Copperas Cove Nursing & Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable, and a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 5 Residents (Resident #1) reviewed for quality of care. The facility failed to complete wound care treatment for Resident #1 on 01/03/2026, 01/30/2026, 02/05/2026, 02/07/2026, 02/08/2026. This failure could place residents at risk of rapid wound deterioration.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for complete and accurate records. The facility failed to ensure Resident #1's wound care cleaning was documented completed in PCC for 01/10/2026, 01/25/2026, 02/14/2026, 02/17/2026, 02/19/2026, 02/21/2026, 02/23/2026, 02/26/2026, 03/06/2026, 03/07/2026, 03/10/2026, 03/11/2026, 03/13/2026, 03/16/2026, 03/17/2026, 03/22/2026, 03/23/2026, and 03/30/2026. This failure could place residents of staff not knowing whether treatment and services were provided for.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 8 residents (Residents #1, #2, & #3) reviewed for resident rights. The facility failed to ensure Residents #1, #2, & #3's call lights were within reach on 12/09/2025. This failure could place residents at risk of their needs not being metFindings include:Record review of Resident #1's admission record, dated 12/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 1 days reviewed (9/23/2025) for nurse staffing posting. The facility failed to post accurate daily staffing information on 9/23/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the need of each resident. On 2 of the 4 medication carts reviewed the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation at each shift change. This failure could place residents at risk of drug diversions and could result in diminished health and well-being. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biological were stored under proper temperature for 1of 1 Medication Rooms reviewed for medication storage. The facility failed to ensure the correct temperature for the storage of refrigerated medications for 4 days in Medication room [ROOM NUMBER]. The facility failed to check the medication storage temperature for 10 of 23 days for the month of September 2024. This failure could place residents receiving medication at risk for lack of drug efficacy.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure food safety by not consistently monitoring, discarding expired food, maintaining sanitary kitchen. These failures can place residents at risk for foodborne illness.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 (Resident #2) of 4 residents reviewed for resident rights. The facility failed to follow their policies and procedures and provide full-time translation or interpretation services to Resident #2, a [NAME] speaking resident. This failure could place residents at risk of miscommunication between the resident and staff, lead to misunderstandings about a resident's medical condition and treatment options, and improper care or inappropriate treatments or prescriptions.

Inspectors wroteBased on record review and interviews, the facility failed to respect a resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 (Resident #1) of 5 residents reviewed for resident rights. The facility failed to obtain a valid DNR for Resident #1 which resulted, on [DATE], in Resident #1 receiving CPR when she was found unresponsive. This failure could place residents at risk of their rights to refuse or discontinue treatment being disrespected, being resuscitated against their wishes or placed on life support.

Inspectors wroteBased on observation, record reviews, and interviews, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for one (Resident #1) of 7 (seven) residents reviewed for weight loss. The facility failed to follow its procedures and provide effective interventions to prevent weight loss in Resident #1, who had a 10.39% weight loss between 10/09/25 and 11/03/25. Resident #1 was not weighed when she was admitted to the facility on [DATE]. Resident #1 was not weighed weekly x 4 weeks after her admission to the facility. Nutritional supplements were recommended by the RD on 10/15/25. They were ordered 11/14/25. Resident #1 died on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure CNA A did not provide personal care for Resident #1 without another staff member (which he required) on 07/27/25. She yanked on his right arm when attempting to roll him to his side, and he heard a pop. He was in excruciating pain and was subsequently diagnosed with a shoulder sprain at the hospital. The noncompliance was identified as PNC. The IJ began on 07/27/25 and ended on 07/29/25. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk of pain, injury, and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's right to be free from abuse, neglect, misappropriation of resident property and exploitation for three of five residents (Resident #1, Resident #2, and Resident #3 ) reviewed for drug diversion. 1. The facility failed to ensure LVN A did not take 100 (one hundred) Torsemide 100 mg tablets prescribed for Resident #1.2. The facility failed to ensure LVN A did not take 100 (one hundred) Torsemide 100 mg tablets prescribed for Resident #2.3. The facility failed to ensure LVN A did not take 30 (thirty) Torsemide 100 mg tablets prescribed for Resident #3. These failures could place residents at risk of misappropriation, medication errors and compromised health conditions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen and food sanitation. 1. The facility failed to ensure food in the refrigerator was properly sealed from air-borne contamination. 2. The facility failed to ensure food stored in 1 of 1 reach in freezer and 2 of 2 reach in refrigerators were labeled and dated with use by date. These failures could place residents at risk for food contamination and foodborne illness. Findings Included: Observations on 02/12/25 at 09:32 AM in the facility's only kitchen revealed: 1 of 1, 3-door reach in refrigerator contained: - 1 large metal tray of cheesecake was not covered or sealed from air-borne contaminants or labeled with use by date. [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure that one (1) resident (Resident #1) of eight residents reviewed for transfer or discharge had the required documentation in the resident's medical record made by the physician and failed to provide information to the receiving health care provider for a safe and effective transition of care. The facility discharged Resident #1 on 9/18/2025 without physician documentation in the EMR and without providing any clinical information for continuity of care to the receiving provider. This failure could put residents at risk for inappropriate discharge from the facility and cause psychological harm.

Inspectors wroteBased on interviews and record review, the facility failed to provide the necessary care and service to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident # 1) of 6 (Resident's 2.3.4.5.amd 6) residents reviewed for following hospital discharge orders. The facility failed to follow hospital discharge orders for follow up with Urology secondary to a urethral stent (a thin tube placed between the kidney and bladder to help urine flow) placement on 4/26/2024. On 10/12/24 at 5:10 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/16/24, the facility remained out of compliance at a scope of Isolated and a severity level of potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 7 (room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7) of 20 resident rooms reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, #6, and #7 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #10, Resident #11, and Resident #52) of eight residents reviewed for Care Plans. The facility failed to ensure Residents #10, #11, and #52 were care planned for oxygen administration. This failure could place the residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for six (Resident #10, Resident #11, Resident #52, Resident #61, Resident #68, and Resident #222) of twelve residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #10, #11, #52, and #68's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) were properly stored. 2. The facility failed to ensure that Resident #61's CPAP (continuous positive airway pressure: machine use to deliver pressurized air through a mask to keep airways open) was stored properly. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure foods in the refrigerator were properly sealed from air-borne contaminations. 2. The facility failed to ensure a pitcher containing juice, located in the refrigerator, was cleaned. 3. The facility failed to ensure the ice scoop holder, located in the kitchen area, was cleaned. 4. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the use by date. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and 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 two (Resident #66 and Resident #68) of eight residents observed for Infection Control. 1. The facility failed to ensure that CNA A performed hand hygiene while providing incontinent care to Resident #66. 2. The facility failed to ensure that LVN F performed hand hygiene during Resident #66's wound care. 3. The facility failed to ensure that CNA C performed hand hygiene while providing incontinent care to Resident #68. These failures could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #41 and Resident #58) of 14 residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #41's room was in a position that was accessible to Resident #41. The facility failed to ensure the call light system in Resident #58's room was in a position that was accessible to Resident #58. This failure could place Resident #41 and Resident #58 at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the right to personal privacy during medical treatment and personal care for two (Resident #1 and Resident #10) of thirteen residents reviewed for privacy. 1. The facility failed to ensure LVN E would close Resident #1's door while administering the resident's bolus feeding (method of tube feeding that delivers large amount of formula over a short period of time). 2. The facility failed to ensure CNA B and CNA D would close Resident #10's door while transferring the resident. These failures could place the residents at risk of not having their right to personal privacy maintained.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for one (Resident #66) of three resident reviewed for pressure ulcers. The facility failed to ensure LVN F cleaned the pressure ulcer on Resident #66's right heel from inside to outside. This failure could place the residents with pressure ulcers at risk for worsening of existing pressure ulcers.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 (Resident #1) of 4 residents reviewed for accident prevention. The facility failed to obtain physician orders or a physician assessment as of 09/18/24 for Residents #1 for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. This failure could prevent residents from having an environment that was free and clear of accidents and hazards.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #1) out of five residents reviewed for showers. The facility failed to provide showers to Resident #1, her preferred method of bathing. Resident #1 was administered two (2) showers, her preferred method of bathing, from her admission on [DATE] until 07/15/2024. This failure placed residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth.

Inspectors wroteBased 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 sanitation. The DM failed to ensure all items were dated when they were opened. The DM failed to properly store beverages. CK B failed to reheat food to the temperature required for serving. These failures placed residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of 20 residents (Residents #24 and 27) reviewed for activities. Residents #24 and 27, who spent most of their time in their rooms, did not have a program of activities based on their needs and preferences. This failure placed residents at risk of depression and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received food that accommodates resident allergies, intolerances, and preferences for one of eight residents (Resident #169) reviewed for food preferences. Resident #169 was not given any meat or meat alternative in her meals for her first fourteen meals at the facility. This failure placed residents at risk of weight loss, slow wound healing, and a lack of enjoyment.