Inspection·August 28, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an interview on 08/28/2025 at 9:30 AM, the RNC stated Resident #6's care plan should include time of use for the CPAP, CPAP settings, and resident preferences of putting the CPAP on and off himself to ensure he was receiving the proper care that reflected his preferences. In an interview on 08/28/2025 at 9:48 AM, the MDS Coordinator stated Resident #6's care plan should include his CPAP settings, and his preferences. She further stated it should include when the CPAP should be put on and removed. She stated failure to ensure accurate information on the care plan could cause the resident not to receive the appropriate care. B) Resident of Resident #12's face sheet, dated 08/27/2025, reflected he was admitted on [DATE] with diagnoses including Intracranial Injury with Loss of Consciousness Status (injury to the brain caused by external force). Record review of Resident #12's admission MDS, dated [DATE], had BIMS score of 14 indicating cognitively intact. Resident #12 was assessed to require extensive assistance with toileting. Resident #12 was not assessed for special treatment such as placement of condom catheter. Record review of Resident #12's physician orders dated 08/28/2025 reflected an order date of 7/10/2025, for Place condom cath. on patient at bedtime every night shift for urinary incontinence at night resident req to have cath. placed before he goes to sleep. Review of Resident #12's comprehensive care plan, dated 06/06/2025, did not reflect a focus, intervention, or goal for placement of condom catheter at night before bed. Review of Resident #12's TAR, dated 08/01/2025- 08/31/2025 reflected, Place condom Cath on patient at bedtime every night shift for urinary incontinence at night resident req to have Cath placed before he goes to sleep. Observation and interview on 08/27/2025 at 11:31AM, revealed Resident #12 was in his room listening to music. Resident #12 stated he wanted to talk to his physician regarding not being able to void his urine completely and sometimes his bowels. He stated when urinating, he felt like his bladder or bowel was not emptying completely. He stated he did not feel any pain but would like to have his doctor order an ultrasound to see if there was a blockage. He sated he did were a catheter at night to help with his frequent urination. In an interview on 08/28/2025 at 09:30AM, the DON stated, after reviewing Resident #12's comprehensive care plan, he was not monitored for condom catheter placement at night. She stated when there was a new order for example.condom catheter at night, she would do a baseline acute care plan, and the MDS would complete a general care plan. She stated placement of a condom catheter would be a general care plan. She stated when a new order is given by the doctor, she would place the order on the TAR and inform their central supplier / medical records, so any equipment was ordered and available for treatment. She stated the condom catheter treatment was documented on his TAR, and his nurses knew to place condom catheter on at bedtime. She stated she did not know why the condom catheter was not documented on the care plan but because it was a general care plan, the MDS Coordinator should have placed it on his care plan. She stated because Resident #12 was admitted in June 2025, his quarterly review was not due yet. She stated she was responsible for all acute care plans, and during a quarterly review the MDS and DON would both be responsible for ensuring a general care plan was updated . She stated if a service was not captured on the care plan during the admission or if there was a change to a Resident's treatment, the MDS or DON would be responsible for ensuring the condom catheter treatment was placed on the care plan before his quarterly review. She stated if a service does not care planned a negative impact to Resident #12 would be not getting his condom catheter placed on at night or his nurse not monitoring any negative side effects. In an interview on 08/28/2025 at 9:50 AM, the MDS Coordinator stated she could not say why Resident #12's condom catheter treatment at nighttime did not document in his care planned. The MDS Coordinator stated she started working at the facility July 21st , and Resident #12 order for condom catheter started 07/10/2025. She stated she believed their regional nurse filled in when the previous MDS coordinator left. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 2 of 5 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 08/28/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete She stated if there was clear communication with the previous MDS Coordinator, DON and regional nurse, she thought his condom catheter treatment would be on his care plan. She stated if the placement of the condom catheter was not on his care plan to monitor a negative impact could be UTI, skin breakdown, not having his bladder emptied, and kidney infection. In an interview on 08/ 28/2025 at 10:20 AM with RNC she stated the DON or ADON was responsible for care plans. She stated Resident # 12's condom catheter should have been on his care plan. She stated their MDS coordinator was responsible for the quarterly care plans. She stated their MDS started working after Resident #12 admission ; however, during that time they had an interim DON for a brief time, and she was responsible for and changes to a care plan. The RNC stated she assisted with care plans during the time they did not have a DON, and she would have been responsible for ensuring Resident #12 care plan was updated .She stated a negative impact for Resident # 12 condom catheter not being on his care planned would be staff not knowing it was in place and being pulled out. Review of the facility's comprehensive care planning policy, undated, reflected, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights 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.Through the care planning process, facility staff will work with the resident and his/her representative, if applicable, to understand and meet the resident's preferences, choices and goals during their stay at the facility. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. Care plans will be person-centered and reflect the resident's goals for admission and desired outcomes. Person-centered care means the facility focuses on the resident as the center of control and supports each resident in making his or her own choices.The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Event ID: Facility ID: 676227 If continuation sheet Page 3 of 5 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 08/28/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled: Residents Affected - Few Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 1 resident (Resident #5) reviewed for enteral nutrition. The facility failed to ensure LVN B raised the head of Resident #5's bed to at least 30 degrees or greater while administering medications and tube feeding solution via gastrostomy tube (g-tube - a tube inserted into the stomach) on 8/27/2025. The facility failed to ensure LVN B flushed Resident #5's g-tube between medications during medication pass on 8/27/2025. This failure could place residents at risk increased risk for aspiration and gastrostomy tube malfunction. Findings included: Review of Resident #5's face sheet, dated 08/28/2025, reflected a [AGE] year-old female, admitted on [DATE] and readmitted on [DATE], diagnoses included dementia (A group of symptoms that affects memory, thinking and interferes with daily life), essential hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body), and congestive heart failure (long-term condition in which your heart can't pump blood well enough to meet your body's needs). Review of Resident #5's admission MDS assessment, dated 05/28/2025, reflected she was assessed to have a 99 BIMS score indicating serve cognitive impairment. Resident #5 was assessed to require substantial/ maximal assistance with ADLs. Resident #5 was further assessed to have a feeding tube and to receive 51% of total calories through the tube feeding. Review of Resident #5's comprehensive care plan reflected a focus area, dated 05/19/2025, The resident requires tube feeding. Interventions included, The resident needs the HOB elevated 30 degrees during and thirty minutes after tube feed.Resident is dependent with tube feeding and water flushes. Review of Resident #5's consolidated physician orders reflected the following orders, Enteral feed order every shift flush tube with 30 ml waster before and after medication dated 05/16/2025, Enteral feed order every shift flush with at least 10 ml of water between each medication dated 05/16/2025, and an order dated 05/16/2025 enteral feed order every shift head of bed up at least 30 degrees during administration of enteral formula or written water. Observation on 08/27/2025 at 7:08 AM, revealed LVN B administered 7 medications via gastrostomy tube to Resident #5. Resident #5 had the head of the bed at less than 20 degrees elevation from the bed frame during the entire medication administration. LVN B failed to flush the gastrostomy tube with water between three of the seven medications, resulting in two failures to flush the gastrostomy tube during the observation. In an interview on 08/27/2025 at 7:43 AM, LVN B stated the head of Resident #5's bed should be greater than 30 degrees during medication administration and while the tube feeding was running. LVN B then raised the head of Resident #5's bed to greater than 30 degrees in elevation from the bed frame. She stated the head of the bed was not greater than 30 degrees while the tube feeding was running when she walked in the room and during the medication administration. She stated that risk to the resident of not having the head of the bed greater than 30 degrees while instilling medication or tube feeding solution was possible aspiration. She stated it was possible she did not flush between three of the medications. She stated she should have flushed between all medications. She stated that potential risk to the resident was that their g-tube could get clogged. In an interview on 08/27/2025 at 7:45AM the DON she stated that the head of the bed for Resident#5 should be greater than 30 degrees while the tube feedings are on and while giving medications via the g-tube. DON observed Resident #5's bed positioning in the room. She stated, I wouldn't put her lower than that. In an interview on 08/28/2025 at 2:04 PM the DON stated that it was her expectation that staff should ensure that the head (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 4 of 5 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 08/28/2025 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete of the bed was at 30 degrees or greater while tube feeding solutions are running and while administering medications via g-tube. She stated that she expected staff to follow the policy regarding g-tube medication administration. She stated that nurses should be flushing the g-tube with water between each medication. She stated that not having the head of the bed at 30 degrees or greater during tube feeding and medication administration with a g-tube puts residents at risk of aspiration and pneumonia. She stated that not flushing with water between medication administration via g-tube could lead to the tube becoming clogged which would cutting off the resident's access to medications and nutrition temporarily. In an interview on 08/28/2025 at 2:17 PM, the RNC stated that she expected staff to follow the policy regarding the head of the bed for residents during g-tube medication administration and tube feedings. She stated the head of the bed should be greater than 30 degrees while the tube feeding was on and while medications were being given. She stated that residents could possibly aspirate if they are lower than 30 degrees. She stated that she expected nurses to flush with water between all medications administered through a g-tube. She stated that if nurses are not flushing between medications the tube could become clogged, and residents could potentially not receive all their medication. In an interview on 08/28/2025 at 10:52AM the ADMIN stated that she had previous experience working as a CNA and that she knew it was important to elevate the head of the bed to 30 degrees or more for a resident that was receiving tube feedings and while they were getting medications through the g-tube. She stated that she expected staff to follow the policy and guidelines regarding medication administration and tube feedings for residents with g-tubes. She stated that the risk to the residents of not raising the head of the bed adequately was possible aspiration. She stated that she expected nurses to follow the policy regarding flushing between medications with g-tubes. She stated that she would defer to her clinical staff regarding the potential risks to the residents of not flushing between medications. Review of the facility's Enteral Tube Medication Administration policy, dated only as 2025, reflected, The facility assures the safe and effective administration of enteral formulas and medications. Selection of enteral formulas, routes and methods of administration, and the decision to administer medications via enteral tubes are based on nursing assessment of the resident condition, in consultation with the physician, dietitian, and Consultant Pharmacist.4. If the resident is in bed, elevate the head of bed to 30-45-degree angle. Empty capsule contents into 10 to 15 ml of water or other appropriate liquid. Administer each medication separately, flushing tube with 5-15 ml of water after each dose. Medications are never added directly to the feeding solution. Flush the tube with 30 ml of water.Allow medication to flow down tube via gravity. Event ID: Facility ID: 676227 If continuation sheet Page 5 of 5