F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to ensure that residents received treatment and care in
accordance with professional standards of practice and the comprehensive person-centered care plan, for
1 of 3 residents (Resident #1) reviewed for quality of care.
Residents Affected - Few
The facility failed to follow physician's orders and the comprehensive care plan to monitor Resident #1 for
edema.
This failure could place residents at risk for untreated medical issues and diminished quality of care.
Findings included:
Review of Resident #1's quarterly MDS assessment, dated 06/19/24, Section A (Identification Information)
reflected a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE].
Section I (Active Diagnoses) reflected diagnoses including heart failure (heart disease that affects pumping
action of the heart muscles), hypertension (high blood pressure), anemia (lack of red blood cells in the
blood), renal insufficiency (impaired kidney function), diabetes (a condition that affects the way the body
processes blood sugar), chronic obstructive pulmonary disease (a lung disease limiting air flow from the
lungs), and chronic respiratory failure with hypoxia (not enough oxygen in the blood). Section C (Cognitive
Patterns) reflected a BIMS score of 8 indicating moderately impaired cognition. Section N (Medications)
reflected Resident #1 took diuretic medication (medicines that increase urine production and help lower
blood pressure and fluid retention).
Review of Resident #1's comprehensive care plan, initiated 06/05/24, reflected a Focus: The resident has
Congestive Heart Failure. The Goal reflected: The resident will have clear lung sounds, heart rate, and
rhythm within normal limits through the review date. Interventions included: Give cardiac medications as
ordered. Monitor/document/report to MD PRN any s/sx of congestive heart failure: dependent edema of
legs and feet, periorbital edema (edema around the eyes), shortness of breath upon exertion, cool skin .
Review of Resident #1's Order Summary, reflected a physician's order dated 07/01/24, Monitor edema
every shift.
Review of Resident #1's medication administration record and treatment administration record, both for July
2024, reflected no monitoring of edema each shift as ordered by the physician.
During an interview on 07/23/24 at 1:35 PM, the REGN stated, she would expect to see edema
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
676227
Printed: 05/15/2026
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
676227
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/23/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
monitoring on the treatment administration record since the doctor had ordered edema to be monitored
each shift. After review of the order, she stated the order was not correctly entered into the computer
system so the order was not reflected on the treatment administration record. She stated the DON and
ADON were responsible for monitoring the physician's orders. She stated if staff did not monitor edema,
they would not have known if the resident had a change in her edema.
Residents Affected - Few
During an interview on 07/23/24 at 1:55 PM, the DON stated the charge nurse was usually responsible for
entering and initiating physician orders when received from the provider. She stated the order to monitor
edema each shift should have been on the treatment administration record. She stated not monitoring
edema could lead to an increase in symptoms or change in condition that was not noticed timely. She
stated the ADON usually monitored the new orders.
During an interview on 07/23/24 at 2:01 PM, the ADM stated physician orders needed to be accurately
transcribed when entered in the computer. She stated she was not a clinical person but knew the
physician's orders should have been followed. She stated the DON was responsible for monitoring the
physician's orders.
Review of a document from the Medical Records Manual 2015, titled Physician Orders, reflected in part,
Purpose: To monitor and ensure the accuracy and completeness of the medication orders, treatment
orders, and ADL order for each resident . Verbal or Telephone Orders by the physician or nurse practitioner
3. The nurse will enter the order into the Electronic Medical Record for the resident and select either verbal
or telephone, depending on how the nurse received the order. 4. If the order requires documentation, it will
be directed to the proper electronic administration once the order is completed .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676227
If continuation sheet
Page 2 of 2
