Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hill Country Heights during CMS and state inspections, most recent first.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors found multiple sanitation issues in the kitchen, including debris on a utility cart, in the microwave, on shelving, on the floor, and on utensils, along with an uncovered trash can. They also found numerous food items that were unlabeled, undated, or past discard dates, while staff interviews showed inconsistent understanding of labeling, dating, and cleaning expectations despite facility policies requiring proper food handling and storage.
A resident with cerebral palsy, severe malnutrition, schizoaffective disorder, and severe cognitive impairment had MD and OT orders for a divided plate and small 4 oz. cups with a straw to support self-feeding. During a meal observation, she was served a standard plate and cups without a straw, and her care plan did not include the ordered adaptive equipment even though it appeared on the meal card.
Improper Aseptic Technique During Tracheostomy Care and Suctioning: An ADNS LVN failed to maintain aseptic technique while providing trach care and suctioning for a resident with a trach, oxygen use, and severe cognitive impairment. She did not perform hand hygiene before touching room surfaces and donning sterile gloves, used a nonsterile barrier instead of the sterile drape, contaminated sterile gloves and tubing, and did not advance the suction catheter far enough to clear mucus. The DON stated staff were expected to maintain a sterile field and suction until resistance was felt.
A resident with cerebral palsy, severe protein-calorie malnutrition, and severe cognitive impairment did not receive physician-ordered adaptive eating equipment at mealtime. The resident was observed eating from a standard plate with no divisions and using cups without straws, even though the meal card listed a divided plate and straw-equipped cups. The OT noted these items were needed to support self-feeding independence, and the care plan did not address the ordered equipment.
A resident with multiple comorbidities developed worsening moisture-associated skin damage (MASD) that progressed to full thickness tissue erosion. Despite ongoing skin assessments and documentation of deterioration, the wound care NP was not promptly notified or involved, resulting in delayed treatment. Facility staff interviews revealed inconsistent processes for escalating care and notifying providers when a resident's skin condition failed to improve.
The facility failed to maintain safe conditions for wheelchairs, affecting four residents. Observations showed cracked armrests with exposed foam, posing potential injury risks. Interviews revealed a lack of communication and follow-up on repairs, with the Maintenance Supervisor unaware of recent issues. The Administrator confirmed inspections and ongoing repairs, but no policy was provided at the survey exit.
A staff member failed to disinfect a blood pressure cuff between uses on two residents, both with diabetes and hypertension, during a morning medication pass. The oversight was acknowledged by the staff member, who admitted to forgetting the protocol. The DON confirmed the requirement for cleaning equipment between uses, as per facility policy, to prevent cross-contamination and infections.
The facility failed to submit complete staffing data to CMS for April 2024, resulting in deficiencies such as no RN hours and lack of 24-hour licensed nursing coverage. The issue arose during a management transition, with both companies potentially submitting data, leading to reporting errors.
A resident with a history of falls and requiring two-person assistance was inadequately supervised during a shower transfer, resulting in a fall and open ankle fracture. The facility failed to update the Kardex and POC for the resident and others, and CNAs were not trained to locate transfer status information, leading to systemic issues in communication and training.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one reviewed kitchen. During an observation of the kitchen, surveyors found multiple sanitation and food storage problems, including a utility cart with dried food debris and spilled dried liquids on all three levels, dried food debris inside the microwave, a trash can without a lid, food debris and dirt on the dry storage room floor and along the edges of walls and shelves, debris on shelf liners, a dirty knife storage rack, and a serving spoon with dried food debris in a utensil drawer. Surveyors also observed numerous food items that were unlabeled, undated, or past the stated discard date. These included opened packages of sliced ham, butter, chopped lettuce, and several dry goods such as pasta, bread, buns, rolls, and chips without dates. Other items had dates that did not clearly identify whether they were open dates or discard dates, and several refrigerated items had use-by or discard dates that had already passed, including potato salad, shredded carrots, and pudding. The observations also included cereal containers with unclear dating information and refrigerated items stored in bags without proper labeling. During interviews, the DM, DON, Admin, DA, and CK gave differing descriptions of expectations and responsibilities for labeling, dating, and sanitation, although several stated that all food items should be labeled and dated and that trash receptacles should be covered. The DM stated there were no cleaning lists in use and that kitchen cleanliness was a team effort. Record review showed the facility’s food preparation and storage policies required food to be handled according to food codes and HACCP guidelines, with all containers labeled and dated, refrigerated foods tightly sealed and labeled, and leftovers used within 72 hours.
Care Plan Did Not Include Ordered Adaptive Dining Equipment
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for one resident. Resident #20 was a female admitted with cerebral palsy, unspecified severe protein-calorie malnutrition, and paranoid schizoaffective disorder. Her MDS showed a BIMS score of 03, indicating severe cognitive impairment, and she required partial/moderate assistance for eating. A doctor’s order dated 04/14/2026 and revised 05/18/2026 specified a divided plate and small 4 oz. cups with a straw, and OT clarification dated 04/17/2026 recommended a divided plate for all meals and small cups with straws for cold liquids to support self-feeding independence. During lunch observation on 05/20/2026, Resident #20 was served a standard dinner plate with no divisions and cups with no straw, even though her meal card listed adaptive equipment as a divided plate, lid for hot beverage, and straw. Her comprehensive care plan dated 05/20/26 did not address the need for the divided plate or the small 4 oz. cups with a straw at mealtimes. In interviews, the OT stated the divided plate and small cups helped the resident self-feed and drink independently, the dietary manager stated adaptive equipment was entered as a standing order and printed on the meal ticket, the MDS nurse stated the equipment did not need to be on the care plan because it was on the meal card, and the DON and Administrator stated doctor and OT orders for adaptive equipment should be added to the care plan.
Improper Aseptic Technique During Tracheostomy Care and Suctioning
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who had a tracheostomy and required daily tracheostomy care and suctioning. The resident had diagnoses including cerebral infarction, diabetes mellitus, tracheostomy status, and cardiac arrest, and the quarterly MDS reflected severe cognitive impairment, oxygen use, and daily tracheostomy care and suctioning. The comprehensive care plan included interventions for shortness of breath and tracheostomy-related impaired breathing mechanics, including providing trach care and suctioning as ordered. During observation, the ADNS LVN and RN A entered the room with PPE, but the ADNS LVN did not perform hand hygiene before touching the overbed table, nightstand, and other room surfaces to gather supplies. She placed the sterile suction kit on the overbed table with wax paper instead of using the sterile drape from the kit, and she donned sterile gloves without hand hygiene, contaminating the gloves by touching the outside of the sterile gloves with contaminated hands. She also touched the non-sterile suction tubing at the bedside with both hands, contaminating both hands during the procedure. The ADNS LVN inserted the suction catheter into the trach but did not advance it past 1.5 to 2 cm, and the suctioning did not clear the resident's mucus after multiple attempts. She contaminated the sterile tubing and sterile gloves multiple times during the procedure. In interview, she stated she had used hand sanitizer when entering the room but did not perform hand hygiene before donning sterile gloves, acknowledged touching dirty surfaces before gloving, and stated she should have performed hand hygiene and kept one hand sterile. The DON stated staff were expected to maintain a sterile field during trach care and suctioning and to insert the suction tubing until resistance was felt and then pull back and suction to ensure the airway was clear.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for Resident #20, including a physician-ordered divided plate and a 4 oz cup with straw and lid for drinking. On 05/20/2026 at 12:52 PM, the resident’s lunch was observed on a standard dinner plate with no divisions and cups with no straw, despite the meal card listing adaptive equipment as a divided plate, lid for hot beverage, and straw. Resident #20 was a [AGE]-year-old female admitted with cerebral palsy, unspecified severe protein-calorie malnutrition, and paranoid schizoaffective disorder. Record review showed the resident had a BIMS score of 03 and required partial/moderate assistance for eating. A doctor order dated 04/14/2026 and revised 05/18/2026 specified a divided plate and small 4 oz cups with straw, and OT clarification stated these items were recommended to promote loading utensils, ease access to liquids, and support independence with self-feeding tasks. The comprehensive care plan dated 05/20/26 did not address the resident’s need for a divided plate or small 4 oz cups with a straw at mealtime.
Failure to Immediately Notify Physician of Significant Change in Skin Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant change in the resident's health status, specifically regarding the development and progression of moisture-associated skin damage (MASD) in a resident with multiple complex medical conditions. The resident, an elderly female with a history of cerebral infarction, end-stage renal disease requiring dialysis, heart failure, diabetes, and other comorbidities, was at high risk for skin breakdown. Upon admission, she had no wounds but was identified as being at risk for pressure ulcers and MASD, with care plans and physician orders in place for prevention and treatment. Despite ongoing skin assessments and documentation of MASD and subsequent deterioration, there was a lack of timely notification and involvement of the wound care nurse practitioner (NP) as the resident's skin condition worsened. The wound care NP was not involved until the MASD had advanced to full thickness tissue erosion, despite facility policy requiring notification of the medical provider for new or worsening wounds. Interviews with staff, including nurses, the DON, and the wound care NP, revealed inconsistent understanding and execution of the process for escalating care and notifying the appropriate provider when the resident's skin condition failed to improve or deteriorated further. Documentation and interviews indicated that the wound care NP was not informed or involved until the condition had significantly worsened, and the previous NP was also not notified of the new or worsening MASD. The lack of immediate consultation and delayed escalation of care resulted in a delay in the treatment and services needed for the resident's skin condition, contrary to facility policy and care plan interventions that required prompt notification of the physician or wound care provider for significant changes in condition.
Facility Fails to Maintain Safe Wheelchair Conditions
Penalty
Summary
The facility failed to ensure that assistive devices, specifically wheelchairs, were maintained and free of hazards for four residents. Observations revealed that the wheelchairs of these residents had cracked armrests with exposed foam, which could potentially cause injury. Resident #13, who is severely cognitively impaired, was found with a wheelchair that had a cracked right armrest. Resident #21, moderately cognitively impaired, was observed in a wheelchair with both armrests cracked. Resident #48, also moderately cognitively impaired, reported that his wheelchair, provided by the facility, had cracked armrests, and he had informed a charge nurse about it. Resident #221, who is cognitively alert, reported discomfort due to a cracked right armrest. Interviews with the Director of Nursing (DON) and the Maintenance Supervisor revealed a lack of communication and follow-up regarding the repair of wheelchairs. The DON mentioned that a sweep was conducted two months prior, and the armrests requiring repair were reported to the Maintenance Supervisor. However, the Maintenance Supervisor stated he had not received any recent reports from staff about wheelchairs needing repair. The Administrator later confirmed that all wheelchairs had been inspected, and necessary repairs were underway, but no policy was provided by the facility at the time of the survey exit.
Inadequate Disinfection of Blood Pressure Cuff
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a staff member, MA A, who did not disinfect a blood pressure cuff between uses on two residents. This oversight was observed during a morning medication pass, where MA A used the same blood pressure cuff on two residents without sanitizing it before or after each use. The residents involved were both elderly females with diagnoses including diabetes and hypertension, and both required assistance with activities of daily living. MA A admitted to forgetting to clean the cuff and acknowledged the potential for spreading germs. The Director of Nursing (DON), who also serves as the infection control preventionist, confirmed that all direct care staff are required to clean equipment, including blood pressure cuffs, after each resident contact. The facility's policy mandates that multi-patient use equipment be cleaned and disinfected between uses. Despite having received prior training on cleaning and storing equipment, MA A did not adhere to these protocols, which could lead to cross-contamination and infections among residents.
Incomplete Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the third quarter of 2024, specifically for the month of April. The Casper3 PBJ report indicated several deficiencies, including a One Star Staffing Rating, excessively low weekend staffing, no RN hours, and a failure to maintain licensed nursing coverage 24 hours a day throughout April 2024. The report showed no RN hours and a lack of licensed nursing coverage for every day in April. Despite the submission of a file to CMS on May 14, 2024, which was accepted, the report confirmed that total employee link records were not submitted. Interviews with the Administrator and the DON revealed that the facility was unaware of the missing RN and nursing hours in the report. The Administrator mentioned that the management company was in bankruptcy and a new company took over on May 1, 2024, which may have contributed to the reporting issues. The DON confirmed that there were no days without a working RN in April and was unaware of any issues. The Administrator speculated that data submission by both companies might have caused the reporting problems. The facility acknowledged the importance of accurate reporting to CMS and attributed the error to the transition between management companies.
Inadequate Supervision and Transfer Assistance Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision for a resident during transfers, leading to a significant injury. A resident, who had a history of repeated falls and required two-person assistance for transfers, was inadequately supervised by a CNA during a shower transfer. The CNA, believing the resident was a one-person assist, attempted to transfer the resident alone, resulting in the resident falling and sustaining an open right ankle fracture that required hospitalization and surgical intervention. The deficiency was compounded by the facility's failure to update the Kardex and plan of care (POC) to reflect the current safe transfer status requirements for the resident and 12 other residents. The CNA involved in the incident was not knowledgeable about how to locate the Kardex to determine the required level of assistance for transfers. This lack of knowledge was not isolated to one CNA, as other CNAs also reported not knowing where to find transfer status information in the medical records or Kardex, relying instead on verbal exchanges with other staff. Interviews with facility staff revealed systemic issues in communication and training regarding resident transfer needs. The MDS Coordinator had a list of residents with missing or incorrect transfer status information, which was only corrected after the state incident investigation began. The facility's policies required that transfer needs be assessed and updated regularly, but these were not adhered to, leading to the resident's injury and the identification of an immediate jeopardy situation.
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What surveyors actually found near you
We read the 78 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Copperas Cove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Copperas Cove Nursing & Rehabilitation | 0.9 mi | ★★★★★ | 12 | 0 |
| Avir At Killeen | 9.6 mi | ★★★★★ | 13 | 0 |
| Rosewood Heights | 10.2 mi | ★★★★★ | 5 | 0 |
| Harker Heights Nursing & Rehabilitation | 14.1 mi | ★★★★★ | 6 | 0 |
| Caraday Of Lampasas | 17.2 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.