Copperas Hollow Nursing & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Copperas Hollow Nursing & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF760May 7, 2025

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

• Immediate jeopardy, isolatedF742Jan 18, 2025

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

• Actual harm, isolatedF689Mar 12, 2023

  Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #1 was supervised in the dining room prior to meal service when she attempted to ambulate and fell resulting in overnight hospitalization due to a laceration to her forehead and small amounts of bleeding between the brain and its outer covering. […]

• Actual harm, isolatedF600Jan 28, 2021

  Based on interview and record review the facility failed to ensure that residents were free from neglect for one (1) of five (5) residents reviewed for neglect, in that Resident #1 exhibited signs and symptoms of a UTI on 01/01/2021(foul smelling, dark urine) Resident #1's physician ordered a UA C&S which was collected on 01/01/2021 by the facility but not sent to the lab. The facility failed to ensure a system was in place to track the collecting and reporting of lab results. Resident #1 did not receive treatment for 22 days from the onset of her UTI symptoms until 01/22/2021. On 01/23/2021 Resident #1 was admitted to the hospital and diagnosed with [REDACTED]. Resident #1's Foley was clogged, and the resident had 2 liters of urine in her bladder. […]

• Actual harm, isolatedF690Jan 28, 2021

  Based on interview and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services for one (1) of three (3) residents reviewed for indwelling urinary catheters (Foley), in that Resident #1 exhibited signs and symptoms of a UTI on 01/01/2021(foul smelling, dark urine) Resident #1's physician ordered a UA C&S which was collected on 01/01/2021 by the facility but not sent to the lab. Resident #1 did not receive treatment for 22 days from the onset of her UTI symptoms until 01/22/2021. On 01/23/2021 Resident #1 was admitted to the hospital and diagnosed with [REDACTED]. Resident #1's Foley was clogged, and the resident had 2 liters of urine in her bladder. […]