Inspection·January 18, 2025

F 0742 Interventions: Level of Harm - Immediate jeopardy to resident health or safety Date initiated 09/15/24 identify situation/events/images that trigger recollection of traumatic event and limit the resident's exposure to these as much as possible. Date 10/04/24 arrange to licensed mental health provider as ordered by physician Residents Affected - Few Review of Resident #1's BIMS assessment dated [DATE] reflected a BIMS score of 9, moderate cognitive impairment. Review of Resident #1's Discharge MDS dated [DATE] reflected discharge assessment, return not anticipated, type of discharge - planned, discharge status short term general hospital (acute hospital), MDS score of 7 indicating severe cognitive impairment, evidence of an acute change in mental status of resident's baseline, disorganized thinking or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject), behavior - delusions, utilized a manual wheelchair, urinary and bowel incontinence - always incontinent. Chronological Review of Resident #1's EMR revealed: Review of standard medication order signed by the MD dated 08/16/24 reflected medication Escitalopram by mouth 1 tablet one time a day for depression related to depression, unspecified. Review of Treatment Administration Order signed by the MD dated 08/16/24 reflected behavior monitoring including hallucinations/paranoid delusion. 09/30/24 12:22 pm called RP to discuss resident concern; no answer and no voicemail activated; will try again this date. 09/20/24 4:43 pm called RP to discuss resident concern; no response; sent email to RP requesting communication. Review of Resident #1 standing order dated 09/30/24 signed by the facility medical director for psychological services to evaluate and treat one time only related to dementia in other diseases, mild with mood disturbance for 1 day. 10/01/24 9:19 am This nurse called RP for verbal consent to have [psychological services] see resident for incident on 9-30-24. no answer received. will inform DON 10/01/24 1:11 pm 2nd attempt made to contact RP, no answer and unable to leave a voice mail, Will inform social worker 10/03/24 10:17 am Behavior Note: This PTA had Resident in therapy gym for her daily therapy session along with COTA. During session resident kept bringing up that the front of our build [sic] is covered with crate [NAME] trees and she is highly allergic to and cannot go near. She then stated that she needs to jump out the therapy gym window when she goes home so she doesn't go near these trees. We discussed with resident that that is not safe, and we cannot be jumping out of windows. Resident kept focusing on this fact that she needs to jump out the window when she leaves and started laughing about it thinking that it is a funny situation. We tried to redirect resident to pay attention to her treatment and to not talk about the window any more to focus on getting better and stronger in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 2 of 9 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 01/18/2025 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 0742 therapy. Resident continued talking about jumping out window and laughing throughout the entire session. Level of Harm - Immediate jeopardy to resident health or safety 10/03/24 10:40 am SS called and residents [name] to inform of care conference meeting on October 9th at 10:30 am. [RP] voice message was not accepting message. SS sent an email with care conference invite. Residents Affected - Few 10/04/24 6:23 am Behavior Note during nurse to nurse previous shift informed this nurse that resident had requested her fork in rm. CNA gave resident her fork where resident proceeded to inform her that she was using fork for her protection. This nurse approached resident and requested that she return the fork. Resident informed this nurse that the fork was the only thing she had for protection in case that nurse comes in her room. Resident assured that the nurse was not in the building and that this nurse would ensure that she would be safe today. Resident reluctantly gave fork to nurse. CNA was informed to be aware of resident's behavior. DON to be informed. 10/04/24 8:24 am Behavior Note Resident continues perseveration re: the [NAME], stating that the person was taken away by the FBI to a criminally insane asylum and the head nurse there let her out. As per Medical Director, will refer to [BHH] 10/07/24 Nursing Progress Note resident left facility at 11:52 am with facility transport. Resident continues with delusions of a [NAME] and feeling unsafe. Interview on 01/03/25 with LVN at 12:13 pm revealed Resident #1 was having hallucinations and was paranoid. Because of these mental health issues she should have been seen by the facility psychological services and the social worker or the DON should have arranged this . Interview on 01/07/24 with the DON at 1:32 pm revealed that when a resident was having mental health issues, they were referred to [the name of the facility psychological service group the facility employees] for services to be evaluated by a mental health professional. Interview on 01/17/25 with the ADON of the psychological service group the facility employees to treat residents at 4:06 pm revealed the group had no referral from the facility for mental health services for Resident #1. Interview on 01/17/25 with the facility DON at 5:56 pm revealed she was not employed at the facility when Resident #1 was a resident, and she does not know why the facility did not reach out to the psychological services as ordered by the facility MD. She revealed that delayed assistance for ordered mental health services could be life or death. A review of the 10/04/24 at 6:23 behavior note during nurse to nurse previous shift informed this nurse that resident had requested her fork in rm. CNA gave resident her fork where resident proceeded to inform her that she was using fork for her protection. This nurse approached resident and requested that she return the fork. Resident informed this nurse that the fork was the only thing she had for protection in case that nurse comes in her room sounded like Resident #1 really needed some help. Review of facility Behavior Management Policy dated 04/19/05 reflected behavior management includes the management of anger, confusion, hallucinations, and other behavior by utilizing techniques such as area limitations, self-responsibility, group interactions, limit setting, and behavior modifications depending on individual needs. Behavior changes can be attributed to dementia disorders or psychological conflicts resulting from a loss of control over body, environment, and unmet needs such as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 3 of 9 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 01/18/2025 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 0742 pain, hunger, thirst, and toileting. They may include combativeness, arguing, agitation, and aggressiveness. Level of Harm - Immediate jeopardy to resident health or safety Goals: Residents Affected - Few 2. The resident will facilitate behavior changes with expression of anger and negative behaviors/responses managed in a constructive fashion. 1. The resident will modify behavior for optimal functioning and well-being. 3. The resident will comply with behavior modification program with behavioral expectations achieved. 4. The resident will experience a decrease in anxiety as evidenced by a calmer and less combative attitude. Dementia and Behavioral Health Policy - undated Monitoring: When monitoring antipsychotics, it is important to not only evaluate ongoing effectiveness and potential adverse consequences, as discussed below, but also to evaluate the use of any other psychopharmacological medications (e.g. mood stabilizers, benzodiazepines) being given to the resident. The ADM was notified on 01/17/25 at 1:18 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 01/18/25 at 10:52 am. Entrance Date: 1/16/2025 Problem: F742 On 01/17/2025 an abbreviated survey was initiated at the facility. On 01/17/2025 the surveyor provided an Immediate Threat (IJ) Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to resident health and safety. The notification of Immediate Threat states as follows: The facility failed to provide a response to Resident #1's dementia related mood disturbance behavior. Action: 5. Resident #1 currently does not reside in the facility as of 1/17/25. 6. The DON/ADON audited all psychology and psychiatry orders for active residents over the last 6 months. Two residents were identified, and both are actively receiving psychiatric services. This was completed on 1/17/25. The facility has 11 total residents on psych services and 2 of those were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 4 of 9 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 01/18/2025 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 0742 referred to psych services within the last 6 months. Level of Harm - Immediate jeopardy to resident health or safety 7. The Administrator and DON will be responsible for initiating all psychological and psychiatry referrals to the provider. This will start 1/17/25. Residents Affected - Few 8. The Administrator DON, and ADON were in serviced 1:1 by the Regional Compliance Nurse on the following topics below on 1/17/25. E. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. F. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. G. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. 9. The Medical Director was notified of the immediate jeopardy on 01/17/2025 by the Administrator. 10. An ADHOC QAPI meeting was completed with interdisciplinary team on 01/17/2025 which included the Medical Director, Administrator, Director of Nursing, and Assistant Director of Nursing to discuss the citations and plan of removal. In-services The Administrator and DON initiated the following in-services for Licensed Nurses. Training began 01/17/2025 and will be completed 01/17/2025. Licensed Nurses not present and PRNs will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift. 11. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 5 of 9 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 01/18/2025 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 0742 12. Level of Harm - Immediate jeopardy to resident health or safety Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. Residents Affected - Few 13. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. The Administrator and DON initiated the following in-services for all staff. Training began 01/17/2025 and will be completed 01/17/2025. All staff not present, and PRNs will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift. A. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. Surveyor Monitoring: The administrator and/or DON will review all orders daily x 5 days a week for any orders in reference to psychological and psychiatry services to ensure that all referrals have been initiated. This will begin 1/17/25 and end on 2/14/25. Interview with the DON confirmed that a facility audit was conducted of all psychology and psychiatry orders for active residents over the last 6 months. Reviewed the orders for the two residents who were identified and confirmed they both are actively receiving psychiatric services by reviewing most recent psychiatric records. Interview with the Administrator and DON confirmed they will be responsible for initiating all psychological and psychiatry referrals to the facility contracted provider. Interview with the ADM and DON (ADON unable to interview the ADON because of family medical emergency) that they were in serviced by the Regional Compliance Nurse on the following topics below on: Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. Reviewed documentation that the Medical Director was notified of the immediate jeopardy on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 6 of 9 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 01/18/2025 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 0742 Level of Harm - Immediate jeopardy to resident health or safety 01/17/2025 by the Administrator and an ADHOC QAPI meeting was completed with interdisciplinary team on 01/17/2025 which included the Medical Director, Administrator, Director of Nursing, and Assistant Director of Nursing to discuss the citations and plan of removal. During interviews on 01/18/25 from 12:07 pm - 2:29 pm six nurses all from various shifts all stated they were in-serviced prior to their assigned shift on: Residents Affected - Few . 1. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. 2. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP. 3. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. During interviews on 01/18/25 from 12:07 pm - 2:29 pm six CNAs, two medication aides, and 1 dietary across various shifts all stated they were in-serviced prior to their assigned shift on: A. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect. The ADM was notified on 01/18/2025 at 2:54 PM, that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 7 of 9 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 01/18/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and records review, the facility failed to ensure that medical records were accurately documented for one (Resident #2) of five residents reviewed for accurate clinical records The facility failed to ensure Resident #2's progress notes and assessments reflected he was slapped by another resident as reported in a facility self-report. This deficient practice could place residents at risk for errors in care and treatment. Findings included: Review of Resident #2's face sheet dated 01/03/25 reflected a [AGE] year-old male who was originally admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, type 2 diabetes, and major depressive disorder. Review of Resident #2's BIMS assessment dated [DATE] reflected a BIMS score of 14, reflecting intact cognition. Review of Resident #2's quarterly MDS dated [DATE] reflected an active diagnosis of non-traumatic brain dysfunction (a complex condition that occurs when the brain is damaged by internal factors, rather than an external force to the head). Review of Resident #2's care plan focus, dated 01/14/20 and revised 12/17/21 revealed impaired cognition function/dementia and impaired thought processes. No entry was made in Resident #2's care plan discussing being slapped by another resident on 07/24/24. Facility self-report dated 07/24/24 reflected on 07/24/24 Resident #2 reported to the DON that another resident slapped him, open handed in his mouth. Review of Resident #2's weekly skin assessments reflect no assessments for the date of 07/24/24. Resident #2's nursing progress notes reflect no entries dated 07/24/24. Interview on 01/03/25 with the area director of operations at 12:48 pm reflected she was not aware the incident had occurred and when she investigated it on 01/03/25, approximately 6 months after the facility self-report, she learned from staff that Resident #2 was not slapped by another resident. A resident attempted to slap him but missed. The area director of operations she spoke to Resident #2 on 01/03/25 and he did not remember being hit. Review of facility policy, documentation, date 05/2015 reflected documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes observations, investigations, and communications of the resident involving care and treatments. It has legal requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 8 of 9 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 01/18/2025 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 0842 (PCC). Level of Harm - Minimal harm or potential for actual harm Goal 1. Residents Affected - Some The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets. 2. The facility will ensure that information is comprehensive and timely and properly signed. Procedure Document completed assessments in a timely manner and per policy. Complete documentation in narrative nursing notes as needed in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title. If PCC is used for the assessment the signature and title of the person entering the information will be signed by entering their password Daily documentation X 72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 9 of 9