Copperas Cove Nursing & Rehabilitation

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident, unless explicitly requested by the resident. If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information.When written translation of vital information is unavailable, or impractical (i.e., an infrequently encountered language), the facility shall attempt to provide oral translation of vital documents.Interpreters and translators must be appropriately trained in medical terminology, confidentiality of protected health information, and ethical issues that may arise in communicating health-related information.Written notification of language access rights may be provided by AI (a set of technologies that empowers computers to learn, reason, and perform a variety of advanced tasks in ways that used to require human intelligence) services online for communication via translation. Competent oral translation of vital information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility):A staff member who is trained and competent in the skill of interpreting;A staff interpreter who is trained and competent in the skill of interpreting;Contracted interpreter service;Voluntary community interpreters who are trained and competent in the skill of interpreting; andTelephone interpretation service.It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to

the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to EnglishIt is understood that in order to provide meaningful access to services provided by

this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual. Staff shall be trained upon hire and at least annually on how to provide language access services to LEP residents.

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If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Copperas Cove Nursing & Rehabilitation

607 W Ave B Copperas Cove, TX 76522

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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident. It was a resident rights issue.Interview on [DATE REDACTED] at 4:58 pm with the Administrator reflected nurse managers and the DON had the responsibility of checking the admission orders within the first 24 hours of

a resident's admission to make sure all documents and the admission was complete. She said there was a process that began with the charge nurse when the resident was admitted , to the admissions coordinator and the DON. She said the worst-case scenario if there was kink in the process of confirming if a resident had a DNR, was the resident could be resuscitated against their wishes, and when the resident's ultimate wishes were not respected, it was a violation of resident rights.Interview on [DATE REDACTED] at 6:02 pm with the DON reflected when the charge nurse admitted a resident, the nurse needed a hard copy of the DNR that was signed and executed, and if there was not a fully executed hard copy DNR, the resident was automatically a full code. She said she did not know what happened regarding Resident #1's DNR. The DON said RN H admitted Resident #1 and RN H would have had to have had the DNR in her hand to enter

the DNR order for Resident #1. The DON said she never saw a DNR for Resident #1. She said it caused Resident #1's family emotional distress when staff was going to provided Resident #1 CPR. She said a family member threatened bodily harm to the staff if they did not cease CPR because Resident #1 was a DNR.Record review of the facility's policy Do Not Resuscitate Order dated [DATE REDACTED] revealed Policy Statement - our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Policy Interpretation and Implementation - Do not resuscitate orders must be signed by the resident's attending physician on the physician's order sheet maintained in the resident's medical record. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record. Do not resuscitate (DNR) orders will remain in effect until the resident (or legal surrogate) provides the facility with

a signed and dated request to end the DNR order. Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request. Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet. The attending physician must be informed of the resident's request to cease the DNR order. The interdisciplinary care planning team will

review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. The resident's attending physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Copperas Cove Nursing & Rehabilitation

607 W Ave B Copperas Cove, TX 76522

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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

responsibility of the ADON to look at the RD recommendations and communicate the recommendation to

the physician. It would have been Resident #1's right to refuse the supplement, but it was the facility's responsibility to offer the supplements. Record review of the facility's undated Weight Assessment and Intervention policy revealed Policy Statement - The nursing staff and the Dietitian will cooperate to prevent, monitor, & intervene for undesirable weight loss for our residents. Policy Interpretation and Implementation The nursing staff will measure resident weights on admission and weekly x 4 weeks. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Significant weight loss will continue to be weighed weekly. All residents will be weighed monthly by the 10th. Weights will be recorded in Weight

Record chart in the individual's medical record. The dietician will also review the Weight Record by the 30th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the Dietitian whether or not the definition of Significant Weight Change is met. Significant Weight Changes are defined as: more or less than 5 percent within 30 days, more or less than 7.5 percent in 3 months; and more or less than I0 percent within 6 months. If a weight loss meets the definition of Significant, the Dietitian should discuss with the Interdisciplinary Team if a Significant Change MDS is necessary. Care Plan interventions will consider Severity of change, medical diagnosis (e.g., condition, prognosis, and stability); activities of daily living status, medications, psychological status, family input, resident preferences, and input from direct care givers. All team members will provide relevant information from their discipline to provide an interdisciplinary approach. Interventions for undesirable weight loss should focus first on food (example extra food, snacks, calorie-dense food), liquid nutritional supplements, per facility formulary may be considered if resident caloric intake remains inadequate to stabilize or increase weight. Interdisciplinary Team members should consider possible interventions relevant to their discipline. The physician my order tests. Appetite stimulants, or medications as appropriate. A weight loss regimen should not be initiated for a cognitively capable resident without his/her approval and involvement.

The Dietitian will discuss the weight issue with the resident and/or family. If a resident declines to participate

in a weight loss goal, the Dietitian will document the resident's wishes, and those wishes will be respected.

Event ID:

Facility ID:

If continuation sheet