Inspection·May 25, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 05/23/2023 at 10:19 AM, revealed Resident #40 was in his room sitting in his wheelchair near his bed. He was not sitting near the door. Resident #40's call light was on the floor under the middle section of his bed near the wall. Resident #40's bed was against the wall. In an interview on 05/23/2023 at 10:20 AM, Resident #40 stated (used Spanish interpreter) he did not know where his call light was located. He stated if it (call light) was under his bed he could not find it. In an interview on 05/23/2023 at 10:24 AM, CNA G stated Resident #40's call light was under the bed, and she could barely see the call light. She stated she would need to ask for assistance to move his bed and pick the call light off the floor and attach the call light where Resident # 40 could reach it. CNA G stated if Resident #40 required assistance, the only option he had was to yell for help. She also stated if the staff was down the hall or in another resident's room, it was a possibility the staff may not hear Resident #40 yell. She stated Resident #40 was a fall risk and if he fell and needed immediate assistance, he would not have access to his call light to alert staff he needed help. She stated it was very important for all residents have their call lights within reach. 2. Record Review of Resident # 18's face sheet, dated 05/24/2023, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included repeated falls (increased risk of injury, hospitalization, and deficits in activities of daily living eg. incontinence), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), muscle weakness ( a lack of strength in the muscles), other seizures ( sudden uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), age-related osteoporosis without current pathological fracture ( a disorder characterized by loss of bone mass and strength due to nutritional, metabolic, or other factors, usually resulting in deformity or fracture), and lack of coordination (uncoordinated movements due to a muscle control problem that causes an inability to coordinate movements). Record Review of Resident #18's Quarterly MDS Assessment, dated 04/24/2023, reflected Resident #18 had a BIMS score of 7 which indicated her cognition was severely impaired. She was assessed to require assistance with ADLs. Resident #18 had a fall since admission or the prior assessment. Record Review of Resident #18's Care Plan, initiated on 05/10/2023, reflected Resident #18 had an ADL self-care performance deficit related to dementia. Intervention: resident required assistance with bathing/showering, toileting, transfers, personal hygiene, and dressing. Resident # 18 had impaired cognitive function/dementia or impaired thought processes. Resident had communication problems related to decreased in cognition. Resident was high risk for falls related to several falls at home. Intervention: be sure the resident's call light is within reach and encourage resident to use the call light for assistance as needed. The resident needs prompt response to all requests for assistance. Resident #18 was further assessed of poor safety awareness. Intervention: staff to assist resident as needed in transfers and toileting for safety. Observation on 05/23/2023 at 10:28 AM revealed Resident #18 was in her room lying in her bed. Her bed was at a 45-degree angle. A small chest of drawers was located against the wall between the resident's bed and the door leading to the hall. The small bed side table was not in reach of Resident #18. The drawer was partially opened (approximately 8 inches) and her call light was laying in the drawer. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 2 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 05/23/2023 at 10:30 AM, Resident #18 stated she did not know where her call light was and stated she had been looking for it on her bed and could not find it. She stated she was not capable of seeing the bedside table and was not able to reach anything in the drawer of the bedside table. She stated if she needed assistance, she did not know what she would do. In an interview on 05/23/2023 at 10:40 AM, CNA G stated Resident #18's call light was in the chest of drawers. She stated Resident #18 was not capable of seeing the chest of drawers related to her bed being raised up and the chest of drawers was behind her bed. CNA G stated Resident #18 may fall and would not be able to call for assistance. She stated if the resident had an emergency or needed anything, she would not be able to call for help. CNA G stated all residents' call lights were expected to be placed in reach of the resident. She stated she did not know why the call light was in the drawer. 3. Record Review of Resident # 42's face sheet, dated 05/24/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (a disease that prevents someone from properly regulating their blood glucose levels), vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and hyperlipidemia ( an elevated level of lipids- like cholesterol and triglycerides- in your blood). Record review of Resident #42's admission MDS Assessment, dated 04/10/2023, reflected Resident #42 had a BIMS score of 1 which indicated his cognition was severely impaired. He was assessed to require assistance with ADLs. Resident #42 had a fall since admission or the prior assessment. Record review of Resident #42's Comprehensive Care Plan dated 04/19/2023 reflected Resident #42 was at risk for falls. Intervention: ensure the resident's call light was within reach and encourage resident to use the call light for assistance as needed. The resident needed prompt response to all requests for assistance. Resident had short attention due to dementia and was at risk for social isolation. Observation on 05/23/2023 at 10:33 AM, revealed Resident #42's call light was on the floor under the bed near the wall. Resident #42's bed was against the wall. Resident #42's bed would need to be moved toward the middle of the room to reach his call light. In an interview on 05/23/2023 at 10:35 AM, Resident #42 was not interview able. Resident #42 mumbled when asked a question. In an interview on 05/23/2023 at 10:40 AM, CNA G stated Resident #42's call light was under the bed and against the wall. She stated she would need to ask for assistance to move Resident #42's bed to obtain the call light from the floor. She stated Resident #42 was at risk for falls and if he fell, he would not have any device or would be difficult to hear him if he did yell. CNA G stated the resident had a soft tone voice and it would be difficult to hear him in the hall. She stated all residents were required to have their call light attached where they could reach them. She stated any staff who came into a room could attach the call light in reach of a resident. She stated she did not know how the call light managed to fall on the floor between the bed and wall. 4. Record Review of Resident #210's face sheet, dated 05/24/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 3 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness (a lack of strength in the muscles), lack of coordination (uncoordinated movements due to a muscle control problem that causes an inability to coordinate movements), restlessness and agitation (tense, confused, or irritable and primary, and may affect you mentally or physically), and osteoarthritis, generalized (caused by the breakdown of cartilage, a rubbery material that eases the friction in your joints). Record review of Resident #210's Quarterly MDS Assessment, dated 05/10/2023, reflected Resident #210 had a BIMS score of a 3 indicated his cognition was severely impaired. Resident #210 required extensive assistance with all ADLs except for eating. He required supervision with one person assist with eating. Resident #210 had a fall in the past 6 months. Record review of Resident #210's Comprehensive Care Plan, dated 05/16/2023 reflected Resident #210 had potential for falls related to weakness. Intervention: place the resident's call light within reach and encourage the resident to use the call light for assistance as needed. Anticipate and meet the resident's needs. Resident had a communication problem related to hearing deficit. Observation on 05/23/2023 at 11:08 AM, Resident #210 was in his room lying in his bed. Resident #210's call light was lying on the floor at the end of his bed. In an interview on 05/23/2023 at 11:10 AM, Resident #210 was not interview able. He would stare at the wall in front of him during conversation. Resident #210 stated, don't know three times during visit. In an interview on 05/25/2023 at 9:20 AM, LVN D stated all residents' call lights were expected to be within reach. She stated a resident may need assistance with any type of physical problem and would not be able to call for assistance. She stated a resident may attempt to assist self out of bed or their wheelchair if they were needing something and fall. LVN D stated if the resident had their call light in reach the resident would use the call light for assistance instead of trying to transfer themselves to get help, go to the bathroom or try to get anything in their room. She stated there were some residents who would not be able to yell for help. LVN D also stated if staff was in another resident's room or was at the end of the hall from their room it would be difficult to hear a resident yell for assistance. In an interview on 05/25/2023 at 9:30 AM, LVN E stated if a resident's call light was not in reach a resident had potential to fall attempting to reach the call light or attempt to assist self out of their bed or wheelchair and fall trying to get help. She stated if the resident had an emergency, they may be able to yell for help but there were some residents would not be able to yell very loud and it would be difficult to hear those residents. She stated the staff makes rounds every 2 hours and if the staff had made rounds and it was another hour or hour and half before they made rounds again, it was possible a resident may attempt to assist self out of bed and fall and lay on the floor 30 minutes to an hour. She stated it was the responsibility of all staff in the facility to check call lights when they entered a resident room to ensure the call light was attached to something where the resident had easy access to the call light. In an interview on 05/25/2023 at 9:42 AM, CNA H stated all staff were responsible to check call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 4 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 0558 Level of Harm - Minimal harm or potential for actual harm lights when they entered a resident's room. He stated if the call light was not in reach the resident may fall attempting to reach the call light or try to find the call light. He also stated a resident may have an emergency of vomiting, having respiratory issues or anything and would not have a device to call for assistance. He stated some residents would be able to yell for help but there were some residents who would not be heard if they attempted to yell. Residents Affected - Some In an interview on 05/25/2023 at 11:12 AM the RN Supervisor stated if a call light was not in reach when a resident was in their room, the residents would not have any device to use if they needed any type of assistance. She stated some residents were able to yell, however, this was not the appropriate protocol for residents to yell for help. She stated a resident had a potential of becoming restless and attempt to assist themselves out of bed or out of the wheelchair to find the call light or assist themselves to the bathroom or whatever they needed from the staff. She also stated if a resident assisted themselves the resident may fall and have an injury from the fall. She stated it was all the staff's responsibility to check the call light to ensure it was in reach of the resident when staff entered a resident's room. In an interview on 05/25/2023 at 2:05 PM, the Administrator stated all staff were responsible for checking call lights when they entered a resident's room. She stated she expected all call lights to be within reach of the residents. She stated she was not going to make a statement of what possibly may happen to a resident if they did not have a call light within reach. She stated it was every employee's responsibility to monitor call lights in residents' rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 5 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record review, the facility failed to post a notice and inform residents of the availability of the results of the most recent survey for 6 of 6 residents reviewed for resident group meeting. Residents Affected - Some The facility failed to inform residents by verbally informing residents or by posting a sign letting the residents know the location of the most recent survey. This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history. Findings included: Observation on 05/24/2023 at 8:00 AM revealed the state survey results manual in the main lobby was in a plastic container on the wall near the administrator office. The manual was not in a low position on the wall. It would be difficult for residents in wheelchairs to reach the manual from the plastic container on the wall. There was a locked door from the main lobby to the section of the facility where the residents' rooms are located and the common areas where residents socialize. In a confidential group interview on 05/24/2023 at 1:30 PM through 2:10 PM, six residents stated they did not know where or how to access survey results in the facility. They did not understand or have knowledge this existed in the facility. The residents in the group stated they would like to have access to this information, because the staff did not tell them anything about visits from the state. Two of the residents stated they did not know the state sent a report to the facility of any type of visits. The other four residents agreed. They all stated it would be great if they knew the results of the surveys. All the residents stated if they were informed at the time of admission they did not recall. All the residents stated when they were admitted to the facility it was difficult on them and they could not remember what was discussed at the time. Residents stated they were too nervous when admitted to the facility and it was difficult to remember anything discussed with them in the first few weeks of their admission. The residents agreed the survey book or the residents having a right to look at the surveys from the state was never discussed during resident council. The residents in the group were asked if they ever went into the lobby to sit or to do anything. All residents agreed the only time a resident went into the main lobby was to leave the facility to go to doctor appointment or to go somewhere with their family. They never stopped in the lobby. The residents stated there was a locked door between the lobby and the facility where the residents lived. One of the residents stated we socialize in the dining room and in the activity room we don't have a reason to go to the lobby. In an interview on 05/24/2023 at 1:15 PM the Activity Director stated she did not know where the results of the state survey book were located. She stated she did not discuss the state survey book, or the resident had the right to review the results of the state surveys to any of the residents. She stated it was her responsibility and the social worker's responsibility to discuss resident rights with the residents. She stated who ever signed the admission paperwork did receive a copy of resident rights when the resident was admitted . She also stated she had been in serviced on resident rights. In an interview on 05/25/2023 at 2:05 PM the Administrator stated it was the Activity Director, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 6 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 0577 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Social Worker, and her responsibility to review the resident rights with the residents. She stated the residents did have a right to view the survey results manual. The administrator stated the residents did not come to the main lobby and the survey results manual was in the main lobby. She stated having the survey manual in the main lobby was not accessible for the residents. The administrator stated the Activity Director, Social Worker and all staff was expected to know where the survey result manual was located. She stated all the staff had been in serviced on resident rights. In an interview on 05/25/2023 at 3:00 PM the Social Worker stated she did not know where the state survey book was in the facility. She stated she had not discussed with any of the residents they had a right to read the results of the state surveys. She stated it was her responsibility and the activity director's responsibility to discuss resident rights with the residents. She stated she had been in serviced on resident rights. Record review of the Facility Policy on Resident Rights dated 2022 reflected the resident has a right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 7 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 interview and record review, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 20 residents (Resident #9) reviewed for care plans. The facility failed to ensure Resident #9's Comprehensive Care Plan reflected a revision of her plan of care after she had dental surgery and the removal of six teeth which affected her ability to chew her food. These failures could place residents at risk of decline due to not attaining the highest practicable well-being possible. Findings included: A record review of Resident #9's face sheet dated 05/24/2023 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of dental caries (tooth decay or dental cavities), chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), dysphagia (swallowing difficulties), repeated falls, major depressive disorder, anxiety disorder, atherosclerotic heart disease of native coronary artery without angina pectoris (when arteries that carry blood to your heart become narrowed and blocked because of atherosclerosis or a blood clot). A record review of Resident #9's MDS assessment dated [DATE] reflected she had a BIMS score of 13, which indicated intact cognition. A record review of Resident #9's care plan last revised on 3/06/2023 did not reflect a dietary care plan for soft foods, cool/lukewarm fluids, and foods, and to avoid spicy foods. A record review of Resident #9's Extraction Post-Op Instructions relevant to physician orders for Resident #9's post-op dietary instructions, undated, reflected resident was required to have soft foods for 24 - 48 hours following surgery and to avoid hot, spicy foods and fed with cool/lukewarm fluids and foods. In an interview on 05/23/2023 at 12:33 PM Resident #9 stated she had 6 teeth pulled and stated she can't bite into anything, and the facility did not grind up her food and they knew they should have ground her food, they did it for one day. A record review of Resident #9's Clinical Notes Report dated 05/16/2023 reflected she had thirteen teeth extracted. In an interview on 05/25/2023 at 2:55 PM with the RN Supervisor reflected Resident #9's dental appointment and extraction post-operation instructions should have been entered into Resident #9's care plan. If dental post-operation instructions are not entered into a resident's care plan the resident could suffer because of lack of care. In the case with Resident #9, she might not have gotten the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 8 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 proper nutrition or could have gotten dry socket (a painful dental condition that sometimes happens after you have a permanent adult tooth extracted), the resident could lose weight, the resident's blood sugar could bottom out, the resident could get dehydrated, the resident could choke, and the resident would not enjoy the food at all. The RN Supervisor revealed that the nurse that is on shift when an order is received is responsible for putting the order into the Medication Administration Record and if the order received involved nutritional or dietary changes, the nurse on shift would have been responsible for filling out a dietary communication form. Interview on 05/23/2023 at 3:07 PM with LVN C revealed she was on duty when the extraction post-operation instructions were received for Resident #9 and put them in the Medication Administration Record and filled out a dietary communication form. She said she did not enter the post-operation instructions into the care plan. Interview on 05/25/2023 at 12:26 PM with the DM revealed she reviewed all her dietary communication forms, and she did not have a dietary communication form for Resident #9. A record review of Therapeutic Diet Orders facility policy, undated, reflected the reason for a therapeutic diet is to be documented in the medical record and/or indicated on the resident's comprehensive plan of care. All diet orders are to be communicated to the dietary department in accordance with facility procedures. Therapeutic diets are provided only when ordered by the attending physician or a registered or licensed dietitian who has been delegated to write diet orders, to the extent allowed by state law. The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 9 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 five of eighteen residents (Resident # 40, Resident #18, Resident #42, Resident #30, and Resident #210) reviewed for quality of care. Residents Affected - Some The facility failed to ensure Resident #40's, Resident #18's, Resident #42's, Resident #30's, and Resident #210's fingernails were trimmed and cleaned. These failures placed residents at risk for poor hygiene, dignity issues and decreased quality of life. Findings include: 1. Record Review of Resident # 40's face sheet, dated 05/24/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (a disease that prevents someone from properly regulating their blood glucose levels), lack of coordination (uncoordinated movements due to a muscle control problem that causes an inability to coordinate movements) and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems). Record review of Resident # 40's Quarterly MDS, dated [DATE], reflected Resident #40 had a BIMS score of 10 which indicated his cognition was moderately impaired. Resident #40 did not reject care. Resident #40 was assessed to require assistance with ADLs. Record review of Resident #40's Comprehensive Care plan reviewed on 03/28/2023 reflected resident had an ADL self-care performance deficit related to chronic kidney disease stage 5. Intervention: Resident #40 was totally dependent on one staff for personal hygiene and bathing. Resident #40 had impaired cognitive function/dementia or impaired thought processes related to altered mental status, unspecified. Observation on 05/23/2023 at 10:19 AM, revealed Resident #40 was in his room sitting in his wheelchair. Resident #40's nails on both hands were long and jagged. There was a blackish/brownish substance underneath the nails on his ring finger, forefinger, and middle finger on both hands. In an interview on 05/23/2023 at 10:20 AM, Resident #40 stated he had asked someone to clean and cut his nails last week and no one would cut or clean his nails. Resident #40 stated he did not ask again. In an interview on 05/23/2023 at 10:24 AM, CNA G stated Resident #40's nails were dirty and rough at the edges. She stated she did not know if she could trim and clean his nails. She stated she needed to find out if he was a diabetic. She also stated the nurses would need to clean and trim his nails if he was a diabetic. She stated the resident did have something black underneath his nails and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 10 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 - Some she stated it looked like BM to her. She stated if it was BM there was possibility, he could put his fingers in his mouth and may swallow BM. She stated Resident #40 may become very ill and require hospital care. 2. Record Review of Resident # 18's face sheet, dated 05/24/2023, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), muscle weakness ( a lack of strength in the muscles), age -related osteoporosis without current pathological fracture ( a disorder characterized by loss of bone mass and strength due to nutritional, metabolic, or other factors, usually resulting in deformity or fracture), and lack of coordination (uncoordinated movements due to a muscle control problem that causes an inability to coordinate movements). Record Review of Resident #18's Quarterly MDS Assessment, dated 04/24/2023, reflected Resident #18 had a BIMS score of 7 which indicated her cognition was severely impaired. Resident #18 did not have any behavior symptoms such as rejection of care. She was assessed to require assistance with ADLs. Record Review of Resident #18's Care Plan, initiated on 05/10/2023, reflected Resident #18 had an ADL self-care performance deficit related to dementia. Intervention: bathing/showering: check nail length and trim and clean on bath day and as necessary and report any changes to the nurse. Personal hygiene: Resident #18 required assistance by staff with personal hygiene. Resident # 18 had impaired cognitive function/dementia or impaired thought processes. Resident had potential for impairment to skin integrity related to fragile skin. Observation on 05/23/2023 at 10:28 AM revealed Resident #18 was in her room lying in her bed. Resident #18's nails on her right hand were long approximately and had a blackish substance underneath the nails. In an interview on 05/23/2023 at 10:30 AM, Resident #18 stated when her arms itched, and she scratched her arms with her fingernails sometimes there would be marks on her skin and sometimes her skin would bleed. She stated that she did not know why her nails was so dirty, but she wished someone would clean them. She stated she had looked at her dirty nails and asked someone to clean them a few days ago. In an interview on 05/23/2023 at 10:40 AM, CNA G stated Resident #18's nails on her right hand were dirty and looked like BM. She stated it was black underneath her nails. She also stated it was the responsibility of any nursing staff to trim and clean nails. She stated there was an exception if a resident was a diabetic it was a Nurse responsibility. 3. Record Review of Resident # 42's face sheet, dated 05/24/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus without complications (a disease that prevents someone from properly regulating their blood glucose levels), vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems), and hyperlipidemia ( an elevated level of lipids- like cholesterol and triglycerides- in your blood). Record review of Resident #42's admission MDS Assessment, dated 04/10/2023, reflected Resident #42 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 11 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 - Some had a BIMS score of 1 which indicated his cognition was severely impaired. Resident #42 did not have any behavior symptoms such as rejection of care. He was assessed to require assistance with ADLs. Resident #42 required extensive assistance with personal hygiene. Record review of Resident #42's Comprehensive Care Plan dated 04/19/2023 reflected Resident #42 was at risk for falls. Resident had short attention due to dementia and was at risk for social isolation. Observation on 05/23/2023 at 10:33 AM, revealed Resident #42 was in his room sitting in his wheelchair. Resident #42's nails on both hands had a thick blackish substance underneath the long and jagged nails. In an interview on 05/23/2023 at 10:35 AM, Resident #43 was not interview able. Resident mumbled when asked a question. In an interview on 05/23/2023 at 10:40 AM, CNA G stated Resident #42's nails did have something black underneath all his nails. She stated the tips of his fingernails were not smooth. She stated he could scratch himself and cause his skin to bleed with the nails not being smooth. She also stated there was a possibility resident may have BM underneath his nails and if he put his fingers in his mouth or ate with his hands it was possible for him to become seriously ill and may need hospital care. She stated if he swallowed the black substance underneath his nails there was a possibility it was some type of major bacteria. 4. Record Review of Resident # 30's face sheet, dated 05/24/2023, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included legal blindness as defined in USA ( vision that allows a person to see straight ahead of them), muscle weakness ( a lack of strength in the muscles), muscle wasting and atrophy, not elsewhere classified, unspecified site ( a significant shortening of the muscle fibers and a loss of overall muscle mass), and unspecified dementia with behavioral disturbance ( when confusion can't be clearly diagnosed as a specific type of dementiaexperience memory loss, poor judgement, and confusion). Record review of Resident #30's Quarterly MDS Assessment, dated 04/12/2023, reflected Resident #30 was rarely/never understood. Staff assessed Resident #30's cognitive patterns . Staff assessment indicated he had poor short- and long-term memory recall. Resident #30's decision making ability was severely impaired. Resident #30 did not have any behavior symptoms such as rejection of care. He required extensive to total dependence with ADLs. Record review of Resident #30's Comprehensive Care Plan, revised on 04/26/2023, reflected Resident #30 was at risk for altered skin integrity secondary to sharp fingernails, and scratching self. Intervention: nursing to keep fingernails trimmed to prevent injury if he scratches himself. Resident #30 had an ADL self-care performance deficit related to dementia and vision deficit. Intervention: personal hygiene: Resident #30 required assistance with personal hygiene. Resident #30 had impaired visual function related to blindness. Resident #30 had a communication problem related to cognitive/communication deficit. Observation on 05/23/2023 at 10:37 AM, revealed Resident # 30 was in his room lying in his bed. Resident #30 was placing his fingers on his left hand in his mouth. Resident #30 had a blackish/brownish substance underneath his fingernails on both hands. His fingernails were long and jagged. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 12 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 - Some In an interview on 05/23/2023 at 10:38 AM, Resident #30 was not interview able. He would moan when addressed by name. In an interview on 05/23/2023 at 10:40 AM, CNA G stated Resident #30 did not speak, and he was constantly placing his fingers in his mouth and moving his hands and arms. She stated his nails were dirty with some type of black substance underneath each of his fingernails. She stated the smell was like BM. She stated when he was placing his fingers in his mouth there was a possibility, he could swallow the black substance. CNA G also stated he may become physically ill with some type of virus from the bacteria. She stated residents' fingernails were cleaned and trimmed during showers or as needed. She stated Resident #30's nails were long and not smooth, and he may scratch his skin and cause a skin tear. CNA G stated it was not safe for him to have dirty and long fingernails. 5. Record Review of Resident # 210's face sheet, dated 05/24/2023, reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness (a lack of strength in the muscles), lack of coordination (uncoordinated movements due to a muscle control problem that causes an inability to coordinate movements), and primary osteoarthritis, generalized (caused by the breakdown of cartilage, a rubbery material that eases the friction in your joints). Record review of Resident #210's Quarterly MDS Assessment, dated 05/10/2023, reflected Resident #210 had a BIMS score of a 3 indicated his cognition was severely impaired. Resident #210 required extensive assistance with all ADLs except for eating. He required supervision with one person assist with eating. Record review of Resident #210's Comprehensive Care Plan, dated 05/16/2023 reflected Resident #210 had potential for falls related to weakness. Intervention: anticipate and meet the resident's needs. Resident #210's hygiene was not identified on care plan. Observation on 05/23/2023 at 11:08 AM, revealed Resident #210 was in his room lying in his bed. Resident #210's nails were long and jagged on both hands. There was a blackish/brownish substance underneath fingernails on both of his hands. In an interview on 05/23/2023 at 11:10 AM, Resident #210 was not interview able. He would stare at wall in front of him during conversation. Resident #210 stated, don't know three times during visit. In an interview on 05/25/2023 at 9:20 AM, LVN D stated the CNAs were responsible for nail care unless a resident was a diabetic. She stated resident's nails were to be trimmed if needed and cleaned during showers. LVN D stated the nursing staff was expected to clean and trim residents' nails immediately if there was blackish substance underneath their nails and/or if their nails needed to be trimmed. She stated if the nursing staff waited until shower the resident had potential of skin tears because of them scratching their skin. She also stated the blackish substance possibly may be fecal matter underneath the residents' nails. LVN D stated a resident may become physically ill with an intestinal problem and may need to be admitted to the hospital. She stated it was the nursing supervisor's responsibility to monitor the CNAs to ensure they are completing ADL care on residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 13 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 - Some In an interview on 05/25/2023 at 9:30 AM, LVN E stated it was the CNAs responsibility of cleaning and trimming resident's nails except residents with diagnosis of diabetes. She stated all diabetics nail care was the duty of an LVN or RN. She stated the CNAs did nail care when residents were in the shower. LVN E also stated any type of nail care can be done anytime if needed. She stated if resident's nails are long and dirty the nursing staff was expected to clean and/or trim residents nails immediately. She also stated there was a possibility bacteria could be underneath resident's nails. LVN E stated a resident had potential of ingesting bacteria and according to what type of bacteria the resident ingested may cause severe GI problems such as vomiting, diarrhea and possibly a resident may become dehydrated and need to be evaluated at the hospital. She stated it was the nursing supervisor's responsibility to monitor the job tasks assigned to the CNAs. In an interview on 05/25/2023 at 9:42 AM, CNA H stated the nurses were responsible for diabetic nail care. He stated the CNAs were responsible for all other resident's nail care such as cleaning, trimming and possibly filing the nails. He stated nail care was usually completed during showers or as needed. He stated nail care was to be completed daily if a resident's nails were dirty or needed to be trimmed. He stated if a resident had a blackish/ brownish substance underneath their nails it could be anything. CNA H stated there was a possibility the blackish substance may be bacteria. He stated if a resident was eating food with their hands and the blackish substance transferred to the food the resident may become physically ill with some type of stomach problems such as vomiting or diarrhea. He stated it was a possibility a resident may need to be evaluated at a hospital if it was severe. In an interview on 05/25/2023 at 11:12 AM the RN Supervisor stated the CNAs were responsible of cleaning and trimming/cutting residents' nails except the residents with a diagnosis of diabetes. She stated for any resident with a diagnosis of diabetes the nurse was responsible for all nail care including trimming and cleaning. She stated if a resident had dirty nails there was a possibility bacteria could be on their fingers and/or underneath the resident's nails. She stated if the resident was eating food with their hands there was a potential a resident could ingest bacteria transferred from their hands and/or fingernails onto their food. She stated it depended on the type of bacteria of what type an illness a resident could receive from the bacteria. She also stated a resident could become ill with stomach issues and develop diarrhea or vomiting. She also stated a resident had a potential to scratch themselves and may develop a skin concern such as a skin tear and may develop an infection. The Nurse Supervisor stated it was the nurse's responsibility to monitor the CNAs to ensure they are completing their duties including nail care. In an interview on 05/25/2023 at 2:05 PM the Administrator stated residents' nail care was the CNAs' responsibility. She stated if a resident was a diabetic it was the Nurses' responsibility. She stated nail care was expected to be taken care of when nails were visibly dirty or needed to be trimmed. She also stated if it was a certain type of bacteria a resident may become physically ill. The Administrator stated a resident may develop diarrhea. She did not respond to the question if a resident became seriously ill with GI problems was there a possibility a resident may require a physician to assess the resident at a hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 14 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services for 1 of 20 residents (Resident #31) reviewed for range of motion (ROM). The facility failed to ensure Resident #31 had interventions in place for her right- and left-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right and left hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: Review of Resident #31's Face Sheet dated 05/25/2023 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses Dementia (A group of symptoms that affects memory, thinking and interferes with daily life) and need for assistance with personal care. Review of Resident #31's Annual MDS assessment dated [DATE] reflected Resident #31 was assessed to have a BIMS score of 00 indicating severe cognitive impairment. Resident #31 was assessed to require extensive assist with all ADLs. Resident #31 was further assessed to have limitations in range of motion of both upper extremities. Review of Resident #31's Comprehensive Care Plan reflected no plan of care to address her limitations for range of motion or contractures of bilateral hands. Review of Resident #31's consolidated physician orders dated 05/25/2023 reflected an order with a start date of 01/21/2023 reflected Apply palm protector to left hand to prevent skin breakdown in the morning at 7:00 AM and remove at 8:00 PM. Further review of the consolidated physician reflected another order with the start date of 01/21/2023 which reflected Apply palm protector to right hand to prevent skin breakdown apply in morning at 7:00 AM and remove at 8:00 PM. Observation on 05/23/2023 at 11:00 AM revealed Resident #31 was up in a Geri chair (recliner type wheelchair) at the nursing station. Resident #31 was not interviewable. Resident #31 was observed to have contractures to both her hand with her hand closed tight with her thumbs under her other fingers. No palm protectors were present in her hands. Observation on 05/24/2024 at 11:30 AM revealed Resident #31 was up in Geri chair no palm protector were present in her hands. Observation on 05/25/2023 at 10:00 AM revealed Resident #31 was in her room in bed. No palm protectors were present in her hands. In an Observation and interview on 05/25/2023 at 10:39 CNA I stated after observing Resident #31 in bed, that Resident #31 did not have palm protectors in her hands and stated she did have palm (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 15 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few protectors that were to be placed in her hands daily. She stated she had not yet put the palm protectors in Resident #31's hands because the Resident was fixing to get a bath. CNA I then opened Resident #31's bedside table drawer and located Resident #31's palm protectors in the back of Resident #31's drawer. In an interview on 05/25/2023 at 11:00 AM LVN E stated the CNAs are tasked to put resident palm protectors in the residents' hands during care. LVN E was asked if the task was not placed on the care plan would the CNAs know to put the palm protectors in the resident's hands and LVN E stated no, the task would not show up for the CNAs task list if the task was not placed on the care plan. LVN E then looked at Resident #31's EMR and stated Resident #31 had a physician's order for palm protectors daily and stated the nurse should check to ensure the palm protectors were in place. LVN E stated she thought Resident #31 had her palm protectors in for the past few days (05/23/2023 and 05/24/2023). Review of Resident #31's TAR dated May 2023 for the orders for her palm protectors reflected no signatures for completion of the application of the palm protectors for 7 days in May 2023 (05/12/2023 through 05/16/2023, 05/18/2023 and 05/22/2023) In an interview on 05/25/2023 at 1:22 PM the RN Supervisor stated if a resident had orders for palm protectors that the devices should be in place. She stated if the devices are not utilized it could lead to skin breakdown or a worsening of the contracture. Review of the facility's policy Prevention of decline in range of motion dated October 2022 reflected Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable .Based on the comprehensive assessment, the facility will provide interventions, exercises and /or therapy to maintain or improve range of motion .The facility will provide treatment and care in accordance with professional standards of practice .Appropriate equipment (braces or splints) .A nurse with responsibility for the resident will monitor for consistent implementation of the care plan interventions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 16 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 3 of 30 days reviewed for RN coverage. Residents Affected - Many The facility failed to ensure they had an RN on duty on 04/27/2023, 04/28/2023, and 04/29/2023. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Review of RN staffing hours for April 2023 reflected zero hours worked by an RN on 04/27/2023, 04/28/2023, and 04/29/2023. During an interview on 05/24/2023 at 3:28 PM the BOM provided the facility's RN time sheets for the four RN's that worked at the facility. The BOM stated that no RN clocked in on 04/27/2023, 04/28/2023, and 04/29/2023. Review of the RN time sheets for May reflected none had clocked in on 04/27/2023, 04/28/2023 and 04/29/2023. In an interview on 05/24/2023 at 3:40 PM the Administrator stated she has been having difficulty filling the RN positions at the facility. The Administrator stated she goes through applications when they come in, but she has not been able to fill the positions. She stated it was the facility's policy to have a RN eight hours a day 7 days a week. Review of the facility's policy Nursing Services- Registered Nurse dated October 2022 reflected It is the intent of the facility to comply with Registered Nurse staffing requirements .1. The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 17 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to properly label food in one of two open front refrigerators , and one of one open front freezer located in the kitchen. 2. The facility failed to ensure Dietary Aide A, Dietary Aide B and LVN E wore hair restraints while in the kitchen. 3. The facility failed to ensure the [NAME] properly sanitized their hands between tasks. These failures could placed residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings included: 1. Observation of one open front refrigerator in the kitchen on 05/23/2023 at 9:40 AM- 10:10 AM revealed left-over chicken noodle soup not in the original container had a use by date of 05/22/2023. Left over green beans not in the original container was not labeled or dated. One gallon of half empty milk in the original container was not covered with a lid and the milk had a slightly yellow color with a sour smell. Observation of one open front freezer in the kitchen on 05/23/2023 at 9:40 AM- 10:10 AM revealed five large bags of frozen okra not in the original box was not labeled or dated. Three large bags of broccoli not in the original box was not labeled or dated. Five large tubes of hamburger meat not in the original box was not labeled or dated. Two of the five large tubes of hamburger meat had approximately one to three inches of ice particles on the hamburger meat. 2. Observation of the kitchen on 05/23/2023 at 9:40 AM-10:10 AM, Dietary Aide A was placing bowls on food prep table. She had a hair restraint covering top and sides of her head. Her hair was not covered from her neck to her waist with a hair restraint. In an interview on 05/23/2023 at 10:00 AM Dietary Aide A stated the hair from her extensions had potential to fall onto surfaces. She stated she was placing bowls on the food prep table. Dietary Aide A stated it was a possibility hair may fall into a bowl. She also stated a resident could possibly become sick with diarrhea or stomach issues if the hair was contaminated. Dietary Aide A stated she had been in serviced on hair restraints. Observation on 05/24/2023 at 10:00- 10:15 AM Dietary Aide B entered the kitchen from outside. The door was located toward the middle to back of the kitchen. Dietary Aide B walked into the kitchen without donning hair net was speaking to Dietary Aide A and observing her wrapping silverware into napkins approximately 8 minutes. When he exited the food prep area, he continued to walk in the kitchen without a hair net. There were hair nets accessible to staff upon entering the kitchen from any doors. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 18 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 an interview on 05/24/2023 at 10:15 Dietary Aide B stated he was an employee in the kitchen. He stated he did not clock in when he entered the kitchen. He stated if he was not on the clock and was in the kitchen, he was not required to wear a hair net. He also stated in a loud tone it was not anyone's business if he was or was not wearing a hair net. Dietary Aide B stated he had to clock in on his phone. He stated he was not a nurse, and it was not his responsibility to know if anything may become contaminated from hair. He stated he was in service on wearing hair nets and hand hygiene. Observation on 05/24/2023 at 10:55 AM LVN E was standing at the juice machine in the kitchen across from the steam table pouring juice from the juice machine into two cups without wearing a hair restraint, In an interview on 05/24/2023 at 11:00 AM LVN E stated she knew the requirements of wearing a hair net in the kitchen. She stated she forgot to don a hair net when she entered the kitchen. She stated she did not ask the dietary staff she needed two juices for a resident. She stated there was a potential for her hair to fall onto surfaces, into the cups, or anywhere in the area she was standing in the kitchen. She stated there was a possibility a resident may become sick with any type of stomach problems if they had ingested hair from a drink. She stated if there were bacteria on the hair the resident had potential of becoming ill with diarrhea, vomiting or any type of food borne illness. She stated she had been in service on wearing a hair net when she entered the kitchen. LVN E also stated the Dietary Manager had informed her in the past to don a hair net prior to entering the kitchen and if she needed something from the kitchen for a resident to ask dietary staff to assist her instead of entering the kitchen. 3. Observation on 05/24/2023 10:00-10:35 AM the [NAME] was wearing gloves. He touched cooked pork chops, the container of sausage with cheese sauce and opened the over door to remove food from the oven. After he removed food from the oven, he touched his shirt and his face mask. He exited the stove area in the kitchen and entered a different section of the kitchen where he touched a large bag of onions. He placed his right hand in his right pocket and removed a pen to write something on the bag of the onions. He placed the pen into his right pocket and entered the area of kitchen where the stove was located. He placed onions on the food prep area. He removed cutting board from another prep area across from where the onions were located and placed it beside the onions. He exited the food prep area of the kitchen and entered the back of kitchen and removed a knife from a magnetic strip on the wall. He touched the middle part of the knife and did not carry the knife by the handle. The cook returned to the food prep area. He removed aluminum foil for the container, and he put his fingers inside the aluminum foil. He proceeded to peel part of the onion with his hands and began to cut the onions and placed the onions inside the aluminum foil. The cook never removed his gloves during this observation. In an interview on 05/24/2023 at 10:20 AM the [NAME] stated he never changed his gloves between tasks. He stated he was required to change his gloves and wash his hands between tasks and place new gloves on his hands. He stated he did touch his clothes, face mask, and put his hands in his pocket. He stated the gloves were considered contaminated and it was a possibility bacteria may transfer from his gloves to the food, knife and/ or aluminum foil. He stated he had been in service on hand washing and when to change gloves in the kitchen. Observation on 05/24/2023 at 10:25 AM the [NAME] removed his gloves disposed the contaminated gloves in the garbage can and donned new gloves without washing his hands. He continued to cut the onions and the Dietary Manager asked him if he washed his hands after removing his contaminated gloves. He stated no he did not. The [NAME] removed second pair of gloves and washed his hands and donned a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 19 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 new pair of gloves. Level of Harm - Minimal harm or potential for actual harm In an interview on 05/24/2023 at 10:35AM the [NAME] stated he was required to wash his hands after removing the dirty/contaminated gloves and prior to placing new gloves on his hands. He stated he did not wash his hands when he removed the dirty gloves and prior to placing on new gloves. He stated he had been in serviced on washing hands after removing dirty gloves and before wearing new gloves. He stated the new gloves would be considered contaminated because he touched outside his dirty gloves and then touched the outside of the clean gloves. He stated any contaminated gloves had a potential of transferring bacteria / germs from the gloves to the food. He stated it was a possibility a resident could become sick with any stomach problems and if they became very sick, they may need medical attention at the emergency room. Residents Affected - Many In an interview on 05/25/2023 at 9:05 AM with the Dietary Manager stated all food was required to be labeled and dated. She stated the left-over food was to be discarded if the food after the use by date. She also stated all food in the refrigerator/ freezer was to be labeled especially if it was not in the original package or box. Dietary manager stated if the food was not discarded an employee possibly use the food for a snack or part of the meal without looking at the use by date and the resident had a potential of getting food poisoning. She stated if there were ice particles on the food it was to be discarded according to how thick the ice was on the food. She stated if it was approximately 1 inch thick the food was expected to be discarded. Dietary manager stated all staff was expected to wear a hair net prior to entering any section of the kitchen including nursing staff. She stated if dietary staff had not clocked in at the time of entering the kitchen the staff was expected not to be in the kitchen and to donn hair net prior to entering section of the kitchen where hair could fall on silverware, cups, plates, and/or food. She stated the dietary staff was expected to stop and donn hair net near the entrance of the door prior to entering the kitchen. She stated it was her responsibility to monitor hand hygiene, label, and date all foods, ensuring all staff was wearing hair nets in the kitchen. She stated all staff was expected to follow proper hand hygiene protocol. She stated the cook was expected to wash his hands in the sink after removing contaminated gloves. She also stated the cook was expected to remove his gloves whenever the gloves were contaminated by touching objects, his clothes, his face mask, or anything may not be clean. Dietary Manager stated it was possible for the cook to transfer bacteria from their dirty gloves onto the food. She stated if the food was contaminated a resident may become sick with a virus, could have diarrhea or vomiting and become dehydrated. She stated there was a possibility a resident may need hospital care. In an interview on 05/25/2023 at 2:00 PM the Administrator stated the Dietary Manager was responsible for monitoring all policies and protocol for the kitchen. She stated all staff including nursing staff was expected to wear hair nets in the kitchen. She stated all food was expected to be labeled and dated. She also stated staff were to practice good hand hygiene and to change their gloves between tasks and wash their hands prior to wearing new gloves. She stated there was a possibility germ may be on the gloves and had a potential to cross contaminate food, utensils and/ or food surfaces. She also stated the residents had potential of becoming ill. The Administrator did not respond to questions asked about the potential of harm to residents if their food may become contaminated, if staff did not wear hair net, if food was served past their use by date, and if the food was not labeled or dated. Review of the Facility's Policy on Maintaining a Sanitary Tray Line revised on 02/2023 reflected wash hands before and after wearing or changing gloves. Change gloves when activities are changed, or when the type of food being handled is changed, or when leaving the workstation. Change gloves after sneezing, coughing, or touching face, hands, or hair with gloved hand. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 20 of 21 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 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836 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 Review of the Facility's Policy on Food Safety Requirements dated 2023 reflected labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 21 of 21