Inspection·November 19, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and hospice being notified of order for IV fluids or attempts made to start IV fluids. There was no documentation regarding change of condition for Resident #1 from 09/23/2025 through 09/29/2025. Review of Resident #1's progress notes dated 09/29/2025 at 09:52 am written by the DON reflected: Late Entry: Residents [family] called to discuss concerns with IV. Educated family on new IV program, assured family member resident was not dehydrated, and was only triggering for possible dehydration d/t decreased oral intake. Family member appreciative of information, assured family that resident is happy and well taken care of here. During an interview on 10/20/2025 at 10:18 am, Resident #1's family stated she and hospice were not made aware of new order for IV fluids to be started on Resident #1. Resident #1's Family stated she found out about the IV fluid order when she went to visit Resident #1 and saw the bruise on her left arm. Resident #1's Family stated she called to find out and Hospice was not notified too. Resident #'s Family stated it was the DON that got the order for the IV fluids and the DON contacted her later after she raised concerns. Resident #1's Family stated IV fluid therapy was too severe for the facility not to contact the family or hospice before initiating the treatment. Resident #1's Family stated the facility was supposed to get permission from hospice for any medication changes, any type of change if Resident #1 was that ill before attempting the care. During an interview on 10/20/2025 at 1:14 pm, the ADON stated When a resident is on hospice, the hospice followed the Resident and the facility get orders from hospice, and the MD is notified to approve the order. The ADON stated the MD had recommended IV fluids for Resident #1 and she worked with Resident #1 on the day of the recommendation. The ADON stated the DON got the orders from the MD for Resident #1's IV fluids, and she [ADON] did not notify Resident #1's family. The ADON stated she attempted to start the IV on Resident #1 twice but was unsuccessful. The ADON stated she tried Resident #1's left full arm and was unsuccessful, the vein blown and then she tried Resident #1's left upper arm area. The ADON stated she could not recall documenting the attempts to start the IV on Resident #1. The ADON stated, my apologies, should have been documented. During an interview on 10/20/2025 at 2:25 pm the DON stated the MD gave the order to start IV fluids on Resident #1 because there were clinical alert triggers. The DON stated she looked at clinical alerts such as eating 50%, diarrhea, s/s of Urinary Tract Infection (an infection of the urinary tract, which includes the kidneys, ureters, bladder, and urethra.) and notified the MD. The DON stated Resident #1 was on hospice care, it was an oversight, she should have notified the hospice and the family before attempting the to start the IV. The DON stated Resident #1 never received the IV fluids because staff were unsuccessful in starting the IV after 2 attempts. The DON stated by the time she realized the IV fluid therapy was unsuccessful, Resident #1's family was in the facility the next day and refused the IV fluids therapy. The DON stated the incident happened on a Friday and she spoke with Resident #1's family on a Monday (09/29/2025). The DON stated she did not document receiving an order for IV fluids for Resident #1. Review of facility's policy revised March 11, 2023, titled Notifying the Physician of Change in Status reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Workday notification of the physician.The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record.5. The resident' s family member or legal guardian should be notified of significant change in resident' s status (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676227 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/19/2025 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete unless the resident has specified otherwise.6. The nurse will monitor and reassess the resident's status and response to interventions. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve.7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician' s response, the physician' s orders and the resident' s status and response to interventions. Review of facility's policy titled Resident Rights revised 11/28/2016 reflected: 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 residents.Exercise of Rights-- The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the resident representative.The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the courtor delegated by the resident, in accordance with applicable law.Planning and implementing care - The resident has the right to be informed of, and participate in, his or her treatment, including:I. The right to be fully informed in language that he or she can understand of his or her total health status, including but notlimited to, his or her medical condition.3. The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in thisright. The planning process must-a. Facilitate the inclusion of the resident and/or resident representative.b. Include an assessment of the residents' strengths and needs.c. Incorporate the president's personal and cultural preferences in developing goals of care. 4. The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.5. The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.6. The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Event ID: Facility ID: 676227 If continuation sheet Page 3 of 3