Inspection·January 31, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was not care planned and Resident #3's preference to place own cover on catheter bag. Resident #3 request if she forgets to place the catheter cover bag prior to leaving the room and she is in public for the staff to remind her and assist her with the catheter cover bag. Resident #3 required assistance with ADL Care. Review of Resident #3's Physician Orders, dated 01/09/2024 reflected a new order on 12/16/2023 for foley care: output every shift (a medical device that helps drain urine from your bladder). Review of Social Workers progress notes from 12/30/2021- 01/19/2024 reflected Resident #3 did not express any preferences of wanting to place a bag over catheter themselves instead of staff. Review of Resident #3's Nurses Notes from 12/16/2023 - 01/30/2024 reflected facility staff did not document Resident #3 preference of placing a catheter bag on her own catheter and if she Resident #3 forgets when she was outside of her room the staff was to remind her and assist with covering her catheter bag. Review of Resident #3's Nurses Notes dated 01/19/2024 reflected IDT met to discuss resident's plan of care. Plan of care updated . Observation on 01/29/2024 at 9:55 AM Resident #3 was sitting in the hallway and her catheter was not covered. Observation on 01/29/2024 at 10:00 AM Resident # 44 was making retching noises (when the body keeps wanting to vomit but cannot). Interview on 01/29/2024 at 10:05 AM Resident #44 stated looking at that pee in the bag. It is making me sick and I almost vomited. I cannot stand to look at pee or anyone's bowels. It makes me sick to my stomach. Interview on 01/29/2023 at 10:08 AM Resident #3 stated she was so embarrassed and humiliated for people to know she wears a catheter. She stated there were times she forgets to put the bag over the catheter and several residents had explained to her it made them sick to look at the urine. Resident #3 stated she told the Social Worker and a nurse (she did not recall the nurses name) she preferred to put the catheter bag on herself but if she was out of her room and forgot to cover the catheter bag, she wanted nursing staff to remind her and assist her with covering the catheter bag. Resident #3 also stated the staff would remind her sometimes but usually the other residents would ask me the cover my catheter bag. She stated when she was overwhelmed having a catheter and it made her nervous. Resident #3 also stated she may have to re-think attempting to place the catheter bag on by herself if she continues to forget. Interview on 01/31/2023 at 9:13 AM The Administrator stated all catheters were expected to be covered. She stated it was the staff's responsibility to ensure the catheter were covered especially when a resident was outside of their room The Administrator stated if Resident #3 stated she wanted to cover her own catheter and she exited her room and went into common areas it was the staff responsibility to ensure the catheter was covered. She stated if other residents made statements, it made them sick to look at the urine in the catheter this does affect the other residents' rights. (The Administrator did not elaborate on her statement). Interview on 01/31/2024 at 9:43 MDS Coordinator/LVN stated Resident # 3's catheter was expected to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 2 of 28 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 01/31/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few be covered. She stated it was a dignity issue. She stated Resident #3 may become embarrassed for staff, visitors, or other residents to see her urine in catheter bag and Resident #3 may not want anyone to know she was wearing a catheter. She stated it was a potential for Resident #3 become anxious and depressed due to her diagnosis of anxiety and other mental diagnosis. MDS Coordinator / LVN stated there was a potential of Resident #3 becoming embarrassed if other residents, staff, and visitors to view her uncovered catheter. MDS Coordinator/LVN stated she did not know if Resident #3 told anyone she wanted to place the catheter bag on herself and if she forgot she wanted the staff to remind her if she forgets. She also stated the staff was expected to place cover on Resident #3's catheter bag if her bag was not covered. She stated it also may affect other residents' rights to view the urine in the bag. Interview on 01/31/2024 at 10:56 AM ADON stated all catheters were expected to be covered when residents are out of room. He stated if Resident #3 care plan should reflect, she had a catheter. He stated if Resident #3 was placing catheter bag over catheter herself and forgot to do this task it was the staff responsibility to ensure Resident #3 catheter was covered. He stated he was not going to comment on other residents not wanting to look at a urine in a catheter bag. ADON also stated if the uncovered catheter embarrassed and humiliated Resident #3 it was a dignity issue. 2. A record review of Resident# 39's face sheet dated 01/31/24 revealed Resident# 39 was admitted on [DATE] with a diagnosis of psychotic disturbance, mood disturbance, and anxiety (mood disorder causing feeling of fear, dread, and uneasiness); ataxic gait (failure of muscle coordination characterized by an irregular foot placement, wide base, and instability), heart failure, age-related physical debility, gout (inflammatory arthritis that causes pain and swelling in joints), hypertension (high blood pressure), unspecified convulsions (seizure disorder), and hyperlipidemia (elevated level of lipids or fats such as cholesterol and triglycerides in the blood). A record review of Resident# 39's MDS last revised 01/11/24 reflected a BIMS score of 5 suggesting cognitive impairment. Resident# 39's MDS functional abilities assessment reflected she required substantial/ maximal assistance in lower/upper body dressing and footwear. A record review of Resident# 39's care plan revised 01/25/24 revealed she required 1 person assist with dressing. An observation and interview on 01/30/24 beginning at 8:29 AM revealed Resident# 39 sitting in her wheelchair at her bedroom door near the hall. Resident# 39 was not wearing pants or socks and wore only a shirt and her incontinence brief. Resident# 39's eyes appeared red, watery, and her mood appeared dejected. In an interview, Resident# 39 said you can call them referring to staff, and she was observed stretching her shirt over her legs attempting to cover herself. In an interview on 01/31/24 at 12:13 PM Resident# 39 stated she was in her wheelchair near the hall attempting to get assistance with getting dressed. She said she relies on care staff for assistance putting her pants on. Resident# 39 stated well it didn't make me feel good said she was embarrassed sitting exposed near the hall. In an interview on 01/31/24 at 01:35 PM CNA E stated it was the CNA's responsibility to dress the residents that require assistance in the morning. CNA E said she was familiar with Resident# 39's care and knows that Resident# 39 requires total care or full assistance regarding getting dressed. CNA E said that Resident# 39 not having pants on and sitting near the hall in her briefs is a dignity issue and could have a negative effect on Resident# 39's mental health. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 3 of 28 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 01/31/2024 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 01/31/24 at 02:53 PM the Administrator revealed it was the CNA's responsibility to dress residents that require assistance in the morning which should be done before breakfast. She said nurses will also make sure they are dressed when entering the room for morning medication administration, and that department heads are also assigned rooms/ halls to check that residents are up, dressed, and are having their needs met. The administrator said it is her expectation that those that require assistance receive assistance. She said adverse effects of someone not being dressed or left exposed could lead to or worsen depression, anxiousness, and cause undo stress. The administrator stated that it could affect a resident's self-worth; they would no longer want to come out of their room or participate in activities. It could also potentially lead them to being victimized or taken advantage of by staff or other residents. Record Review of facility Dignity policy revised February 2021 revealed: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy also revealed demeaning practices and standards of care that compromise dignity is prohibited. Staff are expected to promote dignity and assist residents; for example: Helping the resident to keep urinary catheter bags covered. Individual needs and preferences of the resident are identified through the assessment process. When assisting with care, residents are supported in exercising their rights. For example, residents are encouraged to dress in clothing they preferred. Under Policy Interpretation and Implementation it states, Residents are treated with dignity and respect at all times. Individual needs and preferences of the resident are identified through the assessment process. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. The policy references OBRA regulatory reference numbers §483.l0(a) Resident Rights; §483.l0(b) Exercise of Rights and Survey Tag F550. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 4 of 28 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 01/31/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident within 48 hours of the resident's admission that included instructions for providing effective person-centered care for the resident and met professional standards of quality of care for 1 of 4 residents (Resident # 58) reviewed for care plans, in that: The facility failed to develop and implement a baseline care plan for Resident #58. This failure placed residents at risk of not having their immediate care needs met or not receiving continuity of care. Findings included: Record review of Resident #58's face sheet, dated 01/31/2024, reflected an [AGE] year old female was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus without complications ( a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), chronic kidney disease, stage 4 ( kidneys are moderately or severely damaged and are not working as well as they should be to filter waste from your blood), cutaneous abscess of abdominal wall ( a pocket of puscollection of dead, white blood cells that accumulates when the body's immune system activates in response to an infection- located in the abdomen), acute cholecystitis (a redness and swelling of the gallbladder), hypertension ( occurs when you have abnormally high blood pressure that's not the result of a medical condition), infective myositis ( uncommon group of inflammatory myopathies-( any disease that affects the muscles that control voluntary movement in the body) caused by a range of infective agents such as viral, bacterial, fungal, and parasitic, depression ( a mood disorder that causes a persistent feeling of sadness and loss of interest), generalized anxiety disorder (a condition of excessive worry about everyday issue and situations), and other malaise (a feeling of general discomfort, uneasiness or lack of wellbeing and often the first sign of an infection or other disease). Record review of Resident #58's admission MDS Assessment, dated 12/31/2023, reflected Resident #58 had a BIMS score of 15. Resident #58 required assistance with ADLs. She had medically complex conditions (usually involve multiple body systems and are often chronic in nature. Persist over a long time, usually for a person's lifetime). Resident #58 had a surgical wound. She was at risk of developing pressure ulcers/injuries. Resident #58 was receiving OT (Occupational Therapy- assist people to overcome various problems to live more independent lives). Record review of Resident #58's clinical record reflected her baseline care plan was not completed within 48 hours. Resident #58's baseline care plan was initiated on 01/02/2024 and was not completed. Interview on 01/31/2024 at 9:13 AM with the Administrator stated all baseline care plans were to be completed within 48 hours of admission. She stated if a resident was admitted on a Friday afternoon the baseline care plan was expected to be completed over the weekend. The Administrator stated the social worker, admitting nurse either on weekend or during week, DON, and MDS nurse was responsible for completing the baseline care plan. She stated if a resident was admitted on a Friday afternoon, she expected the baseline to begin at that time and throughout the 48 hours until it was completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 5 of 28 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 01/31/2024 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few She also stated if the baseline were not completed there was a potential of a resident would not receive personalize care to meet their physical and mental needs such as: proper transfers, incontinent care, the correct wound care, and emotional support. The administrator stated it was the MDS nurse responsibility to monitor the baseline care plan to ensure it was completed. Interview on 01/31/2024 at 9:43 AM, MDS Coordinator/LVN stated the baseline care plan was required to be completed within 48 hours of the resident's admission date. MDS Coordinator/LVN reviewed the baseline care plan during the interview and agreed the baseline care plan for Resident #58 was not completed and the baseline care plan was late. She stated Resident #58's baseline care plan was expected to be completed within 48 hours of her admission date. She stated Resident #58's admission date was 12/29/2024 in the afternoon. She also stated the baseline care plan was dated on 01/02/2024. MDS Coordinator/ LVN stated the baseline care plan was used as a tool to know what type of care a resident needed. She stated the Nurses does complete a nurse assessment; however, the baseline care plan gave more information of what type of care the resident required. She stated the nurses did not document in their admission assessment everything on the baseline care plan. MDS Coordinator/ LVN stated if the nursing staff did not have the information from the baseline care plan there was a potential of the resident not receiving proper care such as improper transfers. She stated if a resident was not transferred properly there was a possibility a resident may injure themselves with an improper transfer. She stated the staff would not know the personalize care the resident needed at time of admission. Interview on 01/31/2024 at 10:56 AM, the ADON stated all baseline care plans were to be completed within 48 hours of admission. He stated the resident would continue to receive care from the staff. The baseline care plan had more information of personalize care for the residents. The staff would not have all the information to give care to residents without the baseline care plan. He stated to refer to the MDS Coordinator for further information on baseline care plans and possible negative outcomes of a resident if the baseline care plan was not completed. Review of the Facility's Baseline Care Plan Policy, dated 03/2022, reflected A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality of care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following: A. Initial goals based on admission orders and discussion with the resident/ representative. B. Physician orders. C. Dietary orders. D. Therapy Services. E. Social Services. F. PASARR recommendations, if applicable. (PASARR- a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long term care) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 6 of 28 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 01/31/2024 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 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, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 3 (Resident # 3, 52 and 55) 16 residents reviewed for care plans. 1. The facility failed to ensure Resident # 3's Catheter was addressed on her care plan. 2. The Facility failed to ensure Resident # 52's care plan was updated by removing isolation when the resident no longer medically required it. 3. The facility failed to ensure Resident # 55's Fluid restriction and noncompliance with restrictions was on the care plan. This failure placed the resident at risk for not having their individual needs met in a timely manner and communicated to provide and could result in injury and a decline in physical well-being. Findings included. 1. Review of Resident #3's face sheet, dated 01/31/2022, reflected a 70 -year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of: cognitive communication disorder (difficulty with any aspect of communication that is affected by disruption of cognition such as: attention, memory, organization, and problem solving/ reasoning), complete traumatic( related to physical injury) amputation (surgically cutting off a limb) at level between left hip and knee, pain due to internal orthopedic prosthetic devices ( used to keep fractured bones stabilized and in alignment), implants ( replace missing body parts, and grafts (healthy tissue taken from one part of the body to replace diseased or injured tissue removed from another part of the body), obesity ( having too much body mass- a measurement of a person's weight with respect to his or her height), bipolar disorder (causes extreme mood swings that include emotional highs and lows- depression),schizophrenia (causes delusions- false believe or judgement and hallucinations- see things that are not there like objects, shapes, people or lights) and, anxiety (when the mind and body encounters stressful, dangerous, or unfamiliar situations). 2. Review of Resident # 52 face sheet, dated 1/29/2024, reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Unspecified Dementia, moderate, with mood disturbance ( A group of thinking and social symptoms that interferes with daily functioning mood disturbances can include apathy, anxiety and agitation) Essential Hypertension( elevated Blood pressure), Hypothyroidism( a disorder of the thyroid where it does not produce enough hormones) Insomnia( the ability to fall or stay asleep) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 7 of 28 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 01/31/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 3. Review of Resident # 55's face sheet, dated, 1/29/2024, reflected a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of Hemiplegia and hemiparesis following Cerebral infarction affecting the left side (a paralysis of partial or total body function on one side of the body and weakness as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it. ) Chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe.), Essential Hypertension (elevated blood pressure), Dysphagia (Difficulty swallowing can have causes that aren't due to underlying disease) 1. Review of Resident #3's Five Day Scheduled MDS, dated [DATE], reflected Resident #3 had a BIMS score of 15 indicated her cognition was intact. Resident #3 was assessed to have an indwelling catheter (a flexible tube inserted through a narrow opening into the bladder for removing fluid). 2. Review of Resident # 52 's Quarterly MDS dated [DATE], reflected Resident # 52 had a BIMS Score of 5 which indicates her cognition was severely impaired. 3. Review of Resident # 55 Quarterly MDS dated [DATE] reflects Resident # 55 had a BIMS score of 10 which indicates his cognition was moderately impaired. Review of Resident #3's Comprehensive Care Plan with a target date of 04/19/2024 reflected Resident #3's catheter was not care planned. Resident #3 required assistance with ADL Care. Review of Resident # 54's comprehensive Care plan with a target date of 3/7/2023 indicates that Resident # 54 on 1/16/2024 requires transmission-based precautions due to a positive covid test. The resident had completed the required 10-day isolation per policy and was asymptomatic on 01/26/2024. Review of Resident # 55's Comprehensive Care Plan with a target date of 3/20/2024, reflected Resident #55's fluid restriction was not on the care plan, nor was his non-compliance with the restriction documented on the care plan. Interview on 01/31/2024 at 9:13 AM The Administrator stated Resident #3's catheter was expected to be on the care plan. She stated to refer to the MDS coordinator concerning any questions about the care plans. She also stated to refer to MDS Coordinator for any possible negative outcomes if catheter was not care planned. She stated the MDS Coordinator was responsible for monitoring care plans. Interview on 01/31/2024 at 11:30 am with the ADM stated her expectations are that the MDS Coordinator keeps the care plans up to date and refer to the DON for that process as she only has a passing knowledge of the process. She was not sure if harm could occur if the care plan was not updated. She was not aware that Resident #52's care plan reflected isolation for Covid. She stated that she was aware of Resident # 55's fluid restriction and his non-compliance with it and thought it was care planned. Interview on 1/31/2024 at 11:00 am with DON, her expectations are that the MDS Coordinator updates the care plans as the residents' needs change. She stated that if the care plan was not updated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 8 of 28 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 01/31/2024 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 0656 staff are not aware how to meet the resident's needs. Level of Harm - Minimal harm or potential for actual harm Interview on 01/31/2024 at 9:43 AM The MDS Coordinator / LVN stated after reviewing Resident #3's comprehensive care plan, Resident #3's catheter was not on the care plan. She stated any Resident with a catheter it was expected to be on the care plan. MDS Coordinator/LVN stated it was missed when Resident #3's care plan was revised/ updated in December 2023. She stated if the catheter was not on the care plan it would not be on the [NAME] where the CNAs refer to when giving care to Resident #3. MDS Coordinator/LVN stated the catheter was on Resident #3's physician's orders. She also stated the physician's order on 12/16/2023 for Foley care was referring to Resident #3's catheter. MDS Coordinator stated it was a possibility Resident # 3 may not receive proper treatment during catheter care. She stated it was documented in the nurse's notes Resident #3 was receiving catheter care but it should have been care planned. She also stated it was assessed on the MDS Resident #3 had a catheter. MDS Coordinator/ LVN stated the care plan was developed from the MDS. She stated if the catheter was not care planned the staff would not know the individualized care Resident #13 required for her catheter. Residents Affected - Few Interview on 01/31/2024 at 12:15 pm with MDS Coordinator/LVN stated that she was unaware that Resident # 55 was on a fluid restriction, she reviewed the orders and found the fluid restriction in the dietary order, stating it needed to be care planned so the staff was aware of the restriction. She stated that her plan was to update Resident # 52's care plan when the facility was cleared of all covid and not wearing masks anymore. She stated that it could be confusing for the staff that the care plan stated Resident # 52 was in isolation when there were no supplies outside of her room. Interview on 01/31/2023 at 10:39 AM CNA A stated the CNAs had been in serviced on catheter care (did not know the last time the in-service was given) and CNA B was aware Resident #3 had a catheter. CNA B stated she would need to review the [NAME] to determine if catheter care was on the electronic medical record for the CNAs and would give a more definite answer later. (did not receive a response prior to exit). Interview on 01/31/2024 at 10:46 AM CNA B stated Resident #3 did have a catheter and the nurses reviewed catheter care with the staff. Interview on 1/31/2024 at 3 PM CNA K stated that she was not aware Resident # 55 was on a fluid restriction, she stated it is not on the [NAME] and she did not receive it in report. She stated to her knowledge Resident #52 was taken out of isolation on 1/16/2024 and there was not any PPE outside of her room. Interview on 1/31/2024 10:40 AM Interview LVN J stated she was aware of Resident # 55's fluid restriction as she checks the trays during lunchtime, and she is aware he is non-compliant always asking for extra fluids with meals. She stated she did not document his behavior and she was unaware some of the staff were unaware of the restriction. She stated the Resident # 52 had recovered from covid and was no longer in isolation. Interview on 1/31/2024 1:00 pm Interview with RN I, she stated that she wa aware of Resident #55's fluid restriction and that he was non-compliant, she seemed surprised that some staff were not aware of it. She stated Resident # 52 was recovered and no longer required isolation. Interview on 01/31/2023 at 10:56 The ADON stated he expected catheters to be care planned. He stated he would defer to the MDS nurse to discuss any further questions about care plans or MDS. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 9 of 28 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 01/31/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm stated the MDS Coordinator had more knowledge about care plans. He stated the MDS nurse was responsible for care plans. Record Review 1/31/2024 09:30 am of Policy Care Plans, comprehensive Person-centered revised March 2022 states 7. Residents Affected - Few The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of P ASARR recommendations; and (3) which professional services are responsible for each element of care 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 10 of 28 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 01/31/2024 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 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for two of eight residents (Resident # 11 and Resident # 16) reviewed for quality of life. Residents Affected - Few 1. The facility failed to ensure Resident #11's nails were trimmed. 2. The facility failed to ensure Resident #16's nails were cleaned. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. Findings included: 1. Record review of Resident #11's face sheet, dated 01/31/2024 reflected an [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses included muscle weakness ( a lack of strength in muscles), cerebral infarction ( caused by impaired blood flow to the brain), chronic pain syndrome ( pain that lasts longer than three months), and cognitive communication deficit (difficulty with any aspect of communication that is affected by disruption of cognition such as: attention, memory, organization, and problem solving/ reasoning). Record review of Resident #11's Quarterly MDS assessment, dated 01/17/2024, reflected Resident #11 had a BIMS score of an 8 indicated her cognition was moderately impaired. Resident #11 did not refuse care. Resident #11 required assistance with ADLs including personal hygiene. Resident #11 required partial to moderate assistance with personal hygiene-the helper does more than half the effort. Helper lifts or holds or supports trunk or limbs and provides more than half the effort. Record review of Resident #11's Comprehensive Care Plan with next review date 04/16/2024, reflected Resident #11 required ADL assist and nursing/therapy assist as needed related to cerebral infarction (caused by impaired blood flow to the brain), weakness (lack of strength), muscle spasms (when your muscles can not relax), and chronic pain issues (pain that lasts longer than three months). Intervention: assist with functioning and ADLs. Observation on 01/29/24 at 9:47 AM revealed Resident #11 was breaking off her nails during the observation. Her nails were thin. Resident #11's forefinger, middle finger and ring finger on her right hand were jagged. There was a sharp piece of nail on her ring finger, and middle finger on her left hand. The other nails on her left hand were jagged. In an interview on 01/29/2024 at 9:50 AM Resident #11 stated her nails were long and she had asked someone to cut them last week. She stated she asked a person who brought her meal tray to her and made up her bed. She stated she also asked another staff who passed out medications approximately 2 weeks ago. Resident #11 stated she was afraid she would scratch herself and cause her skin to become infected or rub her eyes and may scratch her eyeball. She stated she was having to be so careful what she did due to not wanting to scratch herself. 2. Record review of Resident # 16's face sheet dated 01/30/2024 reflected an [AGE] year old female was admitted to the facility on [DATE] and was readmitted on [DATE] with a diagnoses included type 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 11 of 28 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 01/31/2024 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 diabetes (a condition that happens because of a problem in the way the body regulates and uses sugar as fuel), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), and muscle weakness (a lack of strength in muscles). Record review of Resident#16's Quarterly MDS Assessment, dated 01/18/2024, reflected Resident #16 had a BIMS score of 2 indicated her cognitive status was severely impaired. Resident was dependent on staff for all ADLs. Resident #16 did not reject care. Record review of Resident #16's Comprehensive Care Plan with a target date of 04/17/2024 reflected Resident #16 required assistance with ADLs. Observation on 01/29/2024 at 10:10 AM revealed Resident #16's forefinger, middle finger and ring finger on her right hand had a blackish hard substance underneath the nails. In an interview on 01/29/2024 at 10:13 AM Resident #16 did not speak during conversation. She would mumble at times. Resident #16 was not interviewable. In an interview on 01/29/2023 at 9:13 AM The Administrator stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNAs responsibility to clean and trim all other residents' nails. The Administrator also stated she did not know the information of when nail care was to be completed on the residents. She stated if the residents' nails were sharp or jagged there was a possibility a resident may cut themselves or may rub their eyes and scratch the cornea (the transparent part of the eye that covers the iris (the color part of the eye that surrounds the pupil) and the pupil (opening at the center of the iris through which light passes) and allows light to enter the inside. The Administrator stated a resident had a potential of ingesting bacteria into their mouth if there was blackish substance underneath their nails. She stated there was a potential a resident may become ill such as vomiting or diarrhea if the black substance was some type of bacteria. She also stated it was the Director of Nurses responsibility to monitor nail care. In an interview on 01/29/2024 at 9:43 AM MDS Coordinator/LVN stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNA's responsibility to clean and trim all other residents' nails. MDS Coordinator/ LVN stated the CNAs report to nurses of any diabetic resident's nails needed to be trimmed or cleaned. She stated the nurses makes rounds and check residents, with diabetes, nails. She also stated the CNAs usually did nail care when residents received a shower or as needed. She stated if anyone observed a brownish and/or blackish substance underneath residents nails the nursing staff were expected to clean the resident's nails or ask the appropriate nurse to complete the nail care. She stated the blackish/ brownish substance possibility could be feces or any type of bacteria underneath the resident's nails. MDS Coordinator/LVN stated if a resident swallowed the bacteria there was a possibility a resident may become extremely ill with stomach issues such as diarrhea or vomiting. In an interview on 01/29/2024 at 10:39 AM CNA A stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated the CNAs usually trimmed and cleaned nails during showers. She stated the nails can be cleaned or trimmed by nurses or CNAs as needed. CNA G stated the nursing staff was expected to clean and trim residents' nails immediately if there was a blackish substance underneath the residents' nails and/ or if their nails needed to be trimmed. CNA G stated the blackish substance may be fecal matter underneath the residents' nails. She stated if a resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 12 of 28 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 01/31/2024 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 swallowed the blackish substance there was a possibility a resident may become ill with stomach issues or any type of intestinal issues. She stated a resident may need to be assessed at the emergency room if they became severely ill. She stated she had been in-serviced on cleaning nails . In an interview on 01/29/2024 at 10:47 AM CNA B stated it was the nurses and the CNAs responsibility to trim, cut, and clean residents' fingernails. CNA B stated only the nurses can trim and clean residents with diagnosis of diabetes. CNA B stated if there was a blackish substance underneath a resident's nails there was a possibility the substance was feces. CNA B stated if a resident placed their finger in their mouth the feces could transfer from their fingers to their mouth. CNA B also stated if the resident swallowed bacteria a resident may develop a stomach infection. Review of the Facilities Policy on Activities of Daily Living Supporting, dated 03/2018, 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. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 13 of 28 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 01/31/2024 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 residents received treatment and care in accordance with professional standards of practice for 2 (Resident # 6 and Resident # 22) of 8 reviewed for Quality of care. Residents Affected - Few The facility failed to maintain the drainage bag to Resident # 6's surgical wound in a position that it could drain. The facility failed to obtain a physician's order for finger sticks for Resident # 22 who was on sliding-scale insulin. These Failures could put the residents at risk for infection, and risk for medical decline. Findings included: Review of Resident # 6's face sheet revealed an [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE], and 1/1/2024 with diagnoses that include Acute Cholecystitis (Inflammation of the Gallbladder), Malignant Neoplasm of Pancreas (A type of cancer that begins as a growth of cells in the pancreas), Diabetes mellitus due to underlying condition (elevated blood sugar due to a medical condition) Review of Resident # 22 face sheet revealed a [AGE] year-old female, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include displaced fracture of the left femur (a misaligned fracture of the left leg bone), Fracture of the left ulna and lower end of the left radius ( a break in the bones of the forearm), Type 2 diabetes mellitus with diabetic chronic Kidney disease ( elevated blood sugar that causes kidney damage ), and End Stage Kidney Disease ( the final permanent stage of kidney disease, where Kidney function has declined to the point that the kidneys can no longer function on their own) Review of Resident # 6's Quarterly MDS dated [DATE] reveals a BIMS score of 15 which indicates Resident # 6 was cognitively intact. Review of Resident # 22's admission MDS dated [DATE] reveals a BIMS score of 13 which indicates Resident # 22 is cognitively intact. Review of Resident #6's care plan with a revision date of 1/18/2024 shows Acute Infection: Cholecystitis with extended antibiotic ordered x 90 days. I also have a drain in place to my right upper abdomen. Interventions include Monitor drain to right upper abdomen for s/s of infection. Review of Resident # 22's care plan with a revision date of 1/29/2024 revealed a listed problem of The resident has Diabetes Mellitus with retinopathy and kidney disease and is on sliding-scale insulin. Interventions include Chemsticks and fasting serum blood sugar as ordered by doctor. A review of Resident # 6's physician orders revealed a current order date of 10/10/2023 Monitor drain site to upper right abdomen for signs and symptoms of infection every shift for prophylaxis, Ordered dated 1/1/2024 Monitor drainage band and notify provide with any concerns every shift. Order dated 1/2/2024 Monitor and document output from drainage bag every shift. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 14 of 28 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 01/31/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident # 22's physician orders revealed a current order date of 1/13/2024 Insulin Lispro ( 1 unit dose) 110 unit/ml solution pen injector Inject as per sliding scale: if 150-199= unit, 200- 249 = 2 unit, 250 -299 = 3 unit, 300- 349 = 4 unit, 350 - 400 = 5 unit, subcutaneously three times a day for D.M. There were no orders present to obtain fingerstick for obtaining blood glucose for sliding scale. Review of Resident #6's MAR from January 2024 indicates that the resident is receiving a fingerstick four times a day to monitor for need for insulin sliding scale. Observation of Resident # 6 in the dining room on 1/29/2024 at 12:13 PM revealed drainage bag with a privacy bag (1000 mg foley drainage bag) in a to the right upper abdominal wound was hanging over the right shoulder of Resident # 6. Observation of Resident # 6 1/29/2024 at 1:30 pm in her room revealed the drainage bag was still hanging over her shoulder. Observation of Resident # 6 on 1/31/2024 at 12:34 in the dining room revealed the drainage bag in a privacy bag hanging off the back of the wheelchair. Interview on 1/31/2024 with LVN J on 01/31/2024 at 11:00 am stated she was aware of the drainage bag on Resident #6's wound but did not notice how it was positioned. She stated that the drainage bag should be hung below the wound to ensure gravity drainage. Interview on 1/30/2024 11:45 am RN I stated that she was unaware that there were no finger sticks ordered for Resident # 22 as part of documenting the medication in the MAR, you must input a blood glucose number, the program will not let you administer the medication without it documented. She states she feels there was no harm to the resident since the medication cannot be given with a fingerstick, she stated she was not aware what their policy stated on the matter. She did look up the order and noted there was no order for the actual fingerstick. Interview with DON 1/31/2024 11:00 am She stated they do not have a policy on the management of surgical wound drains. She stated drains to gravity should be below the wound and was not aware how the bag on Resident # 6 was being positioned. She stated that Resident # 6 runs the risk of clogging the drain or getting an infection if the drainage bag is not correctly positioned. DON stated that she was not aware there was not an order for finger sticks on Resident # 22, but upon review of MAR they are being done. She stated the sliding scale order in the MAR requires a blood sugar reading, so it is being done. She does not know what their policy states about having an order from the physician order for finger sticks. She stated since the MAR requires a blood sugar reading to administer the insulin, she felt the resident was not at risk of harm. Interview with ADM 1/31/2024 11:30 am stated that she was not aware of a policy on the management of surgical wound drains, as far as nursing care of the residents she referred to the DON. She referred to the DON on questions regarding Resident # 22. Record Review on 1/31/2024 9:30 am of Policy Diabetes- Clinical Protocol revised November 2020 page 3 2. As indicated, the physician will order appropriate lab tests (for example, periodic finger sticks of A1C) and adjust treatment based on their results and other parameters. (3) Monitor 3 to 4 times a day if on intensive insulin therapy or sliding scale. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 15 of 28 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 01/31/2024 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 resident ( Resident # 57) of 8 reviewed for accurate weights. Residents Affected - Few The facility failed to establish a consistent method of weighing residents to ensure the accuracy of weight. for 1 resident (Resident # 57) of 8 reviewed for accurate weights. This failure put the residents at risk for undetected weight loss, malnutrition, medical complications poor quality of life. Findings included: Review of Resident # 57 face sheet revealed a [AGE] year-old male, admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include Heart Failure ( a chronic condition in which the heart doesn't pump blood as well as it should), Acute Respiratory Failure with Hypoxia ( a condition where you don't have enough oxygen in the tissues in your body), Metabolic Encephalopathy ( an acute condition of global cerebral ( Brain) dysfunction in the absence of brain disease. ) Review of Resident # 57's readmission MDS dated [DATE] reveals a BIMS score of 9, which indicates Resident #57 is cognitively moderately impaired. Review of Resident # 57's Physician's order dated 11/07/2023 Weight: Upon admission/ readmission and weekly x 4 weeks. Review of Resident #57 Weight log dated 1/31/2024 revealed. 1/24/2024 155 lbs. Wheelchair 1/17/2024 165 lbs. Mechanical lift 1/12/2024 162 lbs. Wheelchair 1/10/2024 162.2 lbs. Wheelchair 1/9/2024 162 lbs. Mechanical lift 1/7/2024 163.1 lbs. Mechanical lift 1/5/2024 162.8 Wheelchair 1/4/2024 164.2 Mechanical lift 1/3/2024 164.2 Mechanical lift 12/27/2023 160. Wheelchair 12/21/2023 155.4 Mechanical lift (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 16 of 28 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 01/31/2024 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview of Adm on 1/31/2024 at 11:30 am she referred all medical questions and concerns to DON. Her expectation was the nursing policy was followed. Interview on 1/31/2024 at 11:00 am with DON, her expectation was that weights are done on the same device each time, and if there was a discrepancy to report it to the nurse. DON states policy does not address using the same scale, the staff knows of her expectations of the same scale. They have a CNA who comes in once a week whose only job is to complete weekly weights. She stated that an inaccurate weight on someone with a medical need for the weight can cause potential harm from medical complications. Event ID: Facility ID: 675536 If continuation sheet Page 17 of 28 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 01/31/2024 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review , the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident reviewed for pain management (Resident #27), in that: Residents Affected - Few RN C failed to assess and evaluate Resident# 27's existing pain and cause for pain in the administration of an opioid (narcotic). RN C failed to verify last administered dose of an opioid (narcotic) and available PRN pain medications putting the resident at risk for overmedication causing oversedation hypoxia oversedation respiratory failure. This failure placed Resident# 7 residents at risk for continued pain and adverse drug consequences. A record review of Resident# 27's face sheet dated 01/31/24 revealed he was admitted on [DATE] with a diagnosis of Hemiplegia and Hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side (weakness on one side of the body), Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery (death of tissue in the brain), type 2 diabetes, pressure ulcer of left ankle stage 3, anemia (deficiency of healthy red blood cells in the blood) in chronic kidney disease, and end stage renal disease. A record review of Resident# 27's most recent quarterly MDS dated [DATE] reflected a BIMS score of 13 suggesting cognition is intact. MDS reflected current use of Opioid medication with indication for use. A record review of Resident#27's care plan revised 01/25/24 reflected resident has pain related to cerebral vascular disease (conditions affecting blood flow to the brain) affecting left non-dominant side, CKD 5 (kidney failure), and wounds. Care plan reflects interventions of administering pain meds as ordered by physician, assess for pain every shift, and assess pain for source, duration, and severity. A record review of Resident# 27's orders reflected an active order with a start date of 08/07/23 for Hydrocodone-Acetaminophen oral tablet 5-325MG , 1 tablet by mouth every 8 hours as needed for pain. It also reflected an active order for Tylenol Extra Strength Oral Tablet 500MG (Acetaminophen), 1 tablet by mouth every 6 hours as needed for pain. A record review of Resident#27's nursing medication administration record for dated 01/31/24 reflected Hydrocodone-Acetaminophen oral tablet 5-325MG, 1 tablet by mouth every 8 hours as needed for pain was administered by RN E 01/31/24 at 07:00 AM with a pain assessment of 7. It also reflected Tylenol Extra Strength Oral Tablet 500MG (Acetaminophen), 1 tablet by mouth every 6 hours as needed for pain administered by RN E 01/31/24 at 12:56 PM with a pain assessment of 8. An interview on 01/31/24 at 12:39 PM with Resident# 27 revealed he was in pain. Nursing staff was notified. An observation and interview what date beginning at 12:45 PM revealed RN E went from the nurse's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 18 of 28 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 01/31/2024 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few station to the medication cart outside Resident# 27's room. Without assessing Resident# 27's pain or verifying last administered dose; RN E dispensed 1 tablet of Hydrocodone-Acetaminophen oral tablet 5-325MG from a pill blister card into a medicine cup. RN E picked up the medicine cup to enter Resident#27's room. An interview with RN E revealed she did not assess for Resident#27's pain or review the last administered dose of Hydrocodone-Acetaminophen oral tablet 5-325MG. RN E was then observed reviewing the MAR, and stated, oh this was given at 07:00 AM today, it's too soon to give. RN E was then observed calling for the DON in order to waste the dispensed Hydrocodone-Acetaminophen oral tablet 5-325MG that was unable to be administered. An observation 01/31/24 at 12:50 PM revealed RN E entering Resident#27's room and assessing for pain. Resident#27 stated his pain level was an 8 on a scale of 1 to 10. RN E advised Resident#27 it was too soon for Hydrocodone-Acetaminophen oral tablet 5-325MG and asked if he would like his PRN Tylenol Extra Strength Oral Tablet 500MG (Acetaminophen) to which he said yes. An observation 01/31/24 at 12:55 PM revealed RN E dispensing 1 tablet of Tylenol Extra Strength Oral Tablet 500MG (Acetaminophen) in a medicine cup and providing it to Resident#27. An Interview on 01/31/24 at 12:59 PM revealed it was not a standard of practice to dispense medication prior to a pain assessment and administration verification. She said she should assess for pain first, check the order, and verify the last administered dose before dispensing the medication. In an interview on 01/31/24 at 03:12 PM RN E said that if Resident#27 would have received Hydrocodone-Acetaminophen oral tablet 5-325MG too soon it could have caused Resident#27 to become lethargic, his respirations could decrease, and it would not have been good for his kidneys. RN E said Resident #27 was on dialysis which makes the medication harder to process by the kidneys. RN E said she should have verified the last administered dose first before attempting to dispense and administer the medication. In an interview on 01/31/24 at 02:00 PM with LVN D she said the standard process when a resident complains of pain was to first conduct a pain assessment on a scale of 1 to 10 or look for non-verbal cues was the resident is unable to communicate. LVN D said that after the pain assessment, the resident is was given a choice on their available PRN pain medications because some people will not want a narcotic as their first choice. LVN D said it was not standard practice to dispense medication prior to a pain assessment or verification of the last dose administered. In an interview on 01/31/24 at 02:29 PM with the DON, she said the standard process in pain management was to complete a pain assessment to determine intensity and type (sharp/dull) and then to verify the physician orders available to the resident. The DON said the last administered dose should be checked as well. The DON stated that it is not standard practice to dispense medication before those steps are completed and verification takes place. She said it is her expectation that pain is assessed and the last dose is verified before administration of any medication. In an interview on 01/31/24 at 02:53 PM with the Administrator she said it is her expectation that nursing staff are verifying orders to determine what is available to the resident, assessing for pain, and verifying the last administered dose. She said after administration of the medication she expects it to be documented and the resident to be monitored for adverse effects. The Administrator said giving a medication too early could result in making the resident sick or result in adverse drug effects. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 19 of 28 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 01/31/2024 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 0697 POLICY: Level of Harm - Minimal harm or potential for actual harm Record review of Administering Medications policy revised April 2019 stated: Residents Affected - Few The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Medications are administered in accordance with prescriber orders, including any required time frame. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 20 of 28 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 01/31/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews , the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: Residents Affected - Many 1. The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food was unidentifiable and did not taste good. 2. The test tray of the lunch meal foods were dry, bland, and cold. This failure could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. The findings included: 1. a. During a confidential interview and observation on 01/29/24 at 12:52 PM a resident stated she was not eating the unstuffed peppers being served and said, I do not eat anything I cannot look at and easily identify or know what it is. An observation of the resident's lunch plate revealed the served unstuffed peppers entrée was not touched by the resident. b. During a confidential group interview on 01/30/24 at 10:00 AM 5 residents voiced complaints about the food. The resident group stated the food was tasteless and the vegetables always have too much water in them. They said the kitchen staff boil the vegetables in a lot of water and don't strain them properly before serving. They also believe all that water is the cause of the vegetables having no flavor in the end. They said, half the kitchen staff can't cook. One resident stated the person that puts the condiments on the meal trays does not always put the correct ones or any at all on some trays. They said that whenever an entrée has any type of gravy or sauce it usually does not have any flavor to it. The group agreed that most of the time the food being served isn't recognizable or easy to identify what is being served. One resident said it looks like dog food. One resident stated, I am constantly having to go to the kitchen to tell them not to give me certain foods and it is on my food slip on my dislikes, and they continue to give me food I can't eat. A resident stated I am lactose intolerant and it's on the food-slip, but they will give me milk and cottage cheese. Anyone else checking the trays should know your likes and dislikes besides just the cook. c. Record review of Resident#4's face sheet dated 01/31/24 indicated Resident# 4 was a [AGE] year-old (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 21 of 28 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 01/31/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many female, admitted to the facility on [DATE] with a diagnosis of retained cholelithiasis (gallstones) following cholecystectomy (removal of gallbladder), muscle weakness, hypothyroidism (condition where thyroid gland does not produce enough thyroid hormones), anxiety, and depression. During an interview on 01/31/24 at 02:30 PM with Resident# 4 spoke about the lunch meal from 01/30/24, the resident stated the pasta was overcooked. She said there was no taste to the sauce over the pasta and she didn't realize there was chicken on the plate until she moved the pasta to the side due to not being able to eat it from being overcooked. The resident said there was so much water in the vegetables she could not eat them. She said it was like eating vegetable soup cooked in water. The resident stated the roll was very hard on the bottom, so she only ate the top part. The resident stated she ate the chicken and asked for a sandwich and something else to eat which she was satisfied with since she couldn't eat the initial meal. d. Record review of Resident#7's face sheet dated 01/31/24 indicated Resident# 7 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis of COPD (a condition involving constriction of the airways and difficulty or discomfort in breathing), mild protein-calorie malnutrition, hypothyroidism (condition where thyroid gland does not produce enough thyroid hormones), abnormal weight loss, and anemia (deficiency of healthy red blood cells in the blood). During an interview on 01/31/24 at 03:00 PM with Resident# 7 about the lunch meal from 01/30/24, the resident stated the noodles on his plate were dry. The resident stated, If I ate a rubber band it would probably taste the same as the noodles. He said the noodles looked like rubber bands and had the same color and consistency. He said he moved the noodles to the side and said he saw the chicken which he didn't know what there because it was covered by the horrible noodles. The resident said the pasta sauce looked like vomit. The resident said the vegetables did not have flavor and laid in too much water. He stated the chocolate cake or whatever it was was not fully cooked. The resident said he requested a different meal and received a sandwich which satisfied him. 2. An observation at 01/30/24 at 02:30 PM a lunch test tray was sampled. The test tray consisted of regular textured food items. The meal tray consisted of fettuccine pasta with chicken and pasta sauce, a small roll, and a small bowl of vegetable medley to the side. A small plate with a brownie for dessert was also provided. On initial observation of the meal, unable to distinguish if there was chicken on the entrée. Chicken was hidden under a large amount of sauce and over very little pasta. The pasta was overcooked and dry, it had a dark appearance to it. The pasta was extremely tough and difficult to swallow, had to have fluids to aid in swallowing. Both the sauce and the chicken had no flavor to it and did not have the appearance of seasonings, they appeared pale and bland. The vegetable medley with a variety of vegetables sat in a bowl with a lot of water and only the corn had some flavor. After pouring the water from the vegetable medley onto the entrée plate it was observed covering half of the entrée dinner plate. The small roll was overbaked and hard on the bottom and on the sides. The roll would not bend when squeezing. The brownie dessert was undercooked, and the center had a dough/ unfinished taste. The appearance of the brownie was thin, flat, and had no visual appeal. It did not appear to rise properly as baked goods should. During an Interview on 01/31/24 at 02:07 PM with the DM she said it is was her expectation that food looks appealing, is edible, and something that the residents enjoy. She said the residents are (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 22 of 28 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 01/31/2024 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 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete also offered alternatives which should be desirable and are always offered on the back of the meal ticket, choices that are developed by the resident and care team. She said if the food isn't good, it could cause residents to lose weight which could affect their health. During an Interview on 01/31/24 at 02:53 PM with the Administrator she said, the food should always look appealing because we eat with our eyes as well. It should be bright, appealing, and should not be too soggy. She said the vegetables should be separated from the main entrée. She said, cold items should be cold and warm items should be warm. The administrator stated, residents should be able to identify what the food is and not have to ask. The administrator said, pleasant to eat and pleasant to smell. The administrator stated that adverse effects of having unappetizing, unappealing, and inedible food could result in the resident becoming depressed or homesick. She said that if a resident is diabetic, it would cause issued with blood sugar levels. She said it could cause a resident to lose weight, and they could also begin to look for other food sources like having family bring meals that may not adhere to their nutritional needs. She said it could also cause residents to steal food from other resident's mini fridges in their rooms. Event ID: Facility ID: 675536 If continuation sheet Page 23 of 28 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 01/31/2024 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 1 of 1 kitchen reviewed for food and nutrition services. 1. The facility failed to ensure dry storage food was properly labeled and dated. 2. The facility failed to ensure dry storage items were sealed properly. 3. The facility failed to properly label and date items in the refrigerator and freezer. 4. The facility failed to ensure expired food was discarded. 5. The facility failed to ensure kitchen staff practiced proper hand hygiene and glove use. 6. The facility failed to ensure hairnets were worn while in the kitchen. These failures could place residents at risk for food contamination and foodborne illness. Findings included: During the initial tour of the kitchen on 01/29/24 at 08:49 AM the following was observed: 1. Baked beans were observed in a metal pan covered with saran wrap with use by date of 01/03/24. 2. Pie crust sealed in a clear bag with no label or date observed in the freezer. 3. Frozen pepperonis wrapped in saran wrap not labeled or dated in the freezer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 24 of 28 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 01/31/2024 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 4. Level of Harm - Minimal harm or potential for actual harm Diced chicken in a clear bag in the freezer with no label or date, bag had a baseball-size hole exposing contents to air. Residents Affected - Many 5. Frozen turkey in the freezer with no label or date. 6. Pork loin in the freezer with no label or date. 7. 10 loafs of bread in dry storage with no labels or dates. 8. White rice in dry storage was kept in a container that did not seal, the lid was only placed on top. 9. Melted chocolate kept in dry storage container dated 1/2/24 was not sealed tightly. 10. Potatoes kept in a cardboard box on the bottom shelf in dry storage was not labeled or dated and contained 15 potatoes that appeared sprouted, wrinkled, and had an old grey appearance. 11. A bag of country style gravy mix stored in a Ziplock bag in dry storage was not labeled or dated. During an observation on 01/29/24 at 10:15 AM of pureed food prep, [NAME] F was observed putting the blender in the dishwashing machine, discarded gloves and did not wash her hands then began mixing and prepping unstuffed peppers for lunch. During an observation on 01/29/24 at 10:51 AM Kitchen aide G was observed changing gloves and not washing hands in between. He was then observed picking an item off the floor with those same gloves and then preparing the regular texture peach cobbler dessert without changing gloves or washing hands. An observation on 01/29/24 at 12:30 PM a residents friend not residing in the facility was observed entering the kitchen without a hairnet. During an interview on 01/29/24 with the DM she said she had trained staff and it wasis h ER expectation that the first items stored are the first ones used she said, first in first out. The DM said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 25 of 28 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 01/31/2024 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 in-services for staff is done on a monthly basis. She said if something is mislabeled or past the expiration date it could affect the residents in that it could make them really sick from foodborne illness. During an interview on 01/29/24 with Kitchen aide G he said that contamination could occur from not washing hands or changing gloves and then prepping food. He said he was not sure why he did not change his gloves after picking the item off the floor. During an interview on 01/30/24 at 09:17 AM the DM stated it is her expectation that all staff wash their hands in the kitchen between meal prep, when changing gloves, and after touching trash or anything else that may cause contamination. She said staff should change their gloves when moving from one food prep item to another and should wash their hands in between. The DM said that if proper handwashing and glove use is not followed then it would lead to cross contamination of food. She said it is also an infection control issue and could make the residents very ill from foodborne illnesses. During an interview on 01/31/24 at 02:07 PM with the DM she said it is her expectation that anyone who enters the kitchen wears a hairnet. She said not wearing one could lead to hair in the food which is an infection control issue. The DM stated that nobody other than kitchen staff is allowed in the kitchen. During an interview on 01/31/24 at 02:53 PM with the Administrator, she said it is her expectation when items arrive in the kitchen that they are inspected to make sure they are intact and then be properly labeled and dated as appropriate. She said all items should cold or dry should be sealed otherwise it would promote bacterial growth. She said that if items are not labeled properly the residents could be exposed to an allergen, something could be expired and they wouldn't know, and a residents religious food aspects could be compromised. She said if items in dry storage are not sealed properly, they could be exposed to moisture or mildew and could attract pests. The administrator stated if items in the freezer were not sealed or stored properly, they could get freezer burn which would make it inedible. The Administrator stated it is her expectation that all kitchen staff follow proper handwashing and glove use. She said hands should be washed when first entering the kitchen, after removing gloves, in between activities such as dishwashing and food handling, and before and in between handling different food items. She said not following proper glove use and handwashing could expose residents to illness causing bacteria or allergens. She said you could also promote cross contamination by touching raw items and not washing your hands. The administrator said it is her expectation that hairnets are always worn by anyone in the kitchen. She said only kitchen staff should be in the kitchen and residents' family members should not be going in because they are not aware of the facilities policies and procedures. The administrator said that by not wearing a hairnet you expose food to hair or hair particles like dandruff and could cause the residents to become sick and develop diarrhea, vomiting, or upset stomach. POLICY: Facility Food and Nutrition Services, Sanitation- Food Storage policy with an effective date of 11/2022 stated: All food purchased will be wholesome, manufactured, processed, and prepared in compliance with all State, Federal, and local laws, and regulations. Food will be stored in a safe and sanitary method to prevent contamination and food-borne illness. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 26 of 28 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 01/31/2024 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 Foods should be used or discarded prior to the expiration date. Level of Harm - Minimal harm or potential for actual harm Food removed from its original packaging should be dated and labeled. Residents Affected - Many Tightly wrap or cover all opened containers and leftover food in clean containers. It should be labeled, dated with the opened or use by date. Facility Food and Nutrition Services, Sanitation- Hand Washing and Glove Use policy with an effective date of 10/2021 stated: 1. Employees are to wash hands: a. Before starting work. b. After handling soiled dishware, equipment, or utensils and after handling boxes, cans, or crates. c. Before handling any clean dishware. d. After all work breaks, using the restroom, tobacco use, eating or any instance of coughing, sneezing, and touching face, hair, or clothing. e. When switching between working with raw food and working with ready-toeat food. f. After visiting resident rooms, when re-entering the kitchen, and prior to any food production. g. During food preparation, as often as necessary to prevent cross contamination when changing tasks. h. After handling chemicals that may affect the safety of foods. i. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 27 of 28 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 01/31/2024 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 After cleaning or bussing tables. Level of Harm - Minimal harm or potential for actual harm j. Before donning gloves to initiate a task that involves handling ready-to-eat food. Residents Affected - Many k. After engaging in any other activity that may contaminate the hands. 2. Change gloves when an un-sanitized item or surface is touched and when gloves are soiled or torn. 3. The use of gloves or the use of hand sanitizer does not replace handwashing. Facility Food and Nutrition Services, General- Personnel Guidelines policy with an effective date of 11/2022 under dress code stated: Hair should be fully covered with hairnet or hair bonnet within the department. Other hair restraints require approval from the Dietitian or designee. All restraints must fully cover the hair, not be worn outside of the kitchen and remain clean. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 28 of 28