Health inspection·December 10, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 3 of 8 residents (Residents #1, #2, & #3) reviewed for resident rights.The facility failed to ensure Residents #1, #2, & #3's call lights were within reach on 12/09/2025.This failure could place residents at risk of their needs not being metFindings include:Record review of Resident #1's admission record, dated 12/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: Epilepsy (a brain disorder causing recurrent seizure), Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), and muscle weakness (loss of strength in muscles making it difficult to move or perform physical task).Record review of Resident #1's admission MDS assessment, dated 10/15/2025, reflected Resident #1 had a BIMS score of 99, which indicated severe cognitive impairment. Resident #1 was dependent in the areas of shower/bathe self, upper body dressing, lower dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #1's care plan, dated 12/10/2025, reflected Resident #1 was care planned for high risk for fall r/t unaware of safety needs, gait/balance problems, and seizure activity. Resident #1 had an intervention of be sure the resident's call light is within reach and encourage the resident to use it. During observations on 12/09/2025 at 10:29am and 2:47pm, Resident #1's call light was observed hanging towards the ground on the right side of her bed Resident #1 could not be interviewed due to her cognitive status. Record review of Resident #2's admission record, dated 12/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: chronic idiopathic constipation (long last/frequent constipation), essential primary hypertension (high blood pressure), unsteady feet (feeling wobbly, off balance, or like you might fall while walking or standing), and muscle weakness (loss of strength in muscles making it difficult to move or perform physical task).Record review of Resident #2's Quarterly MDS assessment, dated 10/08/2025, reflected Resident #2 had a BIMS score of 07, which indicated severe cognitive impairment. Resident #2 was dependent in the areas of toileting hygiene, shower/bathe self, upper body dressing, lower dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #2's care plan, dated 12/10/2025, reflected Resident #2 was care planned for at risk for falls. Resident #2 had an intervention of be sure the resident's call light is within reach and encourage the resident to use it. During an observation on 12/09/2025 at 10:31am, Resident #2's call light was observed hanging towards the ground on the left side of his bed. During an interview with Resident #2 on 12/09/25 at 10:31am, Resident #2 stated that he could not reach his call light, and he would have to yell for assistance if he needed it. Resident #2 stated his call light was never in reach and must wait for staff to pass by to get assistance. Record review of Resident #3's admission record, dated 12/10/2025, Residents Affected - Some Page 1 of 2 455515 455515 12/10/2025 Copperas Cove Nursing & Rehabilitation 607 W Ave B Copperas Cove, TX 76522

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #3 had diagnoses which included: type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood without any common health problems associated with the disease), gastro esophageal reflux disease without esophagitis (when stomach acid frequently flows back up into food pipe causing irritation, heartburn, and a sour taste), and Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills)Record review of Resident #3's admission MDS assessment, dated 10/06/2025, reflected Resident #3 had a BIMS score of 15, which indicated Resident #3 was cognitively intact. Resident #3 required partial/moderate assistance in the areas of oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower dressing, putting on/taking off footwear and personal hygiene. Record review of Resident #3's care plan, dated 12/10/2025, reflected Resident #3 was care planned for ADL self-care performance deficit r/t Alzheimer's with an intervention of encourage the resident to use bell to call for assistance. During an observation on 12/09/2025 at 10:58am, Resident #3's call light was observed approximately 3 feet away from him and out of reach. During an interview with Resident #3 on 12/09/25 at 10:58am, Resident #3 stated that he could not reach his call light, and he would have to get out of bed and crawl to get it. Resident #3 stated he did not know how long his call light had been out of reach. During an interview with CNA A on 12/09/2025 at 2:10 PM, CNA A stated she was providing care for Resident #3 during the time his call light was not within reach. CNA A stated she moved the call light when she was assisting Resident #3 and forgot to put it back within reach. CNA A stated a negative outcome could be that the resident would not be able to call for assistance if he needed. During an interview with CNA B on 12/09/2025 at 2:30 PM, CNA B stated she was providing care for Resident #2 during the time his call light was not within reach. CNA B stated she was not aware that Resident #2's call light was not within his reach. CNA B stated a negative outcome could have been the resident could have fallen attempting to get assistance from staff. During an interview with the DON on 12/09/2025 at 3:45 PM, the DON stated all residents' call lights should be always within reach. The DON stated it was everyone's responsibility to ensure residents call lights were always within reach. The DON stated if a resident's call light was not within reach, the resident would not be able to call for assistance.During an interview with the ADM on 12/09/2025 at 4:00 PM, the ADM stated call lights should always be within reach. The ADM stated it was everyone's responsibility to ensure the call lights were within reach. The ADM stated if a resident's call light was not within reach, then the residents would not be able to express their needs nor have their needs met. The ADM stated her expectation was for staff members to ensure call lights were within reach prior to existing the resident's rooms.A record review of the facility's Answering the Call Light policy, dated 2001, reflected The purpose of this procedure is to ensure timely responses to the resident's requests and needs.General Guidelines5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 455515 Page 2 of 2