Inspection·July 11, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm that are damaged or missing paint would be fixed and painted. The Administrator stated she knew the Maintenance Director was working on getting paint and painting. The Administrator stated, I would want it in my home so the residents would expect that as well, and that paint should be kept up with to make the residents feel more at home in the facility. The Administrator was shown the unpainted and damaged wall areas in rooms [ROOM NUMBERS] and stated they should not be in that condition and need to be painted. Residents Affected - Few Review of the facility's Resident Rights policy with a revised date of 11/2/2016 revealed, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Safe Environment - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide - 2. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 2 of 12 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 07/11/2024 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 observations, interviews, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 2 (Resident #6 and Resident #8) out of 6 residents. Residents Affected - Few The facility failed to provide adequate fingernail grooming for Resident #6 and Resident #8. This deficient practice could place residents at risk of impaired skin integrity and infection. Findings include: Review of Resident #6's face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses of parkinsonism (a disorder of the central nervous system that affects movement, often including tremors), dementia (loss of cognitive functioning - thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life), hemiplegia/hemiparesis (muscle weakness or partial paralysis on one side of the body) and lack of coordination. Review of Resident #6's Quarterly MDS assessment, dated 06/19/2024, revealed a BIMS score of 03 indicating severe cognitive impairment. MDS further indicated the resident had functional deficits and was dependent on staff for personal hygiene. Review of Resident #6's care plan, dated 06/19/2024, revealed the resident was at risk for impaired skin breakdown related to fragile skin, the resident had hemiplegia/hemiparesis related to previous stroke and required assistance with ADL's, and the resident had an ADL self care performance deficit. Interventions to prevent possible skin breakdown included to identify/document potential causative factors and eliminate/resolve where possible. Interview and observation on 07/09/2024 at 01:30 PM revealed Resident #6 lying in bed, family member at bedside. She stated the resident had hand contractures and the staff tried to use handrolls, but the resident did not like them and would not keep the handrolls in place. Observation of the resident's hands revealed long fingernails. Interview and observation on 07/10/2024 at 10:08 AM, Resident #6 was asked and assisted by the ADON to open hands to view palms and fingernails. Resident had long fingernails with nail indentation noted on the left palm. No skin breakdown noted. Upon observation of the nails and the resident's palms, the ADON touched the indented area. The ADON stated the nails were too long and could be a potential cause for skin breakdown, and she would have someone cut them. Observation on 07/10/2024 at 02:00 PM revealed Resident #6's nails had not been trimmed. Observation on 07/11/2024 at 09:00 AM revealed Resident #6's nails had been trimmed. Review of Resident #8's Face Sheet reflected a [AGE] year-old male admitted on [DATE] with readmission on [DATE]. Diagnoses included urinary tract infection, acute kidney failure, morbid obesity and dementia. Review of Resident #8's MDS assessment, dated 05/29/2024, reflected a BIMS score of 03 indicating (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 3 of 12 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 07/11/2024 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 - Few severe cognitive impairment. MDS further reflected the resident required substantial assistance with functional abilities. Review of Resident #8's Care Plan, dated 04/02/2024, reflected the resident had a behavior problem smearing feces on the wall, had potential for impairment to skin integrity related to fragile skin and the fingernails should be kept short, the resident had potential for physical behaviors related to dementia and can be physically abusive and the resident had ADL self care deficit. Observation and interview on 07/10/2024 at 10:25 AM. Peri care was completed on Resident #8 by CNA A and observation of the resident's hands revealed the fingernails were long with brown substance underneath the nails. While providing peri care the CNA A stated the resident often plays with himself and his urinary catheter. In an interview on 07/11/2024 at 10:20 AM, CNA A stated the nurses or the hospice team provide nail care for the residents. Observation on 07/11/2024 at 11:34 AM revealed Resident #8 sitting in a wheelchair in the dining room. Fingernails were still long with brown substance under the nails. In an interview on 07/11/2024 at 12:14 PM, the DON stated it is the responsibility of the charge nurse to provide nail care for residents. She stated residents with long nails could scratch themselves or others and possibly get an infection. She stated for residents with contractures, if the nails are too long, they could scratch their palm and get a wound or possible infection. Review of facility's nail care policy (no date) reflected nail care should be performed regularly to prevent infection and injury from scratching by fingernails. Review of the policy reflected the fingernails should be trimmed and rounded, the resident will be free from abnormal nail conditions, and debris should be removed from under the nails. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 4 of 12 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 07/11/2024 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 0699 Provide care or services that was trauma informed and/or culturally competent. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #24) of 3 residents reviewed for trauma informed care. Residents Affected - Few The facility failed to ensure that Resident #24 diagnosis of Post-Traumatic Stress Disorder (PTSD) and potential triggers were care planned. This failure could place residents at increased risk for psychological distress due to re-traumatization. Findings included: Review of Resident #24's Face Sheet dated 07/10/2024 reflected a [AGE] year-old female initially admitted to the facility on [DATE] with the following diagnoses: Systolic (Congestive) Heart Failure (heart's capacity to pump blood cannot keep up with the body's need), Chronic Post Traumatic Stress Disorder (mental health condition that can affect anyone who has experienced a traumatic event, such as military combat, sexual or physical assault, or a natural disaster - chronic sufferers may experience symptoms such as flashbacks, nightmares, and severe anxiety that can interfere with daily life), and Major Depressive Disorder (persistent feeling of sadness and loss of interest that can interfere with daily life). Review of Resident #24's Quarterly MDS assessment dated [DATE] reflected that she had a BIMS Score of 15, indicating cognition is intact. The MDS reflected that Resident #24 did not exhibit any behavior indicating rejection of care. The MDS reflected that Resident #24 had an active diagnosis for PTSD. Review of Resident #24's Comprehensive Care plan reflected the following focus areas with revised dates: 01/06/2022 [Resident #24] has a diagnosis of major depressive disorder with psychotic features. [Resident #24] will make negative statements about various activities or events believing the worst will come of whatever is going on. She has antidepressan medication ordered, Goal [Resident #24] will remain free of avoidable s/sx of distress, symptoms of depression, anxiety or sad mood by/through review date. Revision on: 2/12/2024. 01/06/2022 [Resident #24 has a diagnosis and history of severe mental illness (SMI) as manifested by: delusions-unrealistic, Hallucinations-visual, Goal [Resident #24] will take medications as prescribed times per week through next review date, Revision on 02/12/2024. Further review of the plan of care reflected no mention of PTSD and no identified triggers or interventions in reference to her active diagnosis. Review of Resident #24's Social Service Quarterly Assessment, Effective Date: 05/15/2024, reflected, A. Quarterly Assessment 7. Provide a brief overview of resident?s current status and address related psychiatric diagnosis, especially those problem areas Social Services is currently working on. Resident has diagnosis of psychotic disorder, major depressive disorder, post traumatic stress disorder. Resident has services with [Psychiatric Service] on 4/23/24 and [Counseling Service] on 4/24/24. Review of Resident #24's Clinical Treatment Plan Review (Plan of Care) date 05/17/2023 revealed, Psychiatric History: Patient reports a prior history of counseling for childhood trauma (sexual abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 5 of 12 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 07/11/2024 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few by a family member) and physical and emotional abuse from [a family member]. She did not report any history of psychiatric hospitalization. She is currently being treated by a psychiatrist. Interview on 07/10/2024 at 3:58 PM, Resident #24 was questioned if she knew she had an active diagnosis for PTSD and she stated she did not, but that it would make sense. Resident #24 stated that she could not think of anything that would cause her to think of bad memories from her past. Resident #24 stated that she could not remember ever speaking with anyone about triggers that may upset her. Interview on 07/11/2024 at 10:55, the MDS Nurse stated care plans provide staff, the resident, and their family an overview of the resident's needs to ensure proper care, safety, and functional ability. The MDS Nurse stated that a resident with a diagnosis of PTSD should have it care planned and the plan should identify triggers. The MDS Nurse stated failure to properly care plan a resident for PTSD and triggers could result in a resident being re-traumatized. The MDS Nurse stated she is responsible for including PTSD with triggers in resident's care plan and that she works with the SW for planning. The MDS Nurse reviewed Resident #24's electronic health records / care plan and stated she was not care planned for PTSD and should be. Interview on 07/11/2024 at 11:11 AM, the DON stated care plans notify staff of care that should be provided for their residents to meet their needs with the goal of resolving issues. The DON stated failure to utilize a resident's care plan could lead to improper or lack of care. The DON stated a resident with a diagnosis of PTSD should have it care planned with triggers and be receiving psychological services. The DON reviewed their electronic health records for Resident #24 stating that she did have an active diagnosis for PTSD and that they had failed to care plan for it. The DON stated the failure could result in staff not being alert to behaviors that should be monitored for Resident #24. Interview on 07/11/2024 at 11:33 AM, the SW stated she was unsure of their specific trauma informed care policy but was sure that the company had one. The SW stated that care plan meetings are set up by her and include input from staff. The SW stated residents with a diagnosis of PTSD should have it care planned in order to address their needs and behaviors to prevent re-traumatization. The SW stated Resident #24 should have been care planned for PTSD with triggers. Interview on 07/11/2024 at 12:20 PM, the Administrator stated care plans are individualized and specific to the resident's needs and must be accurate. The Administrator stated care plans are accomplished with input from the interdisciplinary team and the DON signs off on them. The Administrator stated Resident #24's care plan should have included PTSD with triggers to help manage behaviors that may arise during her care. Review of the facility's Trauma-Informed Care Policy dated 10/2022 revealed, I. Purpose: The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care by professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that my cause re-traumatization of the resident. IV. Assessment Facilities should use a multi-pronged approach to identifying a resident's history of trauma as well as his or her cultural preference. This would include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI) admission Assessment, the history and physical, the social history/assessment, and others. Triggers Facilities must identify triggers that may re-traumatize residents with a history of trauma. A trigger is a psychological stimulus that prompts a recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 6 of 12 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 07/11/2024 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 0699 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete For many trauma survivors, the transition to living in an institutional setting (and the associated loss of independence) can trigger profound re-traumatization. While most triggers are highly individualized, some common triggers may include: Experiencing a lack of privacy or confinement in a crowded or small space; Exposure to loud noises, or bright/flashing lights' Certain sights, such as objects that are associated with those that used to abuse, and/or Sounds, smells, and even physical touch. Care Planning to Address Past Trauma: The facility should collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, and any other health care professionals (such as psychologists, mental health professionals) to develop and implement individualized interventions. In some cases, if a facility has more than one trauma survivor, social services might consider establishing a support group that is run by a qualified professional, or allowing a support group to meet in the facility. In situations where a trauma survivor is reluctant to share his or her history, facilities are still responsible to try to identify triggers that may re-traumatize the resident and develop care plan interventions that minimize or eliminate the effect of the trigger on the resident. Trigger-specific interventions should identify ways to decrease the resident's exposure to triggers that re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. Event ID: Facility ID: 676227 If continuation sheet Page 7 of 12 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 07/11/2024 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for sanitation. The facility failed to discard of refrigerated food products that were past their facility indicated or manufacture suggested use by date. The facility failed to remove dented cans from their dry storage area. The facility failed to clean their industrial can opener. These failures could place residents at risk of cross contamination, loss of nutritional value, and foodborne illness. Findings included: Observation on 07/09/2024 at 9:04 AM, of the facility's double door refrigerator (1) revealed the following food products that were past their use by date: 1 plastic zip bag contained croissants dated 6/26/24 with a displayed use by date of 7/3/24. 1 cardboard box containing 30 individual serving size strawberry yogurts dated 05/23/24 with a manufacture use by date of 06/21/2024. Observation on 07/09/2024 at 9:11 AM, of the facility's double door refrigerator (2) revealed the following food products that were past their use by date: 1 plastic container with hot dog [NAME] dated 7/4/2024 with a use by date of 7/7/2024. 1 plastic container with 3 hard-boiled eggs dated 7/3/2024 with a use by date of 7/4/2024. 1 plastic container with black olives dated 6/26/2024 with a use by date of 7/2/2024. Observation on 07/09/2024 at 9:20 AM, of the facility dry storage area for canned food products revealed the following dented cans: 2 cans of 6 lbs 6 oz enchilada red salsa dated 2/16/2024 with dents on the top and bottom of each. 1 can of 50 oz cream of chicken dated 4/25/2024 dented on the bottom. 1 can of 106 oz spaghetti sauce dated 6/20/2024 dented at the top. Observation on 07/09/2024 at 9:25 AM, of the facility's industrial can opener revealed a stick y black substance and debris under and around the blade. Interview and observation on 07/09/2024 at 9:38 AM, the DS stated all foods were to have the date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 8 of 12 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 07/11/2024 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 - Some placed in the refrigerator recorded on them as well as the use by date, which was not to be more than 7 days depending on the food item. The DS stated all food products past their facility recorded use by date or the manufacture's use by date should be discarded immediately. The DS stated he is responsible for ensuring no expired food products are present in the refrigerator but stated that all kitchen staff should be checking dates as well. The DS stated he wanted to ensure residents are served good quality food and that service of expired food products could result in a resident becoming sick and possible food poisoning. The DS stated dented cans should be refused at delivery if observed and if observed after delivery should be placed in his office to ensure they are not served to residents. The DS stated dents in cans could result in bacteria growth. Observation of the wall above the can storage rack revealed a posting that read, Return all DENTED and UNLABELED Can Goods to the dietary managers office. Never store or place dented can goods on the shelves. The DS stated their industrial can opener should be cleaned at minimum daily, but he would prefer the kitchen staff clean it after every use to prevent cross contamination. The DS was shown the blade area of their industrial can opener and stated it had not been cleaned daily and that they had a new one that was going to be installed. The DS was shown the dented cans on his service shelves and stated that they should not be present due to the visible dents. The DS was shown the food products in both refrigerators that were past their or the manufactures use by dates and stated they should not be present and should have been discarded. Interview on 07/11/2024 at 9:05 AM, [NAME] B stated that any food products that were cooked and then refrigerated needed to have the date it was placed in the refrigerator and a use by date for three days later. [NAME] B stated all kitchen staff are responsible for checking dates on items in the refrigerators and that any found past their use by date needed to be discarded immediately. [NAME] B stated that failure to discard of food past date could result in a resident getting sick. [NAME] B stated no dented cans are to be placed on the shelf or served to residents because they could be contaminated. [NAME] B stated the industrial can opener should be cleaned daily and that failure to do so could result in food being contaminated. Interview on 07/11/2024 at 9:11 AM, DA C stated food products placed in the refrigerators should have a date placed on them and a use by date of three days later as well. DA C stated all kitchen staff are responsible for ensuring that expired food products are discarded and failure to do so could result in a resident getting sick. DA C stated no dented cans were to be on the shelf or ever served to a resident because there could be something wrong with the product inside the can. DA C stated the industrial can opener was to be cleaned every couple days and that this should be done to prevent contamination. Review of the Facility's In Service Training Topic: labeling and dating. Everything lable and dated before put in Refrigerator conducted on 5/3/2024 by the DS and attended by staff, which included [NAME] B and DA C. Review of the Facility's Dietary Services Policy & Procedure Manual dated 2012 revealed, Food Storage and Supplies, Procedure: 6. When items are received from the vendor, they should be first examined for expiration date, and if an expiration date is present, it is beneficial to mark it by circling it so it is readily visible and noticeable. It is important to distinguish between an expiration date and a production date, or a best by or use by date. Production dates indicate when the product was manufactured, not when it expires, and should not be interpreted as a best by or use by date. Best by or use by dates indicate when a product will have best flavor or quality and are not an indicator of the product's safety. As the quality may deteriorate after the date passes, the dietary manager should closely inspect any products that are past the best by date to determine if they are still (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 9 of 12 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 07/11/2024 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 - Some good quality. If in doubt, discard the product. If any stamped date is unclear, contact the food vendor for clarification. If an item does not have a date designated by the manufacturer as an expiration date, then the items should be dated as to when it is received, and shelf-stable items will be stored in a first in, first out manner, to be used within one year. After one year, any product that is shelf stable will be inspected by the dietary manager to ensure that it is good quality before it is used. Any product with a stamped expiration date will be discarded once that date passes. Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that CNA be readily and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 10 of 12 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 07/11/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #8) of 1 resident. Residents Affected - Few The facility failed to ensure CNA A followed standard precautions during peri care for Resident #8 when he failed to perform hand hygiene and change gloves after cleaning feces. These failures could place residents at risk for developing infections. Findings included: Review of Resident #8's Face Sheet reflected a [AGE] year-old male admitted on [DATE] with readmission on [DATE]. Diagnoses included urinary tract infection (infection in any part of the urinary system), acute kidney failure (kidneys suddenly stop working properly), morbid obesity (complex chronic disease in which a person has a body mass index (BMI) of 40 or higher) and dementia (loss of cognitive functioning thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life). Review of Resident #8's MDS assessment, dated 05/29/2024, reflected a BIMS score of 03 indicating severe cognitive impairment. MDS further reflected the resident required substantial assistance with functional abilities. Review of Resident #8's Care Plan, dated 04/02/2024, reflected the resident had bowel and bladder incontinence, a behavior problem smearing feces on the wall, a foley catheter and history of urinary tract infections. Interventions include providing peri care after incontinent episodes. Observation on 07/10/2024 at 10:08 AM, CNA A providing peri care for Resident # 8 after a bowel movement. CNA A cleaned the resident with wipes and then proceeded to touch/reposition the foley catheter tubing, apply a new brief and reposition the resident without washing his hands or changing gloves. At no time after cleaning the feces did CNA A remove the dirty gloves, perform hand hygiene and apply new gloves before touching the resident, the catheter and the linens. In an interview on 07/11/2024 at 10:29 AM, CNA A stated he felt unprepared during peri care for Resident # 8 the previous day. He stated there are normally gloves in the room and he should have changed his gloves after cleaning the feces, but he did not see any, so he did not change them. In an interview on 07/11/2024 at 12:14 PM, the DON stated the staff are trained monthly on infection control practices including hand hygiene and she would expect staff to follow the policy when providing care. In an interview on 07/11/24 at 01:45 PM, the Administrator stated staff are in-serviced regularly on infection control practices and she would expect staff to be aware of and follow policy. Review of the facility's Fundamentals of Infection Control Precautions training and policy, dated March 2024, reflected staff were trained on hand hygiene practices to include cleaning hands when moving from a contaminated body site to a clean-body site. The policy reflected that consistent use by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 11 of 12 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 07/11/2024 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 0880 staff of proper hand hygiene practices and techniques is critical to preventing the spread of infections. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 12 of 12