Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Copperas Cove Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple sclerosis, paraplegia, anemia, and existing pressure injuries, including a Stage 4 coccyx ulcer and foot wounds, had physician orders and a care plan for daily wound cleansing, specific dressings, and monitoring, along with interventions for known resistance to repositioning and care. Review of the TAR showed that on several occasions an LVN did not document completion of ordered treatments for the coccyx ulcer, lateral foot wound, and a left foot blood blister. The resident’s MDS assessments confirmed ongoing risk for pressure injuries and unhealed ulcers, while the responsible party reported concern that wound care orders were not followed after a hospitalization for sepsis. The wound care physician confirmed recent debridement of a foot wound and stated he would have identified changes if treatments were missed, and facility leadership acknowledged that the LVN was expected to complete and document wound care per orders and facility wound care policy.
A resident with paraplegia, MS, anemia, and multiple pressure-related wounds, including a stage 4 coccyx ulcer and foot wounds, had detailed daily wound care orders requiring cleansing and specific dressings each day shift. The care plan noted the resident frequently refused repositioning and wound care. Review of treatment administration records showed that on numerous dates, ordered wound treatments for the coccyx, lateral foot, right lateral foot, and a blood blister were not signed off in PCC by multiple LVNs on the day shift. In interviews, one LVN stated the resident often refused care and admitted not documenting refusals, another admitted completing treatments but failing to sign them off, and a third acknowledged not documenting refusals at shift end. The wound care nurse, DON, and administrator all stated that staff were expected to document completed treatments and refusals in PCC, and that unsigned TAR entries indicate treatments were not done. The facility’s documentation policy requires all procedures and treatments, including refusals, to be fully charted, but this was not followed, resulting in incomplete and inaccurate medical records for this resident.
Three residents with significant medical and cognitive needs did not have their call lights within reach, as observed and confirmed by staff interviews and record review. Staff either forgot to return call lights to accessible positions or were unaware they were out of reach, preventing residents from calling for assistance as required by their care plans and facility policy.
A resident with severe cognitive impairment and limited English proficiency did not receive consistent translation or interpretation services as required by facility policy. Staff relied on gestures and occasional help from a Korean-speaking nurse, with no communication board or regular use of translation tools, resulting in ineffective communication and failure to accommodate the resident's language needs.
A resident with severe cognitive impairment and a documented DNR status did not have a valid, physician-signed DNR order in her file. When the resident was found unresponsive, staff initiated CPR, as the DNR was incomplete and unsigned. Multiple staff members were unclear about who was responsible for verifying code status, and the lack of proper documentation led to the resident receiving CPR against her and her family's wishes.
A resident with multiple health conditions was not weighed upon admission or weekly as required, resulting in a missed 10.39% weight loss over 25 days. Despite the RD recommending nutritional supplements after observing poor intake, the order was delayed by nearly a month due to communication and delegation failures among staff. The facility did not follow its own policy for monitoring and intervening in cases of significant weight loss, and the resident ultimately died from failure to thrive.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The report notes that safety standards were not met and supervision was insufficient, but does not provide further details about the individuals involved.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility's kitchen failed to store and label food items according to professional standards, with uncovered and unlabeled food found in refrigerators and freezers. Interviews revealed a misunderstanding of the facility's policy, which requires all food to be covered, labeled, and dated with a use-by date to prevent contamination and foodborne illnesses.
A resident with multiple medical conditions was discharged to law enforcement without proper physician documentation or communication with the receiving health care provider. The discharge followed aggressive behavior by the resident, but necessary documentation was delayed, and no medical information was shared with the behavioral health hospital. This failure to follow the facility's emergency discharge policy could risk inappropriate discharge and psychological harm.
A resident with a history of diabetes and uropathy was readmitted to a facility with a discharge order for a urology follow-up, which was not scheduled. This oversight led to the resident's hospitalization with severe hydronephrosis, septic shock, and respiratory failure. Interviews revealed a breakdown in the process of reviewing and implementing discharge orders.
The facility failed to provide a clean and safe environment for residents, with observations of dirt and dust in several rooms, including black dirt on windowsills and thick dust on air vents. Staff interviews revealed inadequate supervision of housekeeping duties due to the absence of the housekeeping supervisor, leading to unsanitary conditions that could pose health risks.
The facility failed to develop comprehensive care plans for three residents requiring oxygen therapy, despite physician orders and documented needs. Observations and interviews revealed that the care plans did not include necessary interventions for oxygen administration, leading to potential confusion and unmet needs. Staff acknowledged the oversight and the importance of comprehensive care plans to ensure appropriate care.
A long-term care facility failed to provide proper respiratory care by not storing nasal cannulas, CPAP, and nebulizer equipment correctly for several residents. Observations revealed nasal cannulas on the floor or not bagged, CPAP tubing on the floor, and nebulizer masks not stored in bags. Staff interviews confirmed awareness of proper storage practices, but these were not consistently implemented, leading to potential risks of infection.
The facility's kitchen failed to meet professional standards for food safety, with issues such as improperly sealed refrigerated foods, unlabeled frozen items, and unsanitary conditions of a beverage pitcher and ice scoop holder. The Dietary Manager acknowledged the responsibility for these deficiencies, which were not in line with the facility's policies and FDA regulations.
The facility failed to maintain an effective Infection Prevention and Control Program due to inadequate hand hygiene practices by staff. A CNA did not perform hand hygiene or change gloves appropriately during incontinent care for a resident requiring total assistance. An LVN also failed to sanitize hands between glove changes during wound care for a resident with a pressure injury. Another CNA did not sanitize hands between glove changes while providing incontinent care to a different resident. These deficiencies highlight systemic issues with adherence to hand hygiene protocols.
The facility failed to ensure that the call light systems were accessible for two residents, both with cognitive impairments and requiring assistance with self-care. Observations revealed that the call lights were looped over wall fixtures, making them inaccessible. Staff interviews confirmed that call lights should be within reach to allow residents to express their needs and receive timely assistance.
The facility failed to ensure privacy for two residents during care activities. An LVN did not close the door while administering a bolus feeding to a resident with cerebral palsy and dysphagia. Additionally, two CNAs left the door open while transferring a resident with mobility issues using a Hoyer lift. Staff interviews confirmed the expectation for doors to be closed during care to maintain privacy and dignity.
A resident with an unstageable pressure ulcer on the right heel received improper wound care from an LVN, who failed to sanitize hands and used the same gauze for cleaning both inside and outside the wound. This practice, contrary to facility policy and professional standards, risks cross-contamination and infection. Interviews with the DON, ADON, and Administrator confirmed the correct procedure involves cleaning from the inside out and discarding gauze after each use.
A facility failed to obtain physician orders for a scoop mattress used for a resident with severe cognitive impairment and physical disabilities. The resident was observed on the mattress without documented orders or assessments. Interviews with the ADON, DON, and Administrator confirmed the oversight and acknowledged the potential risk of the resident attempting to get out of bed without proper authorization.
A resident in an LTC facility did not receive showers as preferred, despite requiring extensive assistance with ADLs and having a care plan indicating showers upon request. The resident, diagnosed with neuromuscular dysfunction of the bladder and type 2 diabetes, expressed feeling unclean due to insufficient bathing. The DON was unaware of the issue, which contradicted the facility's policies on promoting cleanliness and skin observation.
Failure to Provide and Document Ordered Pressure Ulcer Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards and physician orders for a resident with multiple pressure injuries. The resident was an adult female with multiple sclerosis, paraplegia, anemia, and existing pressure ulcers, including a Stage 4 coccyx ulcer, a lateral foot wound, a blood blister on the left foot, and an unstageable deep tissue injury. Her care plan identified her as at risk for pressure injury development related to immobility and documented that she was resistive to turning, repositioning, offloading, getting out of bed, and sometimes wound care, with interventions including an air mattress, frequent position changes, wound cleansing, dressing monitoring, weekly wound documentation, and specific approaches to refusals. Physician orders directed daily wound care to the Stage 4 coccyx ulcer with wound cleanser, Medihoney, calcium alginate, and dressing application; daily cleansing and dressing of the lateral foot wound with normal saline or wound cleanser, Xeroform, and foam dressing; and daily cleansing and Betadine application to the left foot blood blister, left open to air. Review of the Treatment Administration Record (TAR) showed that on multiple specified dates, these ordered treatments for the coccyx wound, lateral foot wound, and blood blister were not signed off as completed by the assigned LVN on the day shift. Weekly wound assessments and skin sheets for March showed no wound infections, and there was no wound care assessment documented when the resident was sent to the hospital. The resident’s Minimum Data Set (MDS) assessments documented that she was at risk for developing pressure ulcers and had one Stage 4 pressure ulcer and additional unhealed pressure injuries, with cognitive status ranging from intact to moderately impaired over time. The resident’s responsible party reported being contacted when the resident refused care and believed wound care orders were not being followed after the resident’s hospitalization for sepsis. The wound care physician stated that if wound care had been missed or refused, he would have identified changes or infections, and confirmed performing a debridement on the resident’s right plantar lateral fifth MTP two days before the hospital transfer, which the resident asked to stop due to discomfort. The DON and administrator both stated it was expected that the LVN complete the ordered wound care on the identified dates and follow physician orders, and the facility’s wound care policy required documentation of the type of wound care given, date and time, resident position, assessment data, tolerance, refusals with reasons, and the signature and title of the person performing and recording the care.
Failure to Accurately Document Wound Care Treatments and Refusals in PCC
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident with multiple complex wounds, specifically by not documenting wound care treatments and refusals in the electronic health record (PCC) on numerous dates. The resident was an adult female with multiple sclerosis, paraplegia, anemia, and documented pressure ulcers, including a stage 4 sacral/coccyx pressure ulcer, additional pressure ulcers of unspecified site and stage, a wound on the lateral foot, a blood blister on the left foot, and an unstageable deep tissue injury on the right plantar lateral fifth MTP. Her care plan identified her as at risk for pressure injuries due to immobility and paralysis, and noted that she was resistive to turning, repositioning, offloading, getting out of bed, and wound care, despite ongoing education and encouragement. Interventions included use of an air mattress, monitoring dressings each shift, weekly wound measurements, and specific instructions for staff to explain care, leave, and return in 5–10 minutes if she refused. Physician orders directed detailed wound care regimens for each wound site, including cleansing with wound cleanser or normal saline every day shift, application of Medihoney and calcium alginate to the stage 4 coccyx wound, Xeroform and foam dressings to the lateral foot wound, Betadine to the blood blister and deep tissue injury, and later calcium alginate or Xeroform with gauze border dressings to the right lateral/plantar foot wounds. These orders were to be carried out every day shift and as needed for soiling or dislodgement, and continued until healed or changed by the provider. Review of the Treatment Administration Records (TARs) showed that on multiple specified dates across January, February, and March, the ordered wound care treatments for the coccyx, lateral foot, right lateral foot, and blood blister were not signed off as completed in PCC on the 6:00 a.m.–6:00 p.m. shift by several LVNs (identified as A, B, and D). The missing documentation covered numerous dates for each wound order, indicating that the record did not show whether treatments were completed or refused on those days. Interviews with staff confirmed that the lack of documentation was due to failures to chart treatments or refusals, not to an absence of orders. LVN D stated that the resident was not compliant with wound care and that she would give the resident time to agree during her shift, but admitted she did not sign off in the TAR when the resident refused wound care on multiple listed dates and did not document refusals at the end of her shift. LVN A similarly stated that the resident refused wound care regularly and that he gave multiple opportunities throughout the day, but acknowledged that the TAR was not signed off for several dates because he failed to document the refusals at shift end. LVN B reported that she had actually completed wound care on several of the cited dates but did not sign off in PCC, and agreed that if treatment was not documented it would indicate it was not done. The wound care nurse, DON, and administrator all stated that LVNs were expected to sign off in PCC and document refusals, and that unsigned TAR entries would indicate the treatment was not completed. The facility’s own charting and documentation policy required that all services, including procedures and treatments, be documented with date, time, provider, assessment findings, resident tolerance, refusals, notifications, and signature, underscoring that the missing TAR entries represented a failure to maintain complete and accurate medical records for this resident. Additional documentation and interviews provided context but did not negate the documentation deficiency. MDS assessments showed the resident’s cognition ranged from intact to moderately impaired and confirmed the presence of a stage 4 pressure ulcer and other unhealed pressure injuries. Weekly wound assessments and skin sheets on several March dates documented no wound infections, and the wound care physician reported that he saw the resident weekly or twice weekly, performed a debridement on the right plantar lateral fifth MTP, and observed that the wounds had improved and were not infected. He also stated that nursing staff should sign off in PCC when the resident refused wound care. Hospital records indicated the resident was admitted for sepsis secondary to UTI and possible pneumonia, with confusion and encephalopathy, and the resident’s responsible party expressed concern that wound care orders were not being followed, based on the hospitalization and her understanding of the situation. However, regardless of clinical outcomes, the survey findings centered on the repeated failure of nursing staff to document wound care treatments and refusals in accordance with physician orders, facility policy, and accepted professional standards, resulting in incomplete and inaccurate medical records for this resident.
Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach, as required by their care plans and facility policy. Observations on a specific date revealed that the call lights for these residents were either hanging towards the ground or placed several feet away, making them inaccessible. Two of the residents were unable to reach their call lights and reported having to yell or physically move to get assistance, while the third resident could not be interviewed due to severe cognitive impairment. Record reviews indicated that all three residents had significant medical conditions and varying levels of cognitive impairment, with care plans specifically instructing staff to keep call lights within reach and encourage their use. Staff interviews confirmed that call lights were not always returned to accessible positions after care was provided. One CNA admitted to moving a call light and forgetting to return it, while another was unaware that a call light was out of reach. Both acknowledged that this could prevent residents from calling for help. Interviews with facility leadership, including the DON and ADM, confirmed that it is the responsibility of all staff to ensure call lights are always within reach of residents. The facility's policy also requires that call lights be easily accessible to residents in bed or confined to a chair. The deficiency was identified through observation, interview, and record review, demonstrating a failure to provide reasonable accommodations for resident needs and preferences as required.
Failure to Provide Translation Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide appropriate translation or interpretation services for a resident with limited English proficiency who spoke Korean and had severe cognitive impairment due to Alzheimer's disease and dementia. The resident's care plan identified a communication problem related to a language barrier and indicated the need for an interpreter. Despite this, staff primarily relied on hand gestures, body language, and occasional assistance from a Korean-speaking nurse who was not always present. There was no communication board or consistent use of translation tools available for the resident. Interviews with staff revealed that communication with the resident was often ineffective, with staff estimating successful communication only about half the time. Staff acknowledged the lack of resources to communicate in the resident's preferred language and noted that no attempts had been made to provide more communication in Korean, such as through a communication board or translation application. The Korean-speaking nurse was sometimes called by phone to assist, but this was not a regular or reliable solution. Staff also reported that they did not have any materials or aids to help bridge the language gap. The facility's own policy required meaningful access to information and services for individuals with limited English proficiency, including the use of trained interpreters, communication boards, or translation services. However, the policy was not followed in practice for this resident. The administrator and other staff recognized the importance of effective communication and the potential negative effects of not providing adequate translation or interpretation services, but these services were not consistently implemented for the resident.
Failure to Obtain Valid DNR Results in Unwanted CPR
Penalty
Summary
The facility failed to respect a resident's right to refuse or discontinue treatment by not obtaining a valid, physician-signed Do Not Resuscitate (DNR) order for an elderly female resident with severe cognitive impairment and multiple medical conditions. Although the resident's care plan and admission documents indicated a DNR status, the actual Out-of-hospital DNR form in the resident's file was unsigned by a physician, rendering it invalid. As a result, when the resident was found unresponsive, staff initiated CPR under the assumption that she was a full code, as there was no valid DNR on file. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for verifying and maintaining accurate code status documentation. The Director of Nursing (DON), Assistant Director of Nursing (ADON), charge nurses, social worker, and other staff provided inconsistent accounts of who was responsible for ensuring the presence of a valid DNR order upon admission. Some staff believed the admitting nurse or social worker was responsible, while others cited the DON or admission coordinator. The facility's policy required a physician-signed DNR to be present in the resident's medical record, but this was not adhered to in this case. The absence of a valid DNR led to the resident receiving CPR against her and her family's wishes, causing emotional distress to the family. The incident was further complicated by the fact that the previous facility failed to forward the completed DNR documentation during the resident's transfer. Staff interviews highlighted the negative impact of not having clear code status documentation, including the risk of violating resident rights and providing unwanted medical interventions.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, resulting in significant weight loss and ultimately death. Upon admission, the resident, an eighty-four-year-old female with diagnoses including adult failure to thrive, right femur fracture, and recurrent depressive disorders, was not weighed as required by facility policy. The facility also failed to obtain weekly weights for the first four weeks after admission, which prevented timely identification of a 10.39% weight loss over a 25-day period. There was no documentation that the resident refused to be weighed during her stay. The registered dietitian (RD) recommended nutritional supplements after observing the resident's refusal to eat, but the order for supplements was not placed until nearly a month later. During this time, the resident continued to experience poor intake and weight loss. The delay in implementing the RD's recommendations was due to a breakdown in communication and unclear delegation of responsibilities among staff, including the DON, ADON, and other nursing personnel. Interviews revealed that staff were either unaware of their responsibilities or did not follow through with required actions, such as entering weights into the electronic medical record and ensuring timely dietary interventions. Facility policy required residents to be weighed on admission and weekly for four weeks, with monthly weights thereafter, and for significant weight loss to trigger further interventions. However, these procedures were not followed for this resident. The lack of timely weights and delayed implementation of nutritional interventions meant that the resident's significant weight loss was not addressed promptly, and appropriate care planning and interventions were not initiated in accordance with facility policy.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents, and that supervision measures were insufficient to prevent such incidents. No additional details about specific residents, their medical history, or the exact nature of the hazards or supervision lapses are provided in the report.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was noted that food items in the facility's refrigerator and freezers were not properly sealed, labeled, or dated. Specifically, a large tray of cheesecake was left uncovered, exposing it to air-borne contaminants, and various other food items such as gelatin, diced tomatoes, and tortillas were not labeled with a use-by date. This lack of proper labeling and sealing could lead to food contamination and potential foodborne illnesses among residents. Interviews with the Dietary Manager (DM) and other staff revealed a misunderstanding or lack of adherence to the facility's policy, which requires all refrigerated and frozen foods to be covered, labeled, and dated with a use-by date. The DM acknowledged the expectation for food items to be covered and labeled but did not believe a use-by date was necessary, despite the facility's policy stating otherwise. The Administrator (ADM) also expressed a similar belief, indicating a potential gap in policy enforcement and staff training. The facility's policy and the U.S. Food and Drug Administration Food Code both emphasize the importance of proper food storage practices to prevent foodborne illnesses, which were not fully implemented in this case.
Failure to Document and Communicate During Resident Discharge
Penalty
Summary
The facility failed to ensure proper documentation and communication during the discharge of a resident, leading to a deficiency. A resident with multiple medical conditions, including acute kidney failure and traumatic brain injury, was discharged to law enforcement without the required physician documentation in the electronic medical record (EMR) and without providing clinical information to the receiving health care provider. The discharge was prompted by the resident's aggressive behavior, which included verbal and physical assaults on staff, resulting in police intervention and arrest. However, the necessary documentation from the physician explaining the immediate discharge was not completed until several days later. Interviews with facility staff revealed that there was no attempt to contact the behavioral health hospital where the resident was taken, nor was any medical or clinical information provided to ensure continuity of care. The facility's policy on emergency transfers and discharges was not followed, as it required notifying the receiving facility and preparing a transfer form. The lack of communication and documentation could potentially put residents at risk for inappropriate discharge and psychological harm, as noted in the report.
Failure to Follow Hospital Discharge Orders Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for a resident following hospital discharge orders. Specifically, the facility did not follow up with urology as required after the placement of a urethral stent. This oversight led to the resident's worsening medical condition and subsequent hospitalization. The resident, a male with a history of type 2 diabetes mellitus, obstructive and reflux uropathy, and recurrent UTIs, was readmitted to the facility with a discharge order for a urology follow-up within one week. However, the facility did not schedule or conduct this follow-up. The resident was later found unresponsive with low blood pressure and was transferred to the hospital, where he was diagnosed with severe left-sided hydronephrosis, septic shock, acute renal failure, and respiratory failure. Interviews with facility staff revealed a breakdown in the process of reviewing and implementing discharge orders. The ADON, RN Weekend Supervisor, and DON all acknowledged the failure to follow up on the urology appointment, which was not communicated to the transportation coordinator. The facility's policy on admission assessment and follow-up was not adequately followed, leading to the resident's critical condition.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in seven of the twenty rooms reviewed. Observations revealed that several rooms had issues such as black dirt particles on windowsills, thick dust on air vents, white stains on bathroom handrails, cracked and chipped toilet seats, rust around sink drain holes, and dirt on air conditioning units. These conditions were noted during a survey conducted on September 17, 2024, and were confirmed through interviews with staff members. Housekeeping staff and the facility's administrator acknowledged the deficiencies, citing a lack of supervision due to the housekeeping supervisor being on medical leave. The maintenance director, who was temporarily overseeing housekeeping, admitted that the cleaning efforts were not adequately monitored, leading to the observed unsanitary conditions. The facility's policy on cleaning and disinfection, which aligns with CDC recommendations, was not followed, potentially putting residents at risk of infection and breathing issues.
Failure to Implement Comprehensive Care Plans for Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, which included measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Specifically, the care plans for oxygen administration were missing for these residents, despite their documented need for oxygen therapy. This oversight was identified during a review of the residents' records, which showed that the care plans did not reflect the necessary interventions for oxygen therapy as indicated by their medical conditions and physician orders. Resident #10, a male with chronic obstructive pulmonary disease and a history of COVID, was observed using oxygen therapy at 3 liters per minute, yet his care plan did not include this intervention. Similarly, Resident #11, a female with hypertension and anemia, was noted to have a physician order for oxygen at bedtime, but her care plan lacked this detail. Resident #52, a female with asthma and anemia, also had a physician order for oxygen therapy as needed, but her care plan did not address this requirement. Interviews with facility staff, including the Director of Nursing (DON), Administrator, MDS Nurse, and Assistant Director of Nursing (ADON), confirmed the importance of having comprehensive care plans to ensure appropriate care. The staff acknowledged the absence of care plans for oxygen therapy and recognized the potential for confusion and unmet needs due to this deficiency. The facility's policy on care plans emphasized the need for a person-centered approach to meet residents' physical, psychological, and functional needs, which was not adhered to in these cases.
Improper Storage of Respiratory Equipment in LTC Facility
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as observed through improper storage of respiratory equipment. Residents who required oxygen therapy, such as those with chronic obstructive pulmonary disease (COPD) and other respiratory conditions, were found with nasal cannulas improperly stored. For instance, Resident #10's nasal cannula was observed on the floor, and Resident #11's nasal cannula was coiled on top of the oxygen concentrator without being bagged. Similarly, Resident #52's nasal cannula was hanging on top of the oxygen concentrator, and Resident #68's nasal cannula was looped over the bedrail without proper storage. These observations indicate a lack of adherence to professional standards for storing respiratory equipment. Additionally, the facility did not ensure proper storage and maintenance of CPAP and nebulizer equipment for other residents. Resident #61's CPAP machine was found with its tubing and face mask lying on the floor, and Resident #222's nebulizer mask was not stored in a bag. Furthermore, Resident #222's nasal cannula was connected to an oxygen concentrator without a humidifier bottle, which was empty and not dated. These deficiencies in equipment storage and maintenance could lead to respiratory infections and compromised respiratory care for the residents. Interviews with staff, including Licensed Vocational Nurses (LVNs) and the Director of Nursing (DON), revealed an awareness of the importance of proper storage to prevent cross-contamination and infection. However, the observations indicated a failure to implement these practices consistently. The facility's policy on respiratory therapy infection prevention was not followed, as evidenced by the lack of bagging and dating of respiratory equipment, and the failure to maintain water levels in humidifier bottles.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Several deficiencies were noted, including improper sealing of foods in the refrigerator, which were not protected from air-borne contaminants. Specifically, large containers of refrigerated rice and tuna were wrapped in aluminum foil but not sealed properly. Additionally, a pitcher containing a red beverage in the refrigerator had a lid with visible stains, and the ice scoop holder in the kitchen had yellowish fluids at the bottom. Furthermore, multiple frozen food items, such as fries, chicken parts, pancakes, and okra, were stored in zip-locked bags without use-by dates, violating the facility's policy on food labeling and storage. Interviews with the Dietary Manager revealed that she acknowledged the responsibility of all staff, including herself, for proper food storage and dating. She admitted that the observed conditions were not acceptable and could lead to infections among residents. The Administrator, who had been at the facility for four months, was informed of these findings and expressed that she expected the Dietary Manager to prevent such issues. The facility's policies on food receiving, storage, and kitchen sanitization, as well as FDA regulations, were not followed, leading to potential risks of cross-contamination and food-borne illnesses.
Inadequate Hand Hygiene Practices in Infection Control
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of inadequate hand hygiene practices by staff members. Specifically, CNA A did not perform hand hygiene before and after providing incontinent care to a resident, nor did she change gloves appropriately during the process. This resident required total assistance with daily care and had a diagnosis of unspecified pain, with a care plan goal to maintain the highest level of personal hygiene. The CNA's actions included touching soiled items without gloves and failing to sanitize hands before donning new gloves, which could lead to cross-contamination. Similarly, LVN F did not perform hand hygiene between glove changes while providing wound care to the same resident, who had an unstageable pressure injury on the right heel. Despite washing hands initially, the LVN failed to sanitize hands before putting on new gloves after removing the old dressing and before applying a new one. This oversight occurred despite the resident's vulnerability due to type 2 diabetes mellitus and the presence of pressure ulcers, which required careful management to prevent infection. Another instance involved CNA C, who did not sanitize hands between glove changes while providing incontinent care to a different resident. This resident was frequently incontinent for bladder and always incontinent for bowel, requiring extensive assistance with daily care. The CNA did not change gloves after touching soiled items and failed to perform hand hygiene before donning new gloves, which is crucial to prevent the spread of germs and infection. These deficiencies highlight a systemic issue with adherence to hand hygiene protocols, as confirmed by interviews with the DON, Administrator, and ADON, who acknowledged the importance of hand hygiene in preventing cross-contamination and infection.
Inaccessible Call Lights for Two Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of two residents were accessible, which is a violation of their right to receive services with reasonable accommodation of their needs and preferences. Resident #41, an elderly male with Alzheimer's disease and heart failure, was observed with his call light looped over the fixture on the wall, making it inaccessible. His care plan indicated a high potential for falls and required assistance with daily care, yet the call light was not within reach, potentially compromising his ability to obtain help when needed. Similarly, Resident #58, an elderly male with dementia and major depressive disorder, also had his call light looped over the wall fixture, rendering it inaccessible. This resident had severely impaired cognition and required assistance with all areas of self-care. Interviews with staff, including CNAs and the ADON, confirmed that call lights should be within reach to ensure residents can express their needs and receive timely assistance. The facility's policy also mandates that call lights be within easy reach when residents are in bed or confined to a chair.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
The facility failed to maintain personal privacy for two residents during medical treatment and personal care. In the first instance, a Licensed Vocational Nurse (LVN) did not close the door while administering a bolus feeding to a resident with cerebral palsy and dysphagia. The resident was taken from the activity area to her room, and the LVN proceeded with the feeding without closing the door or pulling the privacy curtain, which was acknowledged by the LVN as an oversight. In the second instance, two Certified Nursing Assistants (CNAs) did not close the door while transferring a resident with unsteadiness and mobility issues from the bed to a wheelchair using a Hoyer lift. The CNAs left the door open during the transfer process, which was later recognized by both CNAs as a failure to provide privacy. The CNAs admitted that the door should have been closed to maintain the resident's dignity and prevent potential embarrassment. Interviews with staff, including the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), confirmed that the expectation was for doors to be closed during all care activities to ensure resident privacy and dignity. The facility's policy on dignity emphasizes the importance of maintaining resident privacy during personal care and treatment procedures.
Improper Wound Care Technique for Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident with an unstageable pressure injury on the right heel. The resident, who was cognitively intact and had a diagnosis of type 2 diabetes mellitus, was observed receiving wound care that did not adhere to professional standards. The Licensed Vocational Nurse (LVN) responsible for the care did not sanitize her hands before putting on a new pair of gloves and used the same gauze to clean both the inside and outside of the wound, which is against proper wound care protocol. This improper technique could lead to cross-contamination and infection, as the gauze that touched the outside of the wound should not have been used again on the inside. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator confirmed that the proper wound cleaning technique involves cleaning from the inside to the outside and discarding the gauze after each wipe to prevent infection. The facility's policy also supports this method, emphasizing the need to cleanse from the least contaminated area to the most contaminated. The failure to follow these procedures placed the resident at risk for worsening of the existing pressure ulcer.
Failure to Obtain Physician Orders for Scoop Mattress
Penalty
Summary
The facility failed to ensure that the environment for a resident was free from accident hazards, specifically by not obtaining physician orders or conducting a physician assessment for the use of a scoop mattress. This mattress was used to assist in fall prevention for a resident with severe cognitive impairment and physical disabilities, including cerebral palsy, lack of coordination, and abnormal involuntary movements. The resident was observed sleeping on a scoop mattress, which had raised sides, without any documented physician orders or assessments in the facility's records. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the resident was placed on the scoop mattress due to a habit of rolling off the bed, particularly at night. However, they acknowledged that physician orders should have been obtained and the use of the mattress should have been included in the resident's care plan. The Administrator, who had been at the facility for four months, confirmed the absence of physician orders and recognized the potential risk of the resident attempting to get out of bed without proper authorization and assessment for the mattress use.
Failure to Provide Preferred Bathing Method
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received necessary services to maintain personal hygiene. Specifically, the facility did not provide showers to a resident who preferred this method of bathing. The resident, who was admitted with diagnoses including neuromuscular dysfunction of the bladder and type 2 diabetes, required extensive assistance with all activities of daily living and had a BIMS score indicating no cognitive impairment. Despite her care plan indicating that staff would shower her as requested, the resident received only two showers from her admission until the time of the report, with no documentation of showers or baths for a significant period. The resident expressed dissatisfaction with the lack of showers, stating that her hair became oily and greasy, and she felt unclean due to the use of adult briefs. She felt that bed baths with wipes did not adequately clean her after bowel movements. The Director of Nursing was unaware of the issue and acknowledged that the lack of proper bathing could lead to serious health issues. The facility's policies emphasized the importance of promoting cleanliness and observing the condition of residents' skin, but these were not adhered to in this case.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Copperas Cove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hill Country Heights | 0.9 mi | — | 1 | 0 |
| Avir At Killeen | 10.5 mi | — | 9 | 0 |
| Rosewood Heights | 11 mi | — | 2 | 0 |
| Harker Heights Nursing & Rehabilitation | 15 mi | — | 4 | 0 |
| Caraday Of Lampasas | 16.4 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.