CALDWELL, TX - A complaint investigation at Copperas Hollow Nursing & Rehabilitation Center on January 18, 2025, resulted in federal regulators issuing an immediate jeopardy citation after discovering the facility failed to arrange required psychiatric services for a resident with dementia-related behavioral disturbances.
Failure to Arrange Required Psychiatric Care
The most serious violation identified during the complaint investigation centered on the facility's failure to provide psychiatric and psychological services to Resident #1, who required professional mental health intervention for dementia-related mood and behavioral issues. When a physician or nurse practitioner orders specialty mental health services, federal regulations require facilities to arrange and ensure those services are delivered in a timely manner.
Federal surveyors determined this failure posed an immediate threat to resident health and safety, triggering the highest level of enforcement action available. An immediate jeopardy designation indicates conditions exist that could cause serious injury, harm, impairment, or death to residents at any time.
According to the inspection findings, the facility had not initiated the ordered psychiatric referral, leaving the resident without access to specialized mental health evaluation and treatment. The resident was no longer living at the facility by the time surveyors arrived on January 17, 2025.
Dementia-related behavioral disturbances require specialized psychiatric assessment to determine appropriate interventions. Without proper evaluation, residents may experience worsening agitation, increased risk of falls, decline in function, and potential harm to themselves or others. Psychiatric specialists can identify underlying causes of behavioral changes, adjust medications, and recommend non-pharmacological approaches tailored to each individual's needs.
Systemic Gaps in Mental Health Service Coordination
The investigation revealed broader concerns about the facility's systems for ensuring residents received ordered specialty services. Following the immediate jeopardy notification, facility leadership conducted an audit of all psychology and psychiatry orders for current residents over the previous six months. This review identified only two residents who required such services, and both were actively receiving psychiatric care at the time of the audit.
However, the facility's tracking revealed 11 total residents were receiving psychiatric services, with two of those referrals initiated within the prior six months. This discrepancy suggests potential gaps in the facility's oversight mechanisms for monitoring whether ordered services are actually being delivered.
The breakdown in coordination meant that despite a clear physician order for psychiatric evaluation, no referral was made to the facility's contracted mental health provider. This type of system failure can occur when facilities lack clear protocols for who is responsible for initiating referrals, tracking follow-through, and documenting service delivery.
Mental health services represent a critical component of comprehensive nursing home care, particularly for residents with dementia, depression, anxiety, or post-traumatic stress disorder. Federal regulations require facilities to provide or arrange for psychiatric and psychological services to meet residents' needs. When these services are ordered but not delivered, residents may deteriorate clinically, require hospital transfers that could have been prevented, or experience unnecessary suffering from untreated mental health conditions.
Inaccurate Documentation of Resident Incident
Beyond the immediate jeopardy violation, inspectors identified a separate deficiency related to incomplete and inaccurate clinical documentation for Resident #2, a resident with Alzheimer's disease, type 2 diabetes, and major depressive disorder.
On July 24, 2024, the facility filed a self-report indicating Resident #2 had been slapped in the mouth by another resident. However, when surveyors reviewed the resident's medical records six months later, they found no nursing progress notes documenting the incident on that date, no skin assessments performed on July 24, 2024, and no updates to the resident's care plan addressing the reported altercation.
The lack of documentation became more problematic when the facility's area director of operations investigated the matter on January 3, 2025—approximately six months after the alleged incident. During that delayed investigation, staff reported the other resident had attempted to slap Resident #2 but missed. When asked about the incident, Resident #2 could not remember being hit.
This discrepancy between the facility's official self-report (stating the resident was slapped) and the subsequent staff accounts (stating the other resident missed) raises questions about the accuracy of initial reporting and the thoroughness of immediate investigation. The absence of contemporaneous nursing notes, skin assessments, and care plan updates further complicated efforts to determine what actually occurred.
Accurate clinical documentation serves multiple essential functions in nursing home care. It creates a legal record of events, ensures continuity of care across shifts and staff changes, supports clinical decision-making, and enables quality monitoring. When incidents occur—whether actual contact or attempted contact between residents—federal standards require immediate assessment, documentation, and follow-up.
The facility's documentation policy, last updated in May 2015, specifically requires recording all objective and subjective information in residents' clinical records, including observations, investigations, and communications involving care and treatment. The policy emphasizes accuracy, completeness, legibility, and timeliness. For incidents specifically, the policy mandates daily documentation for 72 hours following any incident, during acute episodes, or when physiologic, mental, or emotional changes occur.
The absence of any documentation for Resident #2 on the date of the reported incident represents a clear departure from the facility's own standards. Without written records, staff on subsequent shifts would have no knowledge of the event, supervisors could not verify appropriate follow-up occurred, and the resident's care plan could not be modified to address increased risk of future incidents.
Immediate Corrective Actions and Ongoing Monitoring
Upon receiving the immediate jeopardy notification on January 17, 2025, facility leadership implemented several corrective measures aimed at preventing similar failures. The administrator and director of nursing assumed direct responsibility for initiating all psychological and psychiatry referrals to providers, removing this critical function from general nursing workflow where it had apparently been overlooked.
Leadership conducted mandatory training for licensed nurses covering three key policy areas: abuse and neglect (emphasizing that failure to provide ordered mental health services could constitute neglect), behavioral management for residents with mental disorders and PTSD, and protocols for following physician orders regarding specialty referrals. All nursing staff on duty received training on January 17, with arrangements made to train staff on other shifts, PRN employees, and agency personnel before their next scheduled work periods.
The facility also initiated daily monitoring by the administrator or director of nursing to review all orders for five weeks, specifically checking for any psychology or psychiatry referrals to ensure immediate action. This intensive oversight period, scheduled to run from January 17 through February 14, 2025, was designed to embed new practices and identify any remaining gaps in the referral process.
On January 18, 2025, surveyors interviewed six nurses from various shifts, six certified nursing assistants, two medication aides, and one dietary employee. All staff confirmed they had received training prior to their shifts on the abuse and neglect policy and related protocols.
Based on these corrective actions and staff interviews confirming training completion, surveyors notified the administrator at 2:54 PM on January 18, 2025, that the immediate jeopardy had been removed. However, the violation remained cited at a lower severity level, requiring the facility to demonstrate sustained compliance over time.
Additional Issues Identified
Inspectors also documented concerns about the facility's medical records system, noting the need to ensure all clinical documentation accurately reflects resident status and care provided. The investigation specifically examined the accuracy of progress notes and assessments across multiple residents' charts.
The inspection findings highlight the critical importance of systematic oversight in nursing home operations, particularly for specialized services that require coordination with outside providers. While the facility maintained contracts with psychiatric providers and the majority of residents requiring mental health services were receiving them, the breakdown in one case revealed vulnerabilities in the facility's tracking and accountability systems.
The facility's quality assurance committee, which includes the medical director, administrator, director of nursing, and assistant director of nursing, held an emergency meeting on January 17, 2025, to review the citations and discuss long-term improvements to prevent recurrence.
Federal regulations hold nursing homes to strict standards for providing or arranging all necessary services to help residents attain and maintain their highest practicable level of physical, mental, and psychosocial well-being. When facilities fail to deliver ordered mental health services, residents with treatable conditions may decline unnecessarily, and in cases involving behavioral disturbances, the safety of other residents may also be compromised.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Copperas Hollow Nursing & Rehabilitation Center from 2025-01-18 including all violations, facility responses, and corrective action plans.
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