Health inspection·November 9, 2022

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. Monitor /record/report to Nurse any signs or symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations ( grunting, moans, yelling out, silence); Mood/behavior ( changes , more irritable, restless, aggressive, squirmy, constant motion); Eyes ( wide open / narrow slits/shut, glazed, tearing, no focus); Face ( sad, crying, worried , scared , clenched teeth, grimacing) Body (tense, rigid , rocking, curled up, thrashing). Monitor / record/ report to nurse loss of appetite, refusal to eat and weight loss. Administer analgesia as ordered. Monitor // record/ report to nurse resident complaints of pain or requests for pain treatment. Observed and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease in range of motion, withdrawal or resistance to care. She had visual impairment related to diabetes and glaucoma. Interventions: administer eye drops as ordered per physician for treatment of glaucoma. Arrange for consultation with eye care practitioner as required. Identify/ record factors affecting visual function including Physiological (glaucoma, crohn's, macular degeneration, cataracts, color discrimination, light sensitivity, dry eyes); Environmental ( poor lighting, monochromatic color scheme), Choice ( refused to wear glasses , use magnify glass, turn on lights) etc. Monitor / document/ report as needed any signs or symptoms of acute eye problems: change in ability to perform ADL's, decline in mobility, sudden visual loss, pupils dilated, gray or milky, complaint of halos around lights, double vision, tunnel vision, blurred or hazy vision. Record review of Resident #46's Personal Hygiene record, dated 09/26/2022 through 10/25/2022, in the electronic medical record reflected Resident #46 did not refuse any type of personal hygiene which included combing hair, brushing teeth, shaving, applying make-up, washing/ drying face and hands. Observation and Interview on 10/24/2022 at 11:15 AM revealed Resident #46 was awake in bed. Resident #46 had approximately 4-5 inches in length of facial hair and the width was approximately 4-5 inches on her chin. The patches of hair covered half of her chin. Resident #46 stated she wanted the hair to be shaved and if she had a razor, she would shave the hair on her chin. She stated she hasn't seen it, but she could feel it and it felt like a man's beard. Resident #46 stated she asked the staff to shave it for her and the staff wanted her to go to shower and shave it in the shower. She did not recall the person's name who told her to go to the shower. Resident #46 stated she had been asking for someone to shave her chin over the past two weeks. She stated she didn't want anyone to see her with the hair on her chin. Resident #46 stated she did refuse showers sometimes. She stated the staff did not want to shave her chin in her room. She stated she did not know why it was wrong for the staff not shaving her hair on chin in her room. In an interview on 10/24/2022 at 11:30 AM the MDS Coordinator viewed the care plan dates on Resident #46, and she stated the care plan where it had edited was one in progress. She stated the most recent care plan reviewed on Resident #46 was completed on 09/28/2022. In an interview on 10/26/2022 at 8:30 AM, the Director of Nurses stated any resident female or male could have their facial hair removed in their room. She stated Resident #46 was not required to go to the shower to have the facial hair removed. She stated it was the CNA's responsibility to maintain personal hygiene on the residents, but any nursing staff could remove facial hair on a resident. She also stated as she reviewed the personal hygiene form in the electronic medical records, that this would be the form the nursing staff would use to document any refusal of personal hygiene which included removing facial hair from Resident #46. She also stated if Resident #46 refused personal hygiene it would be documented on the care plan. After she reviewed the care plan, she stated there was not any refusal of Resident #46 refusing any type of ADL care which included personal hygiene. She stated it was nursing responsibility to monitor hygiene and ADL care and ultimately it was her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 2 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few responsibility. She stated if a female had thick facial hair there was a potential of the resident experiencing poor self-esteem or wouldn't want to be around other people and it could affect their quality of life. In an interview on 10/26/2022 at 1:00 PM, CNA A stated Resident #46 sometimes refused showers. She stated she was not aware of the resident refusing any other type of ADL care. She stated she thought residents were shaved in the showers, but she did not think about shaving a females facial hair in their room. She stated she did notice the facial hair on Resident #46 and was going to shave it in the shower. She stated the facial hair on Resident #46 had to be growing for a few weeks. She stated it was long and wide she stated for a female, Resident #46 did have a lot of hair on her chin. She stated anyone could trim hair or shave hair on any resident. In an interview on 10/26/2022 at 2:00 PM, the Administrator stated any resident which included females with facial hair were not required to go to the shower to be shaved. If a resident wanted their hair removed from their face, the nursing staff could use a razor in the resident's room. She stated if a female resident had visible facial hair this could potentially have an effect on the resident such as: low self-esteem and not wanting to leave the room. She stated it was the nurse supervisor and Director of Nurses duties to monitor ADL care. Record Review of the facility policy on Activities of Daily Living, dated 2001 and revised in March 2018, reflected Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 3 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. 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 provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging independence and interaction in the community for 4 of 8 residents (Resident # 40, Resident #16, Resident #32 and Resident #15) reviewed for activities Residents Affected - Some The facility failed to consistently provide activities for Resident # 40, Resident #16, Resident #32 and Resident #15. This failure could place residents at risk for a decline in social, mental, psychosocial well-being and a decreased quality of life. Findings include: 1. Record review of Resident # 40's face sheet, dated 10/26/2022, reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included malignant poorly differentiated neuroendocrine tumors (rare tumors that can arise anywhere along the gastrointestinal tract), disorder of bone, malignant neoplasm of nipple and areola, unspecified female breast (form of breast cancer), acute (reversible) ischemia of intestine, part and extent unspecified (a gastrointestinal emergency resulting from a sudden decrement in intestinal blood flow), peritonitis (inflammation of the peritoneum, typically caused by bacterial infection either via the blood or after rupture of an abdominal organ) and generalized abdominal pain disorder (feel pain more than half of your stomach). Record review of Resident #40's admission MDS, dated [DATE], reflected Resident #40 had a BIMS score of 15, which indicated her cognitive status was intact. The resident's mood interview was assessed the resident had trouble falling asleep or sleeping too much. Resident #40 did not exhibit any type of behaviors. Resident #40 indicated her Activity Preferences were the following: Very Important Activities: having books, newspapers, and magazines to read, being around animals such as pets, keeping up with the news and do favorite activities. Somewhat Important Activities: listening to music. Not important at all Activities: doing things with groups of people. Resident #40 required assistance with ADL's. Resident #40 was assessed to have pain. Record review of Resident #40's Comprehensive Care Plan, date initiated on 09/21/2022 and reviewed on 10/10/2022, reflected Resident #40 preferred to stay in bed at all times. Resident #40 had little, or no activity involvement related to poor adjustment to the facility / unit. Resident #40 wished not to participate (doesn't indicate what Resident #40 doesn't want to participate within the activity program). Interventions establish Resident #40's prior level or activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Invite and encourage the resident's family members to attend activities with resident in order to support participation. Resident #40's preferred activities were games, crosswords, television, news, visiting and receiving mail. Resident #40 had a diagnosis of cancer of abdomen/ intestine. Resident #40 had chronic pain. Record review of Resident #40's Activity Interview for Daily and Activity Preferences, dated on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 4 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 09/28/2022 and was locked in the electronic medical record on 09/30/2022, reflected Resident #40's activity preferences were as follows: Very Important Activities: having books, newspapers, and magazines to read, being around animals such as pets, keeping up with the news, and do favorite activities. Somewhat Important Activities: listening to music. Not important at all Activities: doing things with groups of people. Record review of Resident #40's Activity Initial Assessment Form, dated 09/22/2022 and was locked in the electronic medical record on 10/06/2022, reflected Resident #40's cognition was intact. Resident #40 was interested in the following activities: dominoes, word search, crossword puzzles, news on television, reading newspaper and cards: gin, rummy, and canasta. Resident #40 did not prefer any type of group activities or any type of social activities outside of her room. Record review of the, undated, In-Room Record List reflected Resident #40 was on the in-room activity list. Record review of the facility's Participation Record Binder reflected Resident #40 had not received any in room activities. Observation on 10/24/2022 at 10:30 AM revealed Resident #40 lights were turned off, did not see any type of activity items except her cell phone. In an interview on 10/24/2022 at 10:30 AM, Resident #40 stated she had been in the hospital several times prior to being admitted to this facility. She stated in April 2022 she had surgery on her abdomen, and it was very serious, and the doctors gave her 2 or 3 days to live. She stated she was grateful she was still living, and she wanted to stay in her room and in her bed. She stated she loved newspapers but never did see any newspapers since she had been admitted to the facility. She stated she watched the news, and this was the only thing she liked on television. Resident #40 stated she would enjoy if someone from the facility would come in and sit with her and talk to her. She stated she didn't want to do any type of games or anything like that at this time but may at a later date. She stated she didn't like group activities and didn't like to be around a lot of people but loved to talk with one person. She stated she had not received any type of visits where someone would sit and just talk to her. She stated people would come in and ask how she was feeling and then leave. They didn't sit and allow her to talk about what was on her mind or just have a laugh and just talk about different things. She stated she would enjoy this very much. She stated she watched the morning news and turned off her television. She stated sometimes it became lonely. She did not enjoy watching television except for the news and only watched the news for short periods of time. She stated the news was depressing at times. She stated she only preferred the local news. Resident #40 requested for her light to be on due to it being too dark in her room. Resident #40 denied being sleepy or wanting to take a nap. Observation and interview on 10/24/2022 at 1:45 PM revealed Resident #40 were in her room and she was awake and staring at the wall in front of her. Her lights were turned off and there was very little light in her room. Resident #40 stated she was not sleepy or wanted a nap. She asked for the light to be turned on so it wouldn't be so gloomy in her room. She stated she would read the newspaper if she had one and when her family visited, they sometimes bought her a newspaper. She stated no one at the facility never provided her with a newspaper. She also stated she thought about someone coming in and sitting with her and talking to her and she stated she would enjoy just talking with someone. She stated not every day but maybe 4 or 5 times a week would be okay with her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 5 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of Resident #16's face sheet, dated 10/26/2022, reflected an [AGE] year-old male admitted to the facility on [DATE] with a diagnoses which included Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), adjustment disorder with mixed anxiety and depression mood (nervousness, worry, difficulty concentrating, or remembering things, and feeling overwhelmed), adjustment disorder with mixed disturbance of emotions and conduct (symptoms include behavioral issues such as acting rebellious, destructive, reckless or impulsive. Also includes symptoms of anxiety and depression), altered mental status (changes in mood, cognition, and behavior) and unspecified glaucoma (a group of diseases that damage the eye's optic nerve and can result in vision loss and even blindness). Record review of Resident #16's Quarterly MDS Assessment, dated 08/31/2022, reflected Resident #16 had a BIMS score of 6, which indicated his cognition was severely impaired. Resident #16 had a behavior of wandering. Resident #16 required assistance with all ADL's. Record review of Resident #16's Annual MDS Assessment, dated 03/09/2022, reflected Resident #16's had a BIMS score of 6, which indicated Resident #16's cognition was severely impaired. Resident #16's Activity Preferences reflected it was very important for resident to be around animals/ pets, listen to music he liked, keep up with the news, do things with group of people, go outside to get fresh air, and participate in religious services or practices. Resident #16 required assistance with all ADL's. Record review of Resident #16's Comprehensive Care Plan, revised on 09/07/2022, reflected Resident #16's mood would be addressed by keeping the resident engaged in activities they like. The resident preferred activities which did not involve overly demanding cognitive tasks. Engage in simple, structured activities such as watching television, visiting, talking on phone, outdoor activities, spiritual activities, social parties and being around animals. Resident #16's memory problems would be identified and addressed through engaging activities. Record review of the facilities in Room and Group Participation Binder reflected Resident #16 did not attend group activities or receive in room activities from July 1, 2022, through October 25, 2022. Record review of the facility's, undated, in Room Resident Roster reflected Resident #16 was on the in-room activity program. Observation and interview on 10/24/2022 at 9:30 AM revealed Resident #16 were in his room. He was sitting in his wheelchair. The lights were off in the room and there was no stimulation. He had a television, but it wasn't turned on for him to watch it. Resident #16 stated it was too quiet in his room. Resident #16 stated he would like to watch television. Resident #16 stated he did not remember about his activities. Resident #16 stated he did not like to be around very many people. In an interview on 10/25/2022 at 11:30 AM, the Activity Director stated Resident #16 was on the in-room activities program due to the resident's short attention span and not wanting to stay in group activities. She stated he did not enjoy being around group activities for very long periods of time. She stated she did talk to Resident #16, but she did not recall exactly what activities she did with the resident. She stated she did not have any documentation of the resident receiving in room activities or attending group activities. She stated if a resident wanted to participate in religious activities and did not attend religious activities in a group, these could be provided in the resident's room. She stated she did not remember what engaging activities were given to the resident for his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 6 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some memory problems. She stated whatever was addressed on the care plan should be followed through with the activity programming with individual residents. She stated the care plan should match what had been identified as the resident's activity preference. She stated she did not have any excuse of why there were no participation records for in room activities or group activities for Resident #16. She stated all group and in room activities were expected to be documented to prove there were activities being offered and residents participated in the activity program (in room and group activities). She stated she did not know how long Resident #16 had been on the in-room activity program. She stated she was responsible for residents' activities programs in groups and in -room activity programs. 3. Record review of Resident #32's face sheet, dated 10/28/2022, reflected a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (a mental disorder in which a person loses the ability to think, remember, learn , make decisions, and solve problems), Alzheimer's disease (progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment), cognitive communication deficit (thought processes that allow humans to function successfully and interact meaningfully with each other), psychotic disorder with delusions due to known physiological condition (loss of contact with reality, unshakeable belief in something implausible, bizarre, or obviously untrue), schizoaffective disorder, bipolar type (psychosis may occur during episodes of mania or depression but not otherwise) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of Resident #32's Annual MDS Assessment, dated 09/21/2022, reflected Resident #32 had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #32 was interviewed for activity preferences. The activities that were very important to Resident #32 were: being around animals and doing favorite activities. The activities that were somewhat important to her were reading books/newspapers, listening to music she liked, keep up with the news, do things with groups of people, go outside to get fresh air, and participate in religious services/practices. Resident #32 required assistance with all ADL's. Resident #32 did not walk, turn around or move from a seated to standing position. Resident #32 was required to be stabilized with staff when transferring from surface-to-surface (between bed and chair or wheelchair). Record review of Resident #32's Quarterly MDS Assessment, dated 06/21/2022, reflected Resident #32 had a BIMS score of 3, which indicated her cognition was severely impaired. Resident #32 required assistance with all ADL's. Resident #32 did not walk, turn around or move from seated to standing position. Resident #32 was required to be stabilized with staff when transferring from surface-to-surface. Record review of Resident # 32's Comprehensive Care Plan, with a completed review date of 09/6/2022, reflected Resident #32 had social services needs due to mood/ behavior/ cognition issues. Resident #32 had a flat affect. Resident #32 would remain safe and engaged during stay at the facility. Resident #32's mood would be addressed by keeping the resident engaged in preferred activities. Resident #32 short term memory problems would be identified and addressed through engaging activities. Resident #32's preferred activities were: rummaging through belongings, making bed, cleaning room, visiting with family, activity pillow, snack cart and chat visits, outdoor events, parties/socials, nail shop and bingo. Resident #32 had history of being physically aggressive and pushed other residents related to dementia and poor impulse control. Resident #32 had an adjustment disorder with anxiety and depression. Encourage Resident #32 to participate in activities of choice. Facilitate attendance as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 7 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 required. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #32's Annual Activity Interview for Daily and Activity Preferences Record, dated 02/24/2022, reflected Resident #32's activity preferences were as follows as stated by resident during interview: It was very important for resident to participate in: her favorite activities and be around animals and pets. Resident #32's activities preferences were somewhat important such as: reading, listening to music she liked (did not specify her favorite music), keeping up with the news, doing things in groups of people, being outside to get fresh air, and participate in religious services and /or practices. Residents Affected - Some Record review of the facility's in Room and Group Participation Binder reflected Resident # 32did not attend group activities or receive in room activities from July 1, 2022, through October 25, 2022. Record review of the, undated, facilities in Room Resident Roster reflected Resident #32 was on the in-room activity program. Observation and interview with Resident #32 on 10/24/2022 at 10:45 AM revealed Resident #32 was in bed and was constantly moving her hands and legs. Her legs were off the bed, and she pulled at her sheets and was in constant motion. Resident #32 was not interviewable. Resident #32 did not respond appropriately to conversation and was easily distracted. Resident #32's lights were off in her room and there was no stimulation in her room. Her privacy curtain was pulled where she could not see out the door into the hall. The television was not on for stimulation. Resident #32 only made eye contact one time for a few seconds. She was looking at her hands as she was holding the bedspread and later looked at her hands while she rubbed her hands. Resident #32 was not able to be still. In an interview with the Activity Director on 10/25/2022 at 11:30 AM, the Activity Director stated she did not know when Resident #32 was added to the in-room activity list. She stated she did not have documentation of Resident #32 attending group activities or receiving in room activities. She stated she did talk to her sometimes, but she did not know the dates when she talked to Resident #32. She stated Resident #32 was not able to make up her bed or clean her room at this time. She stated when the care plan was updated recently, she did not know if the resident was able to make up her bed or clean her room. She stated if any resident did not walk or was able to turn around or move from a seated to standing position it would be very difficult for any resident to make up their bed. She stated Resident #32 did not enjoy very many group activities due to her mood and did not enjoy being around a lot of people. She stated if a resident had an activity pillow as an intervention on the care plan, she did not provide an activity pillow for the resident. She stated she was responsible for the in-room activity list. 4. Record review of Resident #15's face sheet, dated 10/26/2022, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #15 had diagnoses which included post-traumatic stress disorder (disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended- may feel sadness, fear or anger; and they may feel detached or estranged from other people), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (persistent and excessive anxiety and worry about activities or events- even ordinary routine issues), schizoaffective disorder, bipolar type (psychosis may occur during episodes of mania or depression but not otherwise) and cerebral infarction due to thrombosis of bilateral middle cerebral arteries (middle cerebral artery is the most common artery involved in acute stroke). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 8 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #15's Annual MDS Assessment, dated 08/30/2022, reflected Resident #15 had a BIMS score of 5, which indicated her cognition was severely impaired. The resident was interviewed on her mood. She felt depressed/hopeless and had difficulty falling asleep or sleeping too much. Resident #15 required assistance with all ADL's. Resident #15 answered questions of her activity preferences. The following activities were very important to Resident #15: Residents Affected - Some - have books, newspapers, and magazines to read, - listen to music she liked, - be around animals such as pets, -keep up with the news, - do things with group of people, - do favorite activities, - go outside to get fresh air when the weather is good, and - participate in religious services or practices. Record review of Resident #15's Comprehensive Care Plan, revised on 09/01/2022, reflected Resident #15's mood would be addressed by keeping the resident engaged in activities she liked. Ensure the activities Resident #15 attended were: compatible with physical and mental capabilities; known interests and preferences; adapted as needed such as large print, holders if resident lacks hand strength and task segmentation and compatible with individual needs and abilities, and age appropriate. Resident #15's preferred activities were spiritual activities/services, outdoor/events, music, monopoly, computer/internet, gardening, television, reading, crossword puzzles and writing. Record review of Resident #15's Activity Initial Assessment, dated 11/16/2021 and locked in the electronic medical record on 11/19/2021, reflected Resident #15's activity likes and dislikes. Her likes were the following: -computer/ internet, -wordsearch/ crossword puzzles, - comedies on television, - read romance novels, -rock music, -flower/vegetable gardening, -writing, and -church (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 9 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Resident #15's dislikes were the following: physical activities, social activities, arts and crafts, and games. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #15's Activity Quarterly Note, dated 02/02/2022, reflected the residents' activity interests, however, did not reflect if the resident attended any group activities in the past quarter or received any in room activities in the past quarter. Residents Affected - Some Record review of Resident #15's Activity Interview for Daily and Activity Preferences, dated 08/30/2022, reflected Resident #15's activity preferences were the following: -reading, -listen to music, -being around animals/pets, -keep up with the news, -do things in groups of people, -do favorite activities, -go outside for fresh air, and -participate in religious services/ practices. Record review of the facilities in Room and Group Participation Binder reflected Resident #15 did not attend group activities or receive in room activities from July 1, 2022 through October 25, 2022. Record review of the, undated, facilities in Room Resident Roster reflected Resident #15 was on the in-room activity program. Observation and Interview on 10/24/2022 at 12:45 PM revealed Resident #15 was in her room in bed. There was no stimulation in the room. Resident #15 did not smile during the visit. Resident #15's television was not on and her lights were off in her room. She did not respond to questions except when asked how she felt and she stated alone. Resident #15's facial expression was lip corners pulled down and eyebrows raised. In an interview on 10/25/2022 at 11:30 AM the Activity Director stated Resident #15 was on the in-room activity program. She stated the date Resident #15 was placed on in room activity programs was not known at this time. She stated Resident #15 did not enjoy being in group activities very often. She preferred to stay in her room most of the time. She stated her activity interests were on the care plan. She stated she did not provide any access to the computer due to Resident #15 being confused. She stated she had not attempted to try using a computer with Resident #15 even though it was her activity preference. She stated she did not think about taking gardening items in Resident #15 room and do gardening with her as an activity in her room. She stated she did not have any documentation that Resident #15 attended group activities or received in room activities. She stated she would go by and check on her and talk to her a few minutes, but she did not have the dates or how long she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 10 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stayed in the resident's room. She stated she was trained to document all activity programs on the participation records which included in room and group activities. She stated it was her responsibility to plan in room activities and group activities. She stated she was to monitor each in room resident to ensure all residents got the activity items they needed to do any type of activities of their preferences and to have a consistent in room activity program. She stated if residents were not receiving the right stimulation they needed, the residents had the potential to become depressed or more depressed and it could affect their emotional well-being and possibly their physical condition. She stated one-on- one activities was the same as in room activities. In an interview on 10/25/2022 at 1:00 PM, CNA A stated she had not witnessed anyone including the Activity Director in residents' rooms on 400 hall doing activities or offering activity items to Resident #40, Resident #16, Resident #32 and Resident #15. She stated Activity Department provided activities for the residents. In an interview on 10/26/2022 at 2:00 PM, the Administrator stated the Activity Director was responsible to monitor activities for each resident. She stated all activities were to be documented on the in-room participation records and the group participation records. She stated any changes with residents' activity preferences were expected to be monitored and these activities provided to these residents. She stated activities were an important part of a resident's quality of life. Record review of the facility's, undated, policy on Resident Wellness and Activities Program reflected the facility provided an ongoing program providing a variety of activity functions through the Resident Wellness and Activities Program. The program was designed to include attractions to meet the interests and physical, mental, and psychosocial well-being of each resident in accordance with the resident's comprehensive assessment. Record review of the Activity Director Job Description signed by the Activity Director reflected documents the resident's abilities and needs based on resident evaluation and records each resident's participation in activities (group activity involvement, self-initiated activities, and one-on-one activities, etc.). Record review of the Activity Director certification of qualifications to meet the states requirement to be an Activity Director. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 11 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews the facility failed to ensure the resident environment remained free of accidents hazards as possible for one of six (Resident # 3) residents reviewed for accidents and supervision. The facility failed to ensure Housekeeping Aide B locked the compartment door which contained chemicals and failed to ensure the housekeeping cart was not left unattended and not accessible to residents. This failure could place residents at risk of injuries, illness, and hospitalization. Findings include: Record review of Resident #3 face sheet, dated 10/26/2022, reflected an [AGE] year-old-female admitted to the facility on [DATE] and readmitted on [DATE] and 09/13/2022 with diagnoses which included Alzheimer's disease ( it is a progressive disease- involved parts of the brain that control thought, memory and language), major depressive disorder ( a mood disorder that causes a persistent feeling of sadness and loss of interest) and type 2 diabetes ( disease that keeps your body from using insulin the way it shouldhave insulin resistance. Symptoms feeling hungry, being very thirsty, blurry vision, etc.) Record review of Resident #3's Quarterly MDS Assessment, dated 07/20/2022, reflected the resident had impaired vision and didn't wear glasses. Resident #3's BIMS score was a 3, which indicated her cognitive impairment was severely impaired. Resident ambulated in wheelchair. Record review of Resident #3's Comprehensive Care Plan, revised on 07/27/2022 reflected Resident #3 had mood/behaviors/cognition issues. Impaired Cognition/ Alzheimer's. The resident moved throughout the facility into other residents' rooms but was not exit seeking. Resident #3 was a wanderer related to impaired safety awareness. Resident #3 required redirection. Monitor location every shift and attempt diversional interventions. Observation on 10/24/2022 throughout the day from 9:30 AM - 2:00 PM revealed Resident #3 wandered on 300 and 400 halls, lobby, dining room, around nurses' desk. Resident #3 attempted to enter other residents' rooms. Observation on 10/25/2022 at 10:30 AM revealed Resident #3 propelled herself to the housekeeping cart at the front of the 400-hall, the same hall where she resided. Resident #3 was observed touching a chemical bottle on top of the housekeeping cart and reached for a white plastic basket containing bottles of chemicals that were not labeled as to what type of chemical they were. After surveyor spoke with Resident #3 she was easily re-directed from the housekeeping cart. The chemical was not in a clear bottle. After opening the bottle, it was difficult to view the color of the chemical. Observation on 10/25/2022 at 10:30 AM until 10:40 AM revealed the housekeeping cart continued to be left unattended. Observation on 10/25/2022 at 10:40 AM revealed Housekeeper Aide B walked from another area of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 12 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few facility away from the 400 hall (unable to view the direction he was walking from when approached the housekeeping cart) to the housekeeping cart. In an interview on 10/25/2022 at 10:40 AM, Housekeeper Aide B stated he could not see the housekeeping cart. He stated he was on another hall talking to someone. He stated he did not have a key to lock the housekeeping cart. He stated the Housekeeping Supervisor was aware the housekeeping cart did not have a key to lock the chemicals. He stated he knew the chemicals needed to be where the residents were unable to reach them. He stated if a resident drank some of the chemicals it could hurt them physically and they could become seriously ill and be in the hospital. He stated some chemicals could cause burns on the skin. In an interview on 10/25/2022 at 10:55 AM, the Housekeeping Supervisor stated there were 2 housekeeping carts that did not have keys to lock the compartments where the chemicals were stored. He stated the chemicals were to be always locked except when the housekeeper was getting chemicals out of the compartment to use, and the housekeeper was expected to immediately lock the cart. He stated he had verbally informed the Maintenance Supervisor of not having a key to lock 2 housekeeping carts. He stated there was an electronic system to use to type in requests for repairs, but he was not aware of how to use this computer system. He stated if a resident swallowed a chemical there was a possibility the residents throat could be burned, have stomach issues, and possibly result in death. He stated drinking a chemical or getting certain chemicals on skin was very serious. He stated the skin could be burned from the chemical and a resident may need hospitalization. He stated former employees had taken the keys home with them and he did not remember when their last day of employment. In an interview on 10/26/2022 at 8:00 AM, the Maintenance Supervisor stated he was not aware of any housekeeping carts needing a lock to be replaced. He stated all staff were trained on how to submit a maintenance request and he posted signs in areas where only employees could view it of how to submit the maintenance request form from the computer. He stated there was one of the signs near the copier and he pointed to the sign. He stated the facility had meetings in this room and people used the copier all day and the signs were beside the copier. In an interview on 10/26/2022 at 1:00 PM, CNA B stated Resident # 3 wandered in the halls and would wander into other residents' rooms. She stated Resident #3 would attempt to take things especially if it was something to drink or eat. She stated Resident #3 did not wander in other residents' rooms every day, but she did wander on all the halls, in lobby, dining room and all over the facility. She stated she did not sit still for very long period of time. She stated there were days Resident #3 would be in constant motion. In an interview on 10/26/2022 at 2:00 PM, the Administrator stated all chemicals were to be locked in the housekeeping cart. She stated all staff had been trained on how to submit work orders for the Maintenance Supervisor. She also stated if a resident drank certain chemicals, it could cause physical harm. She stated she didn't know exactly what type of physical harm, but it could be dangerous and possibly result in hospitalization. In an interview on 11/9/2022 at 5:41 PM PTA D stated she had been working at the facility for approximately 2 years. She stated she was familiar with Resident #3 and within the past few months had not been using her hands to move her wheelchair, she had been using her feet instead. She stated Resident #3's hands were usually in her lap. She stated she and other staff had to push her from place to place. She stated Resident #3 would have the strength to pick up a bottle but would not have the dexterity to spray the bottle (operate with her finger) or unscrew the cap. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 13 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record Review of the, undated, Safety Data Sheet of Ready-to-Use Bacterial Odor and Grease Digestant reflected avoid contact with skin, eyes, open cuts, or sores. Do not spray product in the air. Wash thoroughly after handling. Avoid use and contact or product with immune- compromised individuals. Contains bacterial cultures. In case of contact, flush with plenty of water. If irritation occurs and persists, get medical attention. If swallowed, if conscious, dilute by drinking up to a cupful of milk or water as tolerated. If in eyes flush with plenty of water. If irritation occurs and persists get medical attention. Bacterial infection may occur through open wounds or broken skin. If ingested may cause irritation, nausea, vomiting and diarrhea. If ingested may cause irritation, nausea, vomiting and diarrhea. Keep out of reach of children. Record Review of the, undated, Safety Data Sheet of Ready-to-Use Glass and Plastic Cleaner reflected causes eye irritation. If in eyes rinse cautiously with water for several minutes. Remove contact lenses. Continue rinsing for at least 15 minutes. If eye irritation persists, get medical attention. If on skin wash with plenty of water. If skin irritation occurs and persists, get medical attention. If ingested may cause irritation, nausea, vomiting and diarrhea. Keep out of reach of children. Record Review of the, undated, Safety Data Sheet of Concentrated Neutral Floor Cleaner - General Purpose Cleaner reflected if in eyes rinse cautiously with water for several minutes. Continue rinsing for at least 15 minutes. If eye irritation persists, get medical attention. If on skin wash with plenty of water. If skin irritation occurs and persists, get medical attention. If ingested may cause irritation, nausea, vomiting and diarrhea. Keep out of reach of children. Record Review of the, undated, Safety Data Sheet of Disinfectant Cleaner reflected if in eyes may cause eye irritation, may cause discomfort, redness, and watering. If on skin may cause mild skin irritation. If ingested may cause irritation, nausea, vomiting and diarrhea. Keep out of reach of children. Record Review of the, undated, Safety Data Sheet of Liquid Air Freshener reflected delayed, immediate, or chronic effects and symptoms from short and long-term exposure. Skin: may be mildly irritating to skin. Symptoms may include redness and or transient discomfort. Eyes: Corrosive. Causes eye damage. Symptoms may include pain, burning sensation, redness, watering, blurred vision, or loss of vision. Ingestion: causes burns/serious damage to mouth, throat, and stomach. Symptoms may include stomach pain and nausea. Inhalation: may cause irritation and corrosive effects to nose, throat, and respiratory tract. Symptoms may include coughing and difficulty breathing. Record Review of the, undated, Facility Policy on Housekeeping Services reflected all poisonous items and or other items with cautionary labels are kept secured and are only accessible to employees. These containers are labeled properly and are not stored in containers that were previously used to store foods or medicines. The facility provides a safe, functional, sanitary, and comfortable environment for all residents, staff, and the public. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 14 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 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 for one kitchen reviewed for kitchen sanitation. 1. The facility failed to properly thaw 10 pounds of pork. 2. The facility failed to properly store, label and cover food in the facility's refrigerator and freezer located in the kitchen. These failures could place the residents at risk for health complications and foodborne illnesses. Findings include: 1. Observation of the kitchen on 10/24/2022 at 8:40 AM revealed Dietary [NAME] C stood at the preparation area beside the sink. There was 10-pounds of pork in a silver container with approximately 6-8 inches of water in the container. The pork was being thawed to cook for the lunch meal. The pork was not completely thawed. When touched the pork was hard and had some ice particles on part of the end of the pork. In an interview on 10/24/2022 at 8:43 AM, Dietary [NAME] C stated the pork was not completely thawed and she was trying to thaw it in the container. She stated she was not thawing the pork properly. She stated the pork should be in the bottom of the refrigerator on a flat pan or in the sink with running water. She stated she knew how to thaw meat, but she thought it would thaw faster in the pan in some water. She stated if pork wasn't thawed or cooked properly, there was a possibility the residents could become sick and get food poisoning. 2. Observation of the kitchen on 10/24/2022 at 8:50 AM - 9:00 AM revealed the following: - leftover beef in the refrigerator not in the original package was opened and was dated 10/10/2022. - leftover salami in the refrigerator not in the original package was opened, and was not dated, or sealed. -chicken strips in the freezer not in the original package were not labeled or dated. - left over veggie burgers in the freezer were not labeled or dated. In an interview on 10/24/2022 at 9:10 AM, the Dietary Manager stated the pork required to be thawed on a flat pan in the bottom of the refrigerator or in the kitchen sink with running water. She stated the pork was not being thawed properly and pork needed to be thawed but not kept at room temperature prior to cooking. She stated if food was not thawed properly, kept at room temperature, or not cooked properly the residents could become physically ill with some type of food poison. She stated all left-over food was required to be labeled, dated, and sealed. She stated if leftover food was not used within 2 days of the date on the package it was to be thrown away. She stated if leftover food was served to residents after being in the refrigerator for several days the residents could become (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 15 of 16 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 675536 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sick with food poisoning. She stated she was responsible to ensure the dietary staff was following policy. She stated it was her responsibility to ensure the staff stored food properly and every task the dietary staff did in the kitchen. In an interview on 10/26/2022 at 2:00 PM, the Administrator stated the Dietary Manager was responsible to manage storing/ labeling food and the correct process of thawing food especially meats. She stated the pork was not being thawed correctly. She also stated leftover food needed to be thrown away after 2 or 3 days being in the refrigerator. She stated if food was not labeled or dated it also needed to be thrown away especially if the food was not in the original package. Record review of the facility policy of Food Production, dated October 2021, reflected frozen foods are thawed during the cooking process, under refrigeration or by immersion under running water of a temperature of 70 degrees Fahrenheit or lower. Food may be also thawed in the microwave if the food was cooked immediately. Record review of the facility policy on Food Storage reflected food removed from its original packaging will be dated and labeled. All leftover food was to be tightly wrapped or covered in clean containers. It should be labeled, dated with the open or use by date. Do not keep leftover prepared foods in the refrigerator for more than 7 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 16 of 16