Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 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 Copperfield Healthcare And Rehabilitation during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, multiple myeloma, moderate cognitive impairment (BIMS 8), and hospice/DNR status, who was dependent on staff for ADLs and incontinent care, was not treated with dignity during a nighttime interaction with a CNA. Video from authorized electronic monitoring showed the CNA questioning the resident about whether he needed to be changed, responding to his answer with statements such as, “You will? What that mean? You will or you do right now. When I’m leaving, I’m gone,” and, “Don’t talk in riddles, I’m not well in riddles… either you need it now or you don’t.” The resident later indicated the CNA made him feel very small and as if she wanted nothing to do with him. This conduct conflicted with the resident’s care plan interventions for incontinence and psychosocial well-being and with facility resident rights policies requiring respectful, dignified treatment.
A resident experienced slurred speech and altered mental status, which was reported by a family member to nursing staff. The nurse assessed the resident but failed to document the concerns, notify the provider, or communicate the event to the next shift. The following day, after further family concern, the resident was sent to the hospital and diagnosed with an acute ischemic stroke. The delay in notification and documentation led to a delay in treatment.
A resident exhibited signs of stroke, including slurred speech and altered mental status, which were reported by a family member to nursing staff. The nurse on duty did not document the complaint, notify the provider, or communicate the change to other staff, resulting in a delay of over 24 hours before the resident was assessed and transferred to the hospital, where an acute ischemic infarct was diagnosed. Additionally, the facility failed to obtain a timely physician order to discontinue a mid-line catheter for another resident after IV therapy was completed.
A resident with a stage III sacral pressure ulcer did not receive timely assessment or treatment upon admission to the facility. The facility failed to notify the physician or obtain wound care orders for several days, leaving the wound uncovered and untreated. Staff interviews revealed a lack of communication and adherence to protocols, with the Wound Care Nurse not adequately trained and failing to perform necessary assessments.
A LTC facility reported a 12% medication error rate, involving three residents. Errors included incorrect dosing of Trintellix for depression, wrong multivitamin for eye health, and incorrect Lidocaine patch for pain management. These errors were due to pharmacy mistakes, staff oversight, and misunderstanding of physician orders.
A facility failed to maintain accurate clinical records for two residents regarding the administration of controlled substances. The MARs were incomplete, and staff did not sign the correct narcotic count sheets, potentially affecting residents' care. Interviews revealed that nurses signed out medications on incorrect count sheets, and there was a lack of proper reconciliation of narcotic records.
A resident with multiple diagnoses, including pneumonia, was admitted to an LTC facility, but the baseline care plan was incomplete, lacking focus, goals, and interventions for pneumonia. Interviews with staff revealed the omission, with the RN admitting to documenting antibiotic treatment for sepsis instead of pneumonia. The facility's policy requires a comprehensive care plan within 48 hours of admission, which was not met in this case.
Failure to Treat a Resident With Dignity During Incontinent Care Interaction
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with dignity and respect during an interaction about incontinent care. The resident was a 77-year-old man with Parkinson’s disease, difficulty walking, lack of coordination, muscle wasting and atrophy, and multiple myeloma without remission. He was on hospice services, had a DNR order, and his MDS showed moderate cognitive impairment with a BIMS score of 8. He required substantial to maximal assistance for toileting, hygiene, bathing, and transfers, and his care plan identified dependence on staff for activities, cognitive stimulation, social interactions, and incontinence of bowel and bladder, with interventions including checking for incontinence as required and allowing time for him to answer questions and verbalize feelings. The resident’s care plan was updated to include his right to health, safety, and dignity in connection with authorized electronic monitoring in his room, which had been requested and signed for by a family member. On the night in question, video footage from the resident’s room showed CNA A asking the resident if he needed to be changed. When the resident responded, “I will,” CNA A replied, “You will? What that mean? You will or you do right now. When I’m leaving, I’m gone.” After the resident responded inaudibly, CNA A continued, “Well I’m asking, don’t talk in riddles, I’m not well in riddles… either you need it now or you don’t,” before the footage cut off. This exchange was reported by the resident’s family member, who viewed it on the electronic monitoring system and provided the video to the surveyor. In a subsequent interview, the resident stated he could not remember the specific exchange but recalled seeing CNA A later that night and indicated she made him feel “this big,” using his fingers to show something small, and that she made him feel like she wanted nothing to do with him. CNA A reported that she did not remember the exchange, stated she was probably “playing,” and acknowledged she sometimes just said things even though she was not familiar with the resident. She also stated she was aware of the camera in the room and believed the issue might have been related to telling the resident he had feces on his hands. Facility leadership, including the DON and ADM, described the family’s report that CNA A was disrespectful and unprofessional, and the ADM characterized CNA A’s “talking in riddles” comment as inappropriate. The facility’s written policy on Resident Rights and Responsibilities stated that residents are to be informed of their rights and that resident rights information is to be made available and posted, but the observed interaction showed the resident was not treated in a manner that promoted dignity and respect as required.
Failure to Immediately Notify Provider and Representative of Resident Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician and representative when a significant change in the resident's condition was reported. A family member contacted the facility after noticing the resident had slurred speech and altered mental status. The nurse on duty assessed the resident but did not document the family’s concerns or her assessment, nor did she notify the provider or communicate the event to the next shift. There was no documentation of any changes in the resident’s condition in the 24-hour report or progress notes for that day. The following day, the family member followed up and again expressed concern. The nurse practitioner was then notified, assessed the resident, and, after discussion with the family, arranged for the resident to be sent to the hospital for evaluation. Upon hospital admission, the resident was diagnosed with an acute ischemic stroke. Prior to this event, the resident had a history of metabolic encephalopathy, difficulty walking, and high blood pressure, but was able to ambulate with supervision and had only moderate cognitive impairment. Interviews with facility staff revealed that the nurse on duty at the time of the initial report did not follow facility policy regarding documentation and notification of changes in condition. The nurse practitioner and DON confirmed that immediate notification of the provider and documentation are required when a change in condition is reported, regardless of the day of the week. The delay in notification and lack of documentation resulted in a delay in the identification and treatment of the resident’s stroke.
Delayed Response to Stroke Symptoms and Failure to Discontinue Mid-Line Catheter
Penalty
Summary
A facility failed to provide timely assessment and intervention for a resident who exhibited signs and symptoms of a stroke, including slurred speech, altered mental status, and fatigue. The resident's family member reported these symptoms to nursing staff on a Sunday, but the nurse on duty did not document the complaint, did not notify the provider or facility administration, and did not communicate the events to the night shift nurse. The nurse attributed the symptoms to possible early dementia and suggested a psychiatric consultation for the following day, without performing or documenting a thorough assessment or following the facility's change in condition protocol. The following day, another nurse was notified of the family’s concerns and performed an assessment, noting decreased cognition and slower speech. The nurse then notified the nurse practitioner, who ordered laboratory tests and, after discussion with the family, arranged for the resident to be transferred to the hospital for further evaluation. Upon hospital admission, the resident was diagnosed with an acute ischemic infarct (stroke) and experienced a significant decline in activities of daily living, requiring substantial assistance for mobility and care. Interviews with facility staff and review of records confirmed that the initial report of stroke symptoms was not acted upon for over 24 hours, and required notifications and documentation were not completed as per facility policy. Additionally, the facility failed to obtain a timely physician order to discontinue a mid-line catheter for another resident after completion of IV antibiotic therapy, resulting in the device remaining in place for an extended period without medical necessity. These failures were identified through observation, interviews, and record review, and were found to be inconsistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a sacral pressure ulcer, consistent with professional standards of practice. The resident, who was admitted with a stage III pressure ulcer, did not have the wound properly assessed or treated in a timely manner. The facility did not notify the physician or obtain wound care orders from 1/24/25 to 1/27/25, and there was no documentation of the wound's size until 1/27/25. This lack of timely intervention and documentation could have placed the resident at risk for worsening wounds, infection, and hospitalization. Upon admission, the resident was identified as high risk for pressure ulcers due to her medical conditions, including severe protein-calorie malnutrition, COPD, and dementia. Despite this, the facility's staff failed to follow the protocol for assessing and documenting the resident's skin condition. The Wound Care Nurse did not perform a skin assessment until three days after admission, and the initial nurse did not inform the physician about the wound during the admission process. Additionally, there was a lack of communication and coordination among the staff, leading to the wound being left uncovered and untreated for several days. Interviews with staff revealed a breakdown in communication and adherence to protocols. The Wound Care Nurse was not adequately trained and did not know to call the Wound Care MD for orders. The DON acknowledged that the Wound Care Nurse did not complete a head-to-toe assessment and failed to cover the wound. The facility's policy required that any changes in the resident's skin condition be communicated to the physician, but this was not done in a timely manner, contributing to the deficiency.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 12% due to three errors out of 25 opportunities. The errors involved three residents who did not receive their medications as prescribed. One resident was given an incorrect dose of Trintellix, a medication for major depressive disorder, due to a pharmacy error and oversight by the medication aide. The aide administered a 5mg dose instead of the prescribed 10mg, and the discrepancy was not reported immediately to the charge nurse. Another resident was given a standard multivitamin instead of the prescribed Occuvite Eye + Multivitamin with Minerals, which is intended to support eye health. The medication aide misunderstood the physician's order and was unaware of the specific purpose of the medication, leading to the administration of the incorrect supplement. This resident had a history of macular degeneration, making the correct administration of the prescribed supplement crucial. The third resident received a Lidocaine 5% patch instead of the ordered Aspercreme 4% Lidocaine for pain management. The RN administering the medication did not verify the current physician's order, resulting in the application of an incorrect medication. This resident had a history of osteoarthritis and required accurate pain management to maintain her quality of life. The facility's failure to ensure proper medication administration procedures contributed to these errors, potentially impacting the residents' therapeutic outcomes.
Deficient Documentation of Controlled Substances
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically regarding the administration and documentation of controlled substances for two residents. For one resident, the Medication Administration Record (MAR) for June 2024 was incomplete, as RN M did not document or sign off on the administration of Oxycodone with Acetaminophen, a controlled substance prescribed for pain. Similarly, for another resident, the MAR for April 2024 was incomplete, with RN M failing to document or sign off on the administration of Hydrocodone with Acetaminophen, also a controlled substance for pain relief. Additionally, the facility staff failed to sign the correct narcotic count sheets for both residents' medications. The narcotic count sheet for the first resident's Oxycodone with Acetaminophen was not signed correctly, and the same issue was observed with the second resident's Acetaminophen/Codeine. This discrepancy in documentation could potentially affect the residents' care and treatment, as accurate records are crucial for ensuring proper medication administration. Interviews with staff, including the Director of Nursing (DON) and RN A, revealed that the nurses were signing out medications on incorrect count sheets, and there was a lack of proper reconciliation of narcotic records. The DON acknowledged the importance of accurate documentation to prevent drug diversion and ensure the safety of residents. The facility's policies and procedures for medication administration and controlled drugs emphasize the need for accurate record-keeping, which was not adhered to in these instances.
Failure to Develop Comprehensive Baseline Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered admission baseline care plan within 48 hours of admission for a resident diagnosed with pneumonia. The resident, a male with severe cognitive impairments, was admitted with multiple diagnoses including pneumonia, type 2 diabetes mellitus, epilepsy, chronic diastolic heart failure, obstructive hydrocephalus, and hyperlipidemia. Despite these conditions, the baseline care plan for the resident was incomplete, lacking focus, goals, and interventions, particularly for pneumonia. Interviews with facility staff revealed that the resident's pneumonia diagnosis was not included in the care plan, which was acknowledged as an oversight. The RN responsible for the care plan admitted to mistakenly documenting the antibiotic treatment for sepsis instead of pneumonia. The MDS Nurse and ADON also confirmed the omission, emphasizing the importance of including pneumonia in the care plan to monitor respiratory interventions and track the infection's progression. The facility's policy requires the development and implementation of a baseline care plan within 48 hours of admission, including necessary healthcare information and instructions for effective, person-centered care. However, this policy was not adhered to in the case of the resident, as the care plan did not address the pneumonia diagnosis, potentially impacting the resident's care and treatment outcomes.
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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 Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cypress Pointe Health & Wellness | 2.5 mi | — | 12 | 0 |
| Eagle Crest Rapid Recovery | 2.8 mi | — | 26 | 3 |
| Cypress Creek Rehabilitation And Healthcare Center | 4.9 mi | — | 4 | 0 |
| Fallbrook Rehabilitation And Care Center | 5.7 mi | — | 16 | 3 |
| Park Manor Of Cyfair | 5.7 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.