Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 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 Hollow Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with hepatorenal syndrome, COPD, hyperlipidemia, and ESRD, who was cognitively intact per BIMS, was diverted by ambulance to a hospital for respiratory failure while en route to dialysis. Facility documentation noted the transfer and included a section indicating notice to the resident and resident representative, but no boxes were checked to show that notification occurred. The resident’s daughter reported she was not called by the facility and only learned of the hospitalization from the hospital. The DON stated the resident was taken to the ER for shortness of breath and that she contacted the hospital, while the Administrator reported calling only the resident’s phone, which went to voicemail, and did not call the listed emergency contact, despite a policy requiring family notification of any resident change.
A resident with advanced dementia and under hospice care was ordered IV fluids due to clinical alerts. Facility staff attempted to start the IV without notifying the resident's family or hospice, and did not document the attempts or the order. The family discovered the IV order after noticing a bruise on the resident's arm, and confirmed that hospice had not been informed. Facility policy required immediate notification and documentation, which was not followed in this case.
A resident with a history of cognitive impairment and chronic prostate cancer was readmitted after hospitalization for sepsis and prescribed oral Ciprofloxacin, but staff failed to transcribe and administer the antibiotic as ordered. Medical records and staff interviews confirmed the omission, and the resident was later transferred back to the hospital with severe sepsis, where it was determined the antibiotic had not been given.
A resident with multiple chronic conditions did not have required documentation for several prescribed medications on the evening medication schedule. The nurse responsible stated the medications were administered and documented, but the MAR showed missing entries, which the nurse attributed to a possible system glitch. Facility policy requires all medication administration to be recorded, and staff interviews confirmed the documentation was incomplete.
A resident with dementia and mood disturbance did not receive necessary psychological services as ordered by the facility's medical director. Despite exhibiting hallucinations and paranoia, the facility failed to refer the resident to psychological services, leading to an Immediate Jeopardy situation. Interviews revealed that the facility staff did not take appropriate action to address the resident's mental health needs.
A facility failed to document an incident accurately where a resident was reportedly slapped by another resident. The incident was not reflected in the resident's progress notes or assessments, and no skin assessments were conducted. An investigation revealed that the resident was not actually slapped, and the resident did not recall the event. The facility's documentation policy was not followed, resulting in a deficiency.
A facility failed to monitor a resident's edema as ordered by a physician, which was not reflected in the treatment administration record due to an error in entering the order into the computer system. The resident, with multiple health conditions including heart failure, was supposed to have edema monitored every shift. Staff interviews revealed that the charge nurse was responsible for entering orders, and the ADON usually monitored new orders, but the oversight led to a lack of monitoring, potentially risking the resident's quality of care.
The facility's kitchen operations were found deficient due to improper food storage, including expired items and dented cans, and inadequate cleaning of equipment. Refrigerated food past its use-by date was not discarded, and dented cans were improperly stored. The industrial can opener was not cleaned as required, posing a risk of cross-contamination. Staff interviews confirmed awareness of policies, but practices were not consistently followed.
The facility failed to maintain a homelike environment in two rooms, where unpainted and damaged walls were observed. The Maintenance Director was unaware of the issues, and the Administrator expected such issues to be addressed, as per the facility's policy on maintaining a safe and comfortable environment.
Two residents with severe cognitive impairments and other health issues were found with long, untrimmed fingernails, posing risks for skin breakdown and infection. Despite being dependent on staff for personal hygiene, their nails were not adequately maintained, contrary to the facility's nail care policy.
A facility failed to provide trauma-informed care for a resident with PTSD, as her care plan did not include her PTSD diagnosis or identify potential triggers. Interviews with staff revealed a lack of awareness and implementation of trauma-informed practices, despite the facility's policy requiring such measures. This oversight could lead to re-traumatization and psychological distress for the resident.
A CNA failed to follow standard precautions during peri care for a resident with severe cognitive impairment and multiple health issues. The CNA did not change gloves or perform hand hygiene after cleaning feces, before handling the resident's foley catheter and linens. The facility's infection control policy, which emphasizes hand hygiene, was not adhered to.
Failure to Notify Resident Representative of Hospital Transfer and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident representative of a significant change in condition and transfer to the hospital. A female resident with diagnoses including hepatorenal syndrome, COPD, hyperlipidemia, and ESRD, and with an MDS BIMS score of 15/15 indicating no significant cognitive impairment, traveled to dialysis by ambulance. According to progress notes, the ambulance diverted the resident to the hospital for respiratory failure while en route to dialysis. A transfer notification form documented that the resident was transferred to the hospital on the way to dialysis and contained a section stating that notice was provided to the resident and resident representative, but there were no check marks indicating that either the resident or the resident representative had actually been notified. In interviews, the resident’s daughter stated the facility never called her to inform her that her mother was in the hospital and that she only learned of the hospitalization when the hospital called her after obtaining her number from the resident before intubation. The DON reported that the resident became distressed with shortness of breath en route and was taken to the ER, and that she called the hospital to check on the resident while the Administrator attempted to reach the responsible party. The Administrator stated she considered the resident to be her own responsible party and therefore only called the resident’s phone, which went to voicemail several times, and confirmed she did not call the family member listed as Emergency Contact #1. The Administrator also stated she never spoke with the resident’s family member by phone. The facility’s Family Notification Policy states that the family will be notified of any resident change and that each resident and/or family representative is to provide a list of family members to contact in case of emergency or urgency.
Failure to Notify Family and Hospice of IV Fluid Order Prior to Attempted Administration
Penalty
Summary
The facility failed to immediately inform a resident's family and hospice provider of a new order for IV fluids before attempting to initiate the treatment. The resident in question was an elderly female with diagnoses including Alzheimer's Disease, dementia, and generalized anxiety disorder, who was unable to complete cognitive interviews and had significant memory deficits. She was under hospice care with a valid DNR order and a care plan that required family involvement and coordination with hospice for any changes in condition or treatment. A physician ordered IV fluids for the resident due to clinical alerts such as decreased oral intake and possible dehydration. The ADON attempted to start the IV on two occasions but was unsuccessful, resulting in a blown vein. There was no documentation of these attempts or of any notification to the resident's family or hospice prior to the procedure. The family only became aware of the IV order after noticing a bruise on the resident's arm during a visit, and subsequently learned that hospice had not been notified either. Interviews with facility staff confirmed that the family and hospice were not informed before the IV was attempted, and that documentation of the order and the attempts to start the IV was lacking. Facility policy required immediate notification of significant changes in status to both the physician and the resident's representative, as well as thorough documentation of all notifications and interventions. These procedures were not followed in this instance, resulting in a failure to uphold the resident's rights to be informed and involved in care decisions.
Failure to Administer Prescribed Antibiotic Following Hospital Readmission
Penalty
Summary
A significant medication error occurred when a male resident with a history of mild cognitive impairment, generalized muscle weakness, type 2 diabetes, and chronic prostate cancer was readmitted to the facility following a hospital stay for sepsis related to a prostate infection. Upon discharge from the hospital, the resident was prescribed Ciprofloxacin 500 mg orally twice daily for four weeks to treat the prostate infection. The hospital discharge orders, which included this antibiotic regimen, were provided to the facility upon the resident's return. Despite the clear hospital orders, facility staff failed to transcribe and initiate the antibiotic therapy. Review of the resident's medical record, Medication Administration Record (MAR), and order summary revealed no documentation of the Ciprofloxacin order or its administration during the resident's stay from readmission until his subsequent transfer back to the hospital. Multiple nursing progress notes and interviews with staff confirmed that no interventions or treatments, including the prescribed antibiotic, were documented or provided during this period. Staff interviews indicated a lack of clarity and recall regarding the review and implementation of the hospital discharge orders, and the DON did not oversee or in-service staff on the admission/readmission and medication order process during the relevant timeframe. The resident's condition did not improve, and family members requested his transfer back to the hospital, where he was again diagnosed with severe sepsis. Hospital records confirmed that the resident had not received his prescribed antibiotics during his stay at the facility, and this omission was acknowledged by facility staff. The failure to administer the ordered antibiotic was directly linked to the lack of order transcription and follow-through on hospital discharge instructions, as well as insufficient oversight and communication among nursing staff and leadership.
Failure to Document Medication Administration in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple chronic conditions, including dementia, hypertension, hyperlipidemia, and congestive heart failure. On a specific date, the Medication Administration Record (MAR) for this resident showed missing documentation for several prescribed medications, including Atorvastatin, Donepezil, Apixaban, Carvedilol, Oxybutynin, Sacubitril-Valsartan, and Mirtazapine, all of which were to be administered via PEG-tube. The absence of documentation was noted for the evening medication schedule, despite physician orders requiring these medications. Interviews with the Director of Nursing (DON) and the nurse responsible for medication administration revealed conflicting accounts. The nurse stated she administered and documented the medications, attributing the missing records to a possible system glitch in the electronic medical record (PCC). However, the DON confirmed that the nurse admitted to forgetting to document the administration initially, and later claimed to have completed the documentation. The facility's policy requires all medication administration or refusals to be documented in the MAR or TAR, with no blanks permitted. Further review of the facility's policies and additional staff interviews confirmed that all medication administration must be recorded, and that failure to do so could result in miscommunication or medication errors. The resident involved was unable to recall whether the medications were received, and no changes in condition were observed following the incident. The deficiency was identified through review of records and staff interviews, which confirmed the lack of required documentation for medication administration.
Failure to Provide Psychological Services for Resident with Mental Disorder
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with a mental disorder and psychosocial adjustment difficulty. The resident, who had a history of trauma and was diagnosed with dementia with mood disturbance, did not receive the necessary psychological services as ordered by the medical director. Despite the physician's order for psychological evaluation and treatment, the resident was discharged to a behavioral health hospital without receiving the required mental health interventions. The resident exhibited several concerning behaviors, including hallucinations, paranoia, and delusions, which were documented in the facility's records. These behaviors included the resident's belief that someone was taking pictures of her at night and her insistence on using a fork for protection. Despite these documented behaviors and the physician's order for psychological services, the facility did not make the necessary referral to the psychological service group employed by the facility. Interviews with facility staff revealed a lack of action in addressing the resident's mental health needs. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of any referral being made for the resident's psychological services, and the psychological service group confirmed they had not received a referral. This inaction led to the identification of an Immediate Jeopardy situation, highlighting the facility's failure to ensure the resident's mental and psychosocial well-being.
Removal Plan
- The DON/ADON audited all psychology and psychiatry orders for active residents. Two residents were identified, and both are actively receiving psychiatric services. The facility has 11 total residents on psych services and 2 of those were referred to psych services.
- The Administrator and DON will be responsible for initiating all psychological and psychiatry referrals to the provider.
- The Administrator DON, and ADON were in serviced 1:1 by the Regional Compliance Nurse on the following topics: Abuse and Neglect Policy, Behavioral Management Policy, Following Physician Orders Policy.
- An ADHOC QAPI meeting was completed with interdisciplinary team which included the Medical Director, Administrator, Director of Nursing, and Assistant Director of Nursing to discuss the citations and plan of removal.
- The Administrator and DON initiated the following in-services for Licensed Nurses. Licensed Nurses not present and PRNs will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift.
- The Administrator and DON initiated the following in-services for all staff. All staff not present, and PRNs will be in-serviced prior to their next shift. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior to their assigned shift.
- The administrator and/or DON will review all orders daily for any orders in reference to psychological and psychiatry services to ensure that all referrals have been initiated.
Failure to Document Resident Incident Accurately
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for a resident who was reportedly slapped by another resident. The incident was self-reported by the facility, but the resident's progress notes and assessments did not reflect this event. The resident, a male with Alzheimer's disease, type 2 diabetes, and major depressive disorder, was reported to have been slapped in the mouth by another resident. However, there were no entries in the resident's care plan or nursing progress notes regarding the incident, and no skin assessments were conducted on the date of the reported event. Upon investigation by the area director of operations, it was discovered that the incident was not accurately documented, and staff later reported that the resident was not actually slapped, but rather another resident attempted to slap him and missed. The resident himself did not recall being hit when interviewed six months after the incident. The facility's policy on documentation emphasizes the importance of recording all relevant information accurately and in a timely manner, but this was not adhered to in this case, leading to a deficiency in maintaining accurate clinical records.
Failure to Monitor Edema as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not follow the physician's orders and the comprehensive care plan to monitor the resident for edema. The resident, a female with multiple diagnoses including heart failure, hypertension, and diabetes, was supposed to have her edema monitored every shift as per a physician's order dated July 1, 2024. However, the medication and treatment administration records for July 2024 showed no evidence of edema monitoring each shift. Interviews with facility staff revealed that the order to monitor edema was not correctly entered into the computer system, resulting in its absence from the treatment administration record. The Registered Nurse (REGN) and the Director of Nursing (DON) acknowledged the oversight, noting that the charge nurse was responsible for entering and initiating physician orders, and the Assistant Director of Nursing (ADON) usually monitored new orders. The Administrator (ADM) confirmed that physician orders needed to be accurately transcribed into the computer system. This failure to monitor edema as ordered could place residents at risk for untreated medical issues and diminished quality of care.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. Refrigerated food products were found to be past their use-by dates, including croissants, strawberry yogurts, hot dogs, hard-boiled eggs, and black olives. These items were not discarded as required by the facility's policy, which mandates that food past its use-by date should be immediately discarded. The Dietary Supervisor (DS) acknowledged the oversight and stated that all kitchen staff are responsible for checking dates and discarding expired items. Additionally, the facility's dry storage area contained dented cans, including enchilada red salsa, cream of chicken, and spaghetti sauce. The DS stated that dented cans should be refused at delivery or removed from storage to prevent potential bacterial growth. Despite a posted notice instructing staff to return dented cans to the dietary manager's office, these items were found on the shelves, indicating a failure to adhere to the facility's procedures. The industrial can opener in the kitchen was observed to have a sticky black substance and debris around the blade, suggesting it had not been cleaned as required. The DS stated that the can opener should be cleaned daily or after each use to prevent cross-contamination. Interviews with kitchen staff confirmed that they were aware of the policies regarding food storage, labeling, and equipment cleaning, but these practices were not consistently followed, leading to potential risks of cross-contamination and foodborne illness for residents.
Failure to Maintain Homelike Environment Due to Unpainted Walls
Penalty
Summary
The facility failed to maintain a homelike environment in two of the fourteen rooms reviewed, as evidenced by unpainted and damaged walls. In one room, four sections of sheetrock were repaired but left unpainted, creating a stark contrast with the brown-toned walls. In another room, two sections of sheetrock were missing paint, making the unpainted areas noticeable against the rest of the wall. These observations were made during a survey, highlighting the facility's failure to provide necessary maintenance services to ensure a comfortable and homelike environment for residents. Interviews with the Maintenance Director and the Administrator revealed that the Maintenance Director was unaware of the issues in the rooms and had not been notified of the need for painting. He acknowledged that the walls should be painted to match and that residents' rooms should be maintained in a homelike manner. The Administrator also expressed that she expected damaged or unpainted walls to be fixed and painted, aligning with the facility's policy on maintaining a safe, clean, and comfortable environment. The facility's Resident Rights policy emphasizes the importance of treating residents with respect and dignity, which includes maintaining a homelike environment.
Deficient Nail Care for Residents
Penalty
Summary
The facility failed to ensure adequate grooming and personal hygiene for two residents, leading to a deficiency in care. Resident #6, a male with severe cognitive impairment, parkinsonism, dementia, and hemiplegia, was observed with long fingernails that had caused indentations on his palm, posing a risk for skin breakdown. Despite being dependent on staff for personal hygiene, his nails were not trimmed promptly, as observed over two consecutive days. Similarly, Resident #8, a male with severe cognitive impairment, dementia, and other health issues, was found with long fingernails and a brown substance underneath them. This resident required substantial assistance with functional abilities and had a history of behaviors that could compromise skin integrity. The facility's policy on nail care was not adhered to, as the resident's nails remained untrimmed and uncleaned, despite the potential for infection and injury.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, a female with a history of childhood trauma and PTSD, was not care planned for her PTSD diagnosis, and potential triggers were not identified or addressed in her care plan. This oversight was discovered during a review of the resident's comprehensive care plan, which included diagnoses of major depressive disorder and severe mental illness but omitted any mention of PTSD or related interventions. Interviews with facility staff, including the MDS Nurse, Director of Nursing (DON), and Social Worker (SW), revealed a lack of awareness and implementation of trauma-informed care practices. The MDS Nurse acknowledged the importance of care planning for PTSD and identifying triggers to prevent re-traumatization but admitted that the resident's care plan did not include these elements. The DON and SW also confirmed the absence of PTSD care planning and emphasized the necessity of addressing such diagnoses to ensure proper care and prevent psychological distress. The facility's Trauma-Informed Care Policy outlines the need for identifying triggers and developing individualized interventions for trauma survivors. However, the policy was not effectively implemented for the resident in question. The failure to incorporate PTSD care planning and trigger identification into the resident's care plan could lead to re-traumatization and psychological distress, as staff may not be adequately informed or prepared to address the resident's specific needs.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to standard precautions during peri care for a resident. The resident, a male with severe cognitive impairment and multiple health issues including urinary tract infection, acute kidney failure, morbid obesity, and dementia, required substantial assistance with daily activities. During an observation, the CNA was seen cleaning the resident after a bowel movement but did not change gloves or perform hand hygiene before proceeding to handle the resident's foley catheter and linens. The CNA admitted feeling unprepared and acknowledged the lack of glove change due to not seeing any available gloves in the room. The Director of Nursing (DON) and the Administrator both stated that staff are regularly trained on infection control practices, including hand hygiene, and are expected to follow these protocols. The facility's infection control policy emphasizes the importance of hand hygiene when moving from contaminated to clean body sites, which was not followed in this instance.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 39 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Caldwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Caldwell | 2.6 mi | — | 12 | 0 |
| Rockdale Estates & Rehabilitation | 20.9 mi | — | 0 | 0 |
| Lampstand Nursing And Rehabilitation | 22.8 mi | — | 5 | 2 |
| St. Joseph Manor | 23 mi | — | 5 | 0 |
| Crestview Retirement Community | 23.1 mi | — | 0 | 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.