Copperas Hollow Nursing & Rehabilitation Center

F-F742

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 9 676227 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676227 B. Wing 01/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 On 01/17/2025 an abbreviated survey was initiated at the facility. On 01/17/2025 the surveyor provided an Immediate Threat (IJ) Template notification that the Regulatory Services has determined that the condition at Level of Harm - Immediate the facility constitutes an immediate threat to resident health and safety. jeopardy to resident health or safety The notification of Immediate Threat states as follows: The facility failed to provide a response to Resident #1's dementia related mood disturbance behavior. Residents Affected - Few Action:

5. Resident #1 currently does not reside in the facility as of 1/17/25.

6. The DON/ADON audited all psychology and psychiatry orders for active residents over the last 6 months. Two residents were identified, and both are actively receiving psychiatric services. This was completed on 1/17/25. The facility has 11 total residents on psych services and 2 of those were referred to psych services within the last 6 months.

7. The Administrator and DON will be responsible for initiating all psychological and psychiatry referrals to

the provider. This will start 1/17/25.

8. The Administrator DON, and ADON were in serviced 1:1 by the Regional Compliance Nurse on the following topics below on 1/17/25.

E. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect.

F. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP.

G. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP.

9. The Medical Director was notified of the immediate jeopardy on 01/17/2025 by the Administrator.

10. An ADHOC QAPI meeting was completed with interdisciplinary team on 01/17/2025 which included the Medical Director, Administrator, Director of Nursing, and Assistant Director of Nursing to discuss the citations and plan of removal.

In-services

The Administrator and DON initiated the following in-services for Licensed Nurses. Training began 01/17/2025 and will be completed 01/17/2025. 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.

11. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 9 676227 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676227 B. Wing 01/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 12. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate Level of Harm - Immediate treatment and services ordered by a physician or NP. jeopardy to resident health or safety 13. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP. Residents Affected - Few

The Administrator and DON initiated the following in-services for all staff. Training began 01/17/2025 and will be completed 01/17/2025. 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.

A. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect.

Surveyor Monitoring:

The administrator and/or DON will review all orders daily x 5 days a week for any orders in reference to psychological and psychiatry services to ensure that all referrals have been initiated. This will begin 1/17/25 and end on 2/14/25.

Interview with the DON confirmed that a facility audit was conducted of all psychology and psychiatry orders for active residents over the last 6 months. Reviewed the orders for the two residents who were identified and confirmed they both are actively receiving psychiatric services by reviewing most recent psychiatric records.

Interview with the Administrator and DON confirmed they will be responsible for initiating all psychological and psychiatry referrals to the facility contracted provider.

Interview with the ADM and DON (ADON unable to interview the ADON because of family medical emergency) that they were in serviced by the Regional Compliance Nurse on the following topics below on:

Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to

a resident could be considered abuse and neglect.

Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP.

Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP.

Reviewed documentation that the Medical Director was notified of the immediate jeopardy on 01/17/2025 by

the Administrator and an ADHOC QAPI meeting was completed with interdisciplinary team on 01/17/2025 which included the Medical Director, Administrator, Director of Nursing, and Assistant Director of Nursing to discuss the citations and plan of removal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 9 676227 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676227 B. Wing 01/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0742 During interviews on 01/18/25 from 12:07 pm - 2:29 pm six nurses all from various shifts all stated they were in-serviced prior to their assigned shift on: Level of Harm - Immediate jeopardy to resident health or . safety 1. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services Residents Affected - Few to a resident could be considered abuse and neglect.

2. Behavioral Management Policy: Addressing residents who display mental disorders, psychosocial disorders, or who have a history of PTSD, ensuring that residents are assessed and receive appropriate treatment and services ordered by a physician or NP.

3. Following Physician Orders Policy: to include notifying the provider to initiate psychology and/or psychiatric referrals when ordered by a physician or NP.

During interviews on 01/18/25 from 12:07 pm - 2:29 pm six CNAs, two medication aides, and 1 dietary across various shifts all stated they were in-serviced prior to their assigned shift on:

A. Abuse and Neglect Policy: Failure of the facility to initiate and provide psychological or psychiatric services to a resident could be considered abuse and neglect.

The ADM was notified on 01/18/2025 at 2:54 PM, that the IJ had been removed. While the IJ was removed,

the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to

the facility's need to evaluate the effectiveness of the corrective systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 9 676227 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676227 B. Wing 01/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46708

Residents Affected - Some Based on interview, and records review, the facility failed to ensure that medical records were accurately documented for one (Resident #2) of five residents reviewed for accurate clinical records

The facility failed to ensure Resident #2's progress notes and assessments reflected he was slapped by another resident as reported in a facility self-report.

This deficient practice could place residents at risk for errors in care and treatment.

Findings included:

Review of Resident #2's face sheet dated 01/03/25 reflected a [AGE] year-old male who was originally admitted to the facility on [DATE REDACTED] with diagnoses that included Alzheimer's disease, type 2 diabetes, and major depressive disorder.

Review of Resident #2's BIMS assessment dated [DATE REDACTED] reflected a BIMS score of 14, reflecting intact cognition.

Review of Resident #2's quarterly MDS dated [DATE REDACTED] reflected an active diagnosis of non-traumatic brain dysfunction (a complex condition that occurs when the brain is damaged by internal factors, rather than an external force to the head).

Review of Resident #2's care plan focus, dated 01/14/20 and revised 12/17/21 revealed impaired cognition function/dementia and impaired thought processes. No entry was made in Resident #2's care plan discussing being slapped by another resident on 07/24/24.

Facility self-report dated 07/24/24 reflected on 07/24/24 Resident #2 reported to the DON that another resident slapped him, open handed in his mouth.

Review of Resident #2's weekly skin assessments reflect no assessments for the date of 07/24/24.

Resident #2's nursing progress notes reflect no entries dated 07/24/24.

Interview on 01/03/25 with the area director of operations at 12:48 pm reflected she was not aware the incident had occurred and when she investigated it on 01/03/25, approximately 6 months after the facility self-report, she learned from staff that Resident #2 was not slapped by another resident. A resident attempted to slap him but missed. The area director of operations she spoke to Resident #2 on 01/03/25 and

he did not remember being hit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 9 676227 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 676227 B. Wing 01/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Copperas Hollow Nursing & Rehabilitation Center 345 Country Club Dr Caldwell, TX 77836

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of facility policy, documentation, date 05/2015 reflected documentation is the recording of all information, both objective and subjective, in the clinical record of an individual resident. It includes Level of Harm - Minimal harm or observations, investigations, and communications of the resident involving care and treatments. It has legal potential for actual harm requirements regarding accuracy and completeness, legibility and timing. Special forms in the clinical record are utilized in nursing documentation, such as assessment, care plan, nursing progress notes, flow sheets, Residents Affected - Some medication sheets, incident reports, and summary sheets (daily, weekly, monthly, discharge). Documentation also occurs in the clinical software Point Click Care (PCC).

Goal

1. The facility will maintain complete and accurate documentation for each resident on all appropriate clinical

record sheets.

2. The facility will ensure that information is comprehensive and timely and properly signed.

Procedure

Document completed assessments in a timely manner and per policy.

Complete documentation in narrative nursing notes as needed in a timely manner. Each entry will be dated and timed. Each entry will be signed with proper signature and title. If PCC is used for the assessment the signature and title of the person entering the information will be signed by entering their password

Daily documentation X 72 hours will be required for each shift for new admissions, during and following an acute episode, following an incident, and during physiologic, mental, or emotional changes or instability.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 9 676227