danger and
Keep Out of
Reach of Children and a 32-ounce container of bathroom cleaner labeled, Danger, Do Not Drink, and May
Cause Eye and Skin Irritation were found withing the shower room. Further observation at various times on
04/17/2024, 04/18/2024, and 04/19/2024 revealed no residents were inside the shower room without a
member of staff, but residents were observed on the 200 hallway near the shower room throughout each
day.
During an interview with the AIT on 04/17/2024 at 10:45 a.m., the AIT confirmed the presence of two
containers of cleaning fluid within reach of residents in the 200-hall shower room.
During an interview with the DON and ADON on 04/19/2024 at 11:47 a.m., the DON and ADON confirmed
that hazardous materials should not be stored within resident reach.
Record review of the facility's policy titled, Physical Environment, undated, revealed, Purpose: Provide a
safe, functional, sanitary and comfortable environment for residents, staff and the public.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676114
If continuation sheet
Page 15 of 15
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Back to topCitations
16 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.
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F801 - Staffing
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F813 - Food Safety Requirements
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0353GeneralS&S Epotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F741 - The facility must have sufficient staff who provide direct services to
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
FAQ · About this visit
Common questions about this visit
What happened during the April 19, 2024 survey of RIVER HILLS HEALTH AND REHABILITATION CENTER?
This was a inspection survey of RIVER HILLS HEALTH AND REHABILITATION CENTER on April 19, 2024. The surveyor cited 16 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at RIVER HILLS HEALTH AND REHABILITATION CENTER on April 19, 2024?
Yes, 16 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Keep residents' personal and medical records private and confidential."
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 . If you believe any information is inaccurate, report it here.