Copperfield Healthcare And Rehabilitation
Copperfield Healthcare and Rehabilitation in Houston, TX — inspection on September 17, 2025.
Found 14 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
676230 09/17/2025
Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095
Federal health inspectors cited Copperfield Healthcare and Rehabilitation in Houston, TX for a deficiency under regulatory tag F-F0583 during a standard health inspection conducted on 2025-09-17.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Keep residents' personal and medical records private and confidential.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Copperfield Healthcare and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-11.
Federal health inspectors cited Copperfield Healthcare and Rehabilitation in Houston, TX for a deficiency under regulatory tag F-F0640 during a standard health inspection conducted on 2025-09-17.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Copperfield Healthcare and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-11.
Observation on 09/09/25 at 9:47AM of Resident #84 in room sitting on the left side of her bed. Resident #84 had mobility bars on her bed.
Interview on 9/14/2025 at 10:59AM, the DON said the purpose of the care plan was to put intervention in place for residents' condition.
The DON said the facility communicated interventions for staff to see by placing them in resident's medical records, communicating between nursing shifts through 24-hour reports and putting in ancillary or acute orders for staff to ensure interventions were being done for residents.
The DON said care plans were individualized, so if residents were not care-planned for diagnoses or conditions, residents could have a decline due to not being treated and missing potential treatments.
The DON said care plans were also utilized to let staff know that residents were stable.
The DON said both herself and the MDS nurses were responsible for ensuring the residents had comprehensive centered care plans.
Interview with the Administrator on 9/14/2025 at 11:48am, said the DON was responsible for ensuring residents were receiving treatments for their diagnoses.
The Administrator said if resident did not get treatments for diagnoses, it could affect their quality of life.
The Administrator said the purpose of a care plan was an individualized intervention, and if they were not care-planned their condition would not get addressed.
Interview on 09/16/25 at 10:20AM with the MDS nurse said she had been working at the NF for over a year and became the MDS nurse September 01, 2025.
The MDS nurse said she was responsible for Resident 84's care plan.
The MDS nurse said it was important for the residents to have person-centered care plans to address the residents' diagnoses and needs.
The MDS nurse said interventions also needed to be put in place to set obtainable goals, and to reduce the risk of further complications.
The MDS nurse said she was not aware that Resident #84 was not being care planned for mobility bars.
The MDS nurse said she recognized now that mobility bars needed to be specifically care planned for, because it placed the residents at risk for falls, entrapment, skin alterations such as skin tears, or other injuries.Interview on 09/16/25 at 10:30AM with MDS Coordinator said she was Resident #84's MDS nurse prior to MDS nurse.
The MDS Coordinator said she was aware that Resident #84 had mobility bars on her bed.
Further interview with the MDS Coordinator said it was an oversite on her part that Resident #84 was not care planned for mobility bars.
Record review of the facility policy on Comprehensive Person-Centered Care Planning last revised April 2025 reflected in part: .It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.
The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, which includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.
676230 09/17/2025
Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095
- On 09/14/25 the facility completed an audit on the 24-hr. report for 09/13/25.
An IJ was identified on 09/10/25.
The IJ template was provided to the Administrator on 09/10/25 at 01:06 PM.
While the IJ was removed on 09/14/25 at 02:04 PM, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal.
676230 09/17/2025
Copperfield Healthcare and Rehabilitation 7107 Queenston Blvd Houston, TX 77095
Federal health inspectors cited Copperfield Healthcare and Rehabilitation in Houston, TX for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-09-17.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Copperfield Healthcare and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-11.
Federal health inspectors cited Copperfield Healthcare and Rehabilitation in Houston, TX for a deficiency under regulatory tag F-F0693 during a standard health inspection conducted on 2025-09-17.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Copperfield Healthcare and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-11.
Federal health inspectors cited Copperfield Healthcare and Rehabilitation in Houston, TX for a deficiency under regulatory tag F-F0694 during a standard health inspection conducted on 2025-09-17.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Copperfield Healthcare and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-11.
Federal health inspectors cited Copperfield Healthcare and Rehabilitation in Houston, TX for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-09-17.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Copperfield Healthcare and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-11.
Federal health inspectors cited Copperfield Healthcare and Rehabilitation in Houston, TX for a deficiency under regulatory tag F-F0700 during a standard health inspection conducted on 2025-09-17.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Scope/Severity Level K: pattern, immediate jeopardy to resident health or safety.
This represents an immediate jeopardy situation, the most serious level of deficiency.
This was one of 14 deficiencies cited during this inspection of Copperfield Healthcare and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-11.
Federal health inspectors cited Copperfield Healthcare and Rehabilitation in Houston, TX for a deficiency under regulatory tag F-F0760 during a standard health inspection conducted on 2025-09-17.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure that residents are free from significant medication errors.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Copperfield Healthcare and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-11.
Federal health inspectors cited Copperfield Healthcare and Rehabilitation in Houston, TX for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-09-17.
Category: Pharmacy Service Deficiencies
The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Copperfield Healthcare and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-11.
prevent cross contamination and infections. RN E said it was important to wash hands before putting
resident care equipment which included blood pressure devices and blood glucose machines after
infections. RN E said the reason he was not practicing infection control regarding handwashing/sanitizing hands and sanitizing resident care equipment was because he must have gotten in a hurry and forgot. RN E said this placed the residents at risk for cross contamination and infections.
Interview on 09/11/25 at 10:58 AM, LVN M said resident personal care items such as wash pans should be labeled and bagged separately to prevent cross contamination and infections.
LVN M said it was the CNA's who were supposed to label resident wash pans and bag them separately. LVN M said it was the nurse's responsibility to ensure was being done.
Interview on 09/11/25 at 11:09 AM, the DON said the resident personal care items were supposed to be labeled and bagged to prevent cross contamination.
The DON said the facility had not designated this task to anyone yet.
The DON said the facility had just hired a new staff member who would be taking the resident weights and this particular staff member would be assuming the role of making sure all resident personal care items were labeled and bagged.
The DON said although this role had not been assigned to the new hire, the nurses and the CNA's were responsible in making sure residents personal care items were labeled and bagged.
Record review of the facility's policy on Equipment cleaning, revised May 2007, reflected in part: .It is the policy of this facility to implement the following procedures to ensure equipment is cleaned and care for appropriately.
Durable medical equipment must be cleaned before reuse by another resident.Reusable resident items are cleaned and disinfected between residents .
Record review of the facility's policy on Hand Hygiene, revised April 2025, reflected in part: .It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards.
Residents, family, and visitors will be encouraged to practice hand hygiene.Hand hygiene after removing gloves.
Federal health inspectors cited Copperfield Healthcare and Rehabilitation in Houston, TX for a deficiency under regulatory tag F-F0921 during a standard health inspection conducted on 2025-09-17.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 14 deficiencies cited during this inspection of Copperfield Healthcare and Rehabilitation.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-10-11.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.