Health inspection·March 20, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an attempt to interview on 03/18/2025 at 11:45 a.m. Resident #21 revealed she was not interested in talking about her wheelchair. Review of Resident #48's quarterly MDS assessment, dated 02/12/2025, reflected he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses of muscle weakness, Cerebral infarction (stroke), ataxic gait (shuffling walk), and hypertension (high blood pressure). Resident #48 had a BIMs score of 8 reflecting he was moderately cognitively impaired and able to make decisions for herself. Section GG of the MDS reflected wheelchair mobility for locomotion. Review of Resident #48's plan of care dated 02/20/2025 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 03/18/2025 at 12:00 p.m. revealed Resident #48 sitting in his wheelchair in the dining room. Resident #48 revealed the wheelchair's left and right armrests were cracked with foam exposed. Resident #48 was asked about his wheelchair, and he stated, It was needing some work, and the wheelchair had been provided to him by the facility. Resident #48 stated he had told the charge nurse but could not recall when or which nurse. There were no skin tears on the arms. Review of Resident #221's other MDS assessment, dated 02/10/2025, reflected she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses of chronic congestive heart failure (heart does not pump correctly), respiratory failure (lungs weak), and muscle weakness. Resident #221 had a BIMs score of 15 reflecting she was cognitively alert and oriented and able to make decisions for himself. Section GG of the MDS reflected wheelchair mobility for locomotion. Review of the Resident #221's updated plan of care dated 02/20/2025 with updates reflected goals and approaches to include wheelchair mobility. Observation and interview on 03/18/2025 at 11:45 a.m. revealed Resident #221 in her wheelchair in her room eating lunch. Resident #221 stated that her arm rests were rough on the right side. The wheelchair's right armrest cracked with exposed foam. Resident #221 stated she had not been hurt, just was uncomfortable. In an interview on 03/19/2025 with the DON at 2:43 p.m. revealed the wheelchairs were repaired by the maintenance supervisor. The DON stated all the departments head did a sweep about two months ago and then the armrest requiring repair were given to the maintenance supervisor, I do not know why the wheelchairs have not been repaired. In an interview on 03/19/2025 at 3:21 p.m. the Maintenance Supervisor stated that he was responsible for the repair of wheelchairs. He stated he finds most of his information through the staff telling him, or if he sees it himself. Sometimes the department heads complete angel rounds and give him a list of what they see during rounds. The Maintenance Supervisor stated he had not had any staff members tell him about any wheelchairs needing repair, recently. In an interview on 03/20/2025 at 9:00 a.m. with the Administrator revealed the wheelchair had all been looked at, all that required armrest had been replaced and he had ordered additional armrest. The Administrator stated the facility was going to be doing monthly rounds and keep additional supply on hand for any repairs. There was no policy provided by the facility by the time of exit, that had been requested from the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 2 of 7 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 03/20/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Hill Country Heights 810 Industrial Ave Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Adminstrator. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 3 of 7 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 03/20/2025 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information for the third quarter (April 1, 2024, to June 30, 2024) reviewed for Administration. The facility failed to submit complete PBJ staffing information to CMS for April 1, 2024, to April 30, 2024. This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: Record review of the Casper3 PBJ report revealed the facility had four areas triggered on the FY Quarter 3 (April1- June30) report. The areas were One Star Staffing Rating, Excessively low Weekend Staffing, No Rn hours, and Failed to have Licensed Nursing Coverage 24 hours/day. The report details no RN hours for every day in April 2024. It also details Failed to have Licensed Nursing Coverage 24 hours/day for every day in April 2024. Record review of an email sent from the Administrator on 03/18/25 at 11:37 AM revealed a file with programming code entries. Employee and employee ID were listed. Workday was entered and hours were entered. Record review of an email received from the Administrator on 03/18/25 at 5:15 PM, revealed the submission email to CMS dated 05/14/2024. It showed 1 file processed, 1 file accepted, 0 rejections,0 Files submitted without authority, O Messages. This page reported 97 records and 1311 Total Staffing Hour Records. The report confirmed Total Employee Link Records Not Submitted. A second attachment listed a CMS Payroll Based Journal- Upload Date File. This confirmed the submission was received and will be checked for Errors. It also provided additional details and instructions. The third attachment was a repeat of the coding sent at 11:37 AM. Record review of an email received from the Administrator on 03/19/2025 revealed a handwritten schedule for April 2024 was provided. This schedule confirmed the shifts were covered by both RN and LVN staff for the entire month of April 2024. In an interview with the Administrator on 03/18/25 at 8:46 AM. The PBJ report was discussed during the entrance conference. The administrator was unaware the report did not include RN and Nursing hours for the month of April 2024. He stated there were no problems The administrator was asked was there was anything that happened with staffing for the month of April. He stated the management company was in bankruptcy and they switched companies on May 1 2024. He stated that corporate office enters the PBJ information. He stated that he is not sure what information they can still access but he will provide me with whatever information they have. He agreed to have to DON pull the working schedule for April 2024. In an interview with the DON on 03/18/2025 at 8:57AM. She stated that she was working during the month of April and there would have been no days without a working RN. She stated that she was unaware (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 4 of 7 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 03/20/2025 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many of any issues and stated she would pull the working schedule. She stated she did not know if she could get the punch records but would let the surveyor know during the survey. In an Interview with the Administrator on 03/18/2025 at 2:35 PM. He stated that he is not sure if they can get the punches but he has corporate looking into it. He stated that they were able to get into some records and they should be coming shortly. He stated that he doesn't know what they can find but someone from ABRI may be able to get some documents. In an interview with the Administrator on 03/20/2025 at 1:30 PM. He stated that he thinks both companies submitted the data and it could have caused the problems in reporting the hours worked by Nursing staff. He stated that he understand the need for accurate reporting to CMS and stated it could affect the care Residents receive when hours are reported. He stated that this was the only month and the error is most likely related to the change from one company to the new company and does not expect any issues in the future. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 5 of 7 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 03/20/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 (MA A) staff members and 2 of 4 residents (Residents #47, and #221) reviewed for infection control procedures. Residents Affected - Few MA A failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #47 and #221. This failure could place residents at risk for cross contamination and infections. Findings included: Record review of Resident #47's quarterly MDS assessment, dated 01/25/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47 had diagnoses which included: Diabetes (high blood sugar), and hypertension (high blood pressure). Resident #47 was cognitive and able to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #47's physician orders dated 03/20/24 reflected, carvidol (high blood pressure) 3.125mg give one tab by mouth two times a day and to obtain blood pressure one time a day on each shift. Record review of Resident #221's other payment MDS Assessment, dated 02/10/25, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #221 had diagnoses which included: diabetes (increased blood sugar), hypertension (increased blood pressure), and heart failure (weak heart). Resident #221 was cognitively able make all decisions for herself and required one staff for assistance with activities of daily living. Record review of Resident #221's physician orders dated 03/05/25 (open ended) reflected, Coreq (high blood pressure) 10 mg give one tab by mouth every day, Lisinopril (high blood pressure med) 2.5mg one tab by mouth every day. Obtain blood pressure one time a day on each shift. Observation on 03/18/25 at 9:43 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure on Resident #221. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #221. Observation on 03/18/25 at 10:01 a.m., revealed MA A performing morning medication pass, during which time she checked the blood pressure, on Resident #47, used the same blood pressure cuff used on Resident #221. MA A failed to sanitize the blood pressure cuff before or after using it on Resident #47. An interview on 03/18/25 at 10:25 a.m., MA A stated she did not think about cleaning the blood pressure cuff between usage, she had forgotten. MA A stated she used hand sanitizer between each usage when she took the blood pressure. MA A stated if the cuff was on the residents and then not cleaned it could spread germs to others. An interview with the DON, who was the infection control preventionist on 03/19/25 at 2:43 p.m., (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 6 of 7 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 03/20/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm revealed the DON stated that all direct care staff must clean equipment, including blood pressure cuffs after having contact with each resident. The DON stated, the staff has available the disinfectant wipes that will kill all germs. The DON stated the staff would be in-serviced on infection control and she would perform teaching concerning infection control. If they do not clean the blood pressure cuffs appropriately, they could spread germs to themselves and the residents. Residents Affected - Few Record review of an in-service log dated 02/10/25 revealed MA A, had received cleaning and properly storing equipment after each use. Record review of the Facility's Policy titled Infection Prevention and Control dated March 2019, reflected: Compliance Guidelines: The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program. The elements of the infection prevention and control program consist of coordination/oversight, guidance/procedures, surveillance, data analysis, antibiotic stewardship, outbreak management, prevention of infection, and employee health and safety. Staff Responsible: .e. staff will receive training in community's infection prevention and control program to include but not limited to preventative measures, standard precautions . and are expected to comply with all designated precautions 9. Prevention of infection . (6) educating staff and ensuring that they adhere to proper infection prevention and control practices when performing resident care activities as it pertains to his/her role responsibilities and situation Record review of the Facility's Policy titled Cleaning and Disinfecting Resident Care items and Equipment dated February 2018 reflected: Multi-patient use equipment should be cleaned and disinfected between patient use . 1. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: . c. Non-critical items are those that come in contact with intact skin but not mucous membranes. Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers . 2. Multi-patient use (reusable items) equipment to That is designated reusable should be used by more than one resident . should be cleaned and disinfected between resident use . 3. Approved cleaning/disinfecting/sanitizing products should be used FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675536 If continuation sheet Page 7 of 7