Inspection·July 30, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few people providing him care, and he normally did. He stated he got an x-ray the same day, the results came back the next day saying he had a fracture. He stated the staff sent him to the hospital where he was told it was just a sprain. He stated the staff had been giving him pain medication when he needed it which was managing his pain, and he was happy CNA A got fired. He did not have any further concerns. During an interview on 07/30/25 at 11:40 AM, the CRN, the ADM, and the DON stated CNA A was suspended the same day (07/27/25) and texted the DON the following day stating she had quit. They were unable to get a statement from her. The ADM stated Resident #1's RP, NP, and the Ombudsman were notified of the incident immediately. The DON stated a STAT x-ray was immediately ordered, they conducted safe surveys on all residents, emotional assessments were being conducted for Resident #1 every shift by nursing staff, and all staff were in-serviced on abuse and neglect, resident rights, and ADL self-care. During an interview on 07/30/25 at 11:52 AM, RN B stated on 07/27/25 in the morning she asked Resident #1 how his night was, and he told her he had a rough night. She asked him to explain further, and he told her CNA A was really rough with him and he felt a pop when she yanked his right arm. She stated she assessed him, administered him pain medication, applied bio freeze, and notified the ADM, his RP, and the NP. The NP ordered a STAT x-ray which was done that day. She stated she was in-serviced that day on abuse and neglect and safe ADL care. She stated no one should provide care to a resident alone when they required two people. During an interview on 07/30/25 at 1:18 PM, MA C stated she was recently in-serviced by the DON and ADM on abuse and neglect and two-person assistance. She stated the ADM was their abuse and neglect coordinator and types of abuse could be stealing, verbal, or physical. She stated if a resident required two people for any kind of care, they must find someone to assist them, no matter what. She stated the aides looked in the Kardex (documentation system) to determine how much assistance a resident needed. During an interview on 07/30/25 at 1:26 PM, LVN D stated she was recently in-serviced on safe ADL care, abuse and neglect, and resident rights. She stated her abuse and neglect coordinator was their ADM and different types of abuse were physical, emotional, or negligence. She stated the aides looked in the Kardex to locate what kind of assistance the residents needed, and the nurses would look in their care plans. She stated if a resident needed two people for care, utilizing one person would never be acceptable. She stated she told the aides all the time that if they needed help with transfers or care, she was always available to assist. During a telephone interview on 07/30/25 at 1:58 PM, Resident #1's NP stated she was notified of the incident between him and CNA A in the morning of 07/27/25 and ordered a STAT x-ray. She stated she assessed him the following morning, 07/28/25. She stated she believed the facility handled the situation appropriately and had no concerns. During an interview on 07/30/25 at 2:04 PM, CNA E stated she was recently in-serviced on resident rights, safety, abuse and neglect, and checking the Kardex. She stated the abuse and neglect coordinator is the ADM, and different types of abuse could be verbal, emotional, or physical. She stated no one should ever provide care to a resident by themselves when they required two people because anything could happen. She stated she could get hurt or the resident could get hurt. During an interview on 07/30/25 at 2:11 PM, CNA F stated she was recently in-serviced on abuse and neglect and checking the Kardex to check the assistance level needed for residents. She stated their ADM was the abuse and neglect coordinator and types of abuse were sexual, physical, verbal, emotional, and financial. She stated if a resident needed two people with care, she would never provide care by herself. She stated it could risk her life, their life, and her license. On 07/30/25 at 11:58 AM and 2:45 PM, telephone calls were made to CNA A. A call was not returned prior to exit. Review of the facility's self-report to HHSC, dated 07/27/25, reflected the ADM reported the incident between Resident #1 and CNA A the same day it occurred. Review of CNA A's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455515 If continuation sheet Page 2 of 3 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 455515 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Cove Nursing & Rehabilitation 607 W Ave B Copperas Cove, TX 76522 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete suspension form, dated 07/27/25, reflected she was on an unpaid suspension due to the incident between herself and Resident #1. Review of an in-service, dated 07/27/25 and conducted by the ADON, reflected all staff were in-serviced on their resident rights policy. Review of an in-service, dated 07/27/25 and conducted by the ADON, reflected all staff were in-serviced on their ADL policy. Review of an in-service, dated 07/27/25 and conducted by the ADON, reflected all staff were in-serviced on their abuse and neglect policy and recognizing signs of abuse and neglect. Review of an in-service, dated 07/27/25 and conducted by the ADON, reflected all staff were in-serviced on the following: It is critically important to use the right amount of staff for safe resident transfers and repositioning, protecting both residents from falls and injuries, and staff from bodily injuries. Review of safe survey's conducted for all residents, dated 07/28/25, reflected no concerns or issues. Review of an in-service, dated 07/29/25 and conducted by the DON, reflected all staff were in-serviced on professionalism. Review of the facility's QAPI agenda, dated 07/29/25, reflected the ADM, the MD, the DON, the ADON, the BOM, the SW, and the AD were in attendance. Review of the facility's Resident Rights Policy, dated 2021, reflected employees shall treat all residents with kindness, respect, and dignity and residents had the right to be free from abuse and neglect. Review of the facility's ADL Policy, revised March 2018, reflected appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care. Review of the facility's Identifying Abuse Policy, date April 2021, reflected it defined the different types of abuse such as physical, verbal, mental, and sexual. Review of the facility's Abuse and Neglect Policy, revised March 2018, reflected any allegations of abuse or neglect will be investigated followed through with a cause identification, treatment/management, and monitoring and follow-up. Review of the facility's Performance Expectations Policy, dated 01/01/25, reflected conduct that was dishonest, insubordinate, immoral, or illegal would not be tolerated. Event ID: Facility ID: 455515 If continuation sheet Page 3 of 3