Cycle 1
Health 2025-12-11 · Fire 2025-12-11
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Gatesville, TX
Hillside Medical Lodge
2-star overall rating with 3-star inspections with 8 recent health deficiencies
300 S. Highway 36 Bypass, Gatesville, TX
(254) 865-7575
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
128
Certified beds
Average residents
101
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Coryell County Memorial Hospital Authority
Operator or chain grouping
Approved since
1993-11-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.23
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
2.89
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,933
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.33% · Performance 25.04% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.38% · Performance 7.92% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.85
Baseline 49.33% · Performance 39.76% · Measure score 5.85 · Achievement 5.85 · Improvement 3.41
Adjusted total nurse staffing
0
Baseline 2.15 hours · Performance 2.18 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.04% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 145 · Observed rate 13.1% · Lower 95% interval 8.05% |
| Discharge to community | 50.48% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 126 · Observed rate 49.21% · Lower 95% interval 42.91% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 68 · Denominator 68 |
| Falls with major injury | 1.47% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 68 |
| Discharge self-care score | 96.55% |
53.69%
42.9 pts better
|
Numerator 28 · Denominator 29 |
| Discharge mobility score | 82.76% |
50.94%
31.8 pts better
|
Numerator 24 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 4.41% |
2.29%
2.1 pts worse
|
Numerator 3 · Denominator 68 · Adjusted rate 3.44% |
| Healthcare-associated infections requiring hospitalization | 7.92% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 110 · Observed rate 7.27% · Lower 95% interval 4.79% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 122 |
| Staff flu vaccination coverage | 36.67% |
42%
5.3 pts worse
|
Numerator 44 · Denominator 120 |
| Discharge function score | 93.1% |
56.45%
36.6 pts better
|
Numerator 27 · Denominator 29 |
| Transfer of health information to provider | 97.06% |
95.95%
1.1 pts better
|
Numerator 33 · Denominator 34 |
| Transfer of health information to patient | 97.06% |
96.28%
0.8 pts better
|
Numerator 33 · Denominator 34 |
| Resident COVID-19 vaccinations up to date | 5.56% |
25.2%
19.6 pts worse
|
Numerator 2 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.1
0.5 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.1% |
3.3%
4.8 pts worse
|
3.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 8.8% · Q3 7.8% · Q4 5.7% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 50.8% |
2.7%
48.1 pts worse
|
11.4%
39.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.7% · Q2 66.7% · Q3 53.7% · Q4 35.1% · 4Q avg 50.8% |
| Percentage of long-stay residents who lose too much weight | 0.4% |
3.3%
2.9 pts better
|
5.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.6% |
18.9%
9.7 pts worse
|
19.6%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 28.0% · Q3 29.5% · Q4 30.6% · 4Q avg 28.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
10.8%
2.5 pts worse
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 14.3% · Q3 16.9% · Q4 11.1% · 4Q avg 13.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.6% |
15.4%
2.8 pts better
|
16.3%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
16.1%
0.8 pts worse
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 24.7% · Q3 10.8% · Q4 16.7% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.5%
1.2 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 3.5% · Q3 0.8% · Q4 1.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
0.8%
2 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.5% · Q3 1.2% · Q4 2.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
15.0%
11.1 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 29.4% · Q3 30.3% · Q4 18.0% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 6.8% |
4.2%
2.6 pts worse
|
5.1%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 7.3% · Q3 7.4% · Q4 7.6% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
89.7%
9.4 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 98.3% · Q4 99.2% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.9% |
12.0%
6.9 pts worse
|
12.0%
6.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 17.0% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.6% · Q3 0.0% · Q4 2.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.0% |
88.0%
11 pts better
|
79.7%
19.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
25.9%
0.7 pts better
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 25.9% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-13 · Fire 2024-08-13
3 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-11 · Fire 2023-07-11
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2026-01-12
E · Potential for more than minimal harm
2025-12-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-11
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-11
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-12
D · Potential for more than minimal harm
2025-01-28
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-11-14
E · Potential for more than minimal harm
2024-08-13
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-08-14
E · Potential for more than minimal harm
2024-08-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-14
D · Potential for more than minimal harm
2023-09-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-07-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-03
J · Immediate jeopardy
2023-03-24
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-03-25
Penalties and ownership
What sits behind the stars
Ownership
Coryell County Memorial Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Byrom, David
Corporate Director · Individual
Lewis, Shane
Operational/Managerial Control · Individual
Uptown Fs LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
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3-star overall rating with 4-star inspections with 6 recent health deficiencies
#2
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1-star overall rating with 1-star inspections with $49,443 in total fines with 8 recent health deficiencies
#3
Killeen Nursing & Rehabilitation
Killeen, TX
1-star overall rating with 1-star inspections with abuse icon flag with $125,321 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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