Copperas Hollow Nursing & Rehabilitation Center

Inspectors wroteBased on interview, and record reviews, the facility failed to immediately notify the resident representative when there was a change in residents health status for 1 of 5 resident (Resident #1) reviewed for notification of changes. The facility failed to immediately notify Resident #1's Emergency contact when resident was transferred to hospital for respiratory failure while enroute to dialysis. This failure could place residents at risk of injury, hospitalization, and/or decreased quality of life. Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted on [DATE]. [...]

Inspectors wroteBased on record review, and interview, the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a signficant change in his or her treatment for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to notify Resident #1's family of an IV fluid (solutions administered directly into a patient's vein to provide hydration, electrolytes, and nutrients.) order before attempting to start the IV fluid. This failure could place the residents, who received care at the facility, at risk of not being informed of their health status, in order to make informed decisions regarding their care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive care plan that describes the services that are to be furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Resident #6 and Resident #12) of 24 reviewed for care plans. A) The facility failed to ensure Resident #6's comprehensive care plan reflected his CPAP machine (machine is a common treatment for sleep apnea, helping to keep airways open during sleep by delivering a continuous stream of air) settings were identified, time of use (when to put on and when to remove), or his preferences to put on and remove the CPAP on his own. [...]

Inspectors wroteNumber of residents sampled: 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.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that residents are free of any significant medication errors for 1 (Resident #1) of 6 residents reviewed for pharmacy services. The facility failed to ensure staff ordered and administered Resident #1's antibiotic medication when he returned from the hospital on [DATE] after being diagnosed with sepsis (a life-threatening condition that occurs when the body's response to an infection damages its own tissues and organs) from a prostate infection. Resident #1 was sent back to the hospital by EMS on 03/22/25 due to no improvement in his condition. Resident #1 was readmitted to the hospital and diagnosed with Severe Sepsis. An IJ was identified on 05/02/25. The IJ template was provided to the facility on [DATE] at 6:15 p.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for one resident (Resident #3) of 5 residents reviewed for medical records. The facility failed to ensure LVN B documented administration of Atorvastatin Calcium (for cholesterol), Donepezil (for dementia), Apixaban (for pulmonary embolism), Carvedilol (for high blood pressure), Oxybutynin Chloride (for myopathy), Sacubitril-Valsartan (for congestive heart failure), and Mirtazapine (for depression) to Resident #3 on 05/20/25 during the evening medication schedule. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for one (1) of ten (10) residents reviewed for behavioral health services. (Resident #1) The facility failed to provide a response to Resident #1's dementia related mood disturbance behavior. On 09/30/24 the MD ordered psychological services to evaluate and treat Resident #1, no mental health interventions were received, and she was discharged to a BHH seven days later. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/17/25 at 1:18 PM. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan, for 1 of 3 residents (Resident #1) reviewed for quality of care. The facility failed to follow physician's orders and the comprehensive care plan to monitor Resident #1 for edema. This failure could place residents at risk for untreated medical issues and diminished quality of care.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide maintenance services necessary to maintain an orderly and comfortable homelike environment for two (rooms [ROOM NUMBERS]) of fourteen rooms reviewed in the facility for homelike environment. The facility failed to paint damaged and repaired areas of residents' walls in rooms [ROOM NUMBERS]. This failure could place residents at risk of living in an unhomelike and uncomfortable environment.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 3 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on 04/27/2023, 04/28/2023, and 04/29/2023. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.

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 kitchen sanitation. 1. The facility failed to properly label food in one of two open front refrigerators , and one of one open front freezer located in the kitchen. 2. The facility failed to ensure Dietary Aide A, Dietary Aide B and LVN E wore hair restraints while in the kitchen. 3. The facility failed to ensure the [NAME] properly sanitized their hands between tasks. These failures could placed residents who were served from the kitchen at risk for health complications and foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of each resident's needs for 4 of 18 Residents (Resident #40, Resident #18, Resident #42, and Resident #210) reviewed for call lights in that: Residents #40, #18, #42 and #210 were observed in their rooms with their call lights not in reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to post a notice and inform residents of the availability of the results of the most recent survey for 6 of 6 residents reviewed for resident group meeting. The facility failed to inform residents by verbally informing residents or by posting a sign letting the residents know the location of the most recent survey. This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for five of eighteen residents (Resident # 40, Resident #18, Resident #42, Resident #30, and Resident #210) reviewed for quality of care. The facility failed to ensure Resident #40's, Resident #18's, Resident #42's, Resident #30's, and Resident #210's fingernails were trimmed and cleaned. These failures placed residents at risk for poor hygiene, dignity issues and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for each resident 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 for 1 of 20 residents (Resident #9) reviewed for care plans. The facility failed to ensure Resident #9's Comprehensive Care Plan reflected a revision of her plan of care after she had dental surgery and the removal of six teeth which affected her ability to chew her food. These failures could place residents at risk of decline due to not attaining the highest practicable well-being possible.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services for 1 of 20 residents (Resident #31) reviewed for range of motion (ROM). The facility failed to ensure Resident #31 had interventions in place for her right- and left-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her right and left hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures. Findings Include: [...]