Copperas Hollow Nursing & Rehabilitation Center
345 Country Club Dr, Caldwell, TX 77836 · Burleson County · 90 certified beds · avg 45 residents/day · certified since Jun 26, 2009
Part of chain: CREATIVE SOLUTIONS IN HEALTHCARE (149 facilities, chain avg rating 2.1★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · May 7, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Jun 3, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 18, 2025 · F-0742 · triggered by a complaint
The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD).
Why it matters: Residents with mental health needs who go untreated can suffer worsening symptoms, distress, and isolation.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 19, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (24)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 11, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Nov 19, 2025 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Aug 28, 2025 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| May 7, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 7, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jan 18, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint |
| Jan 18, 2025 | E · Potential for harm, repeated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Jul 23, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jul 11, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Jul 11, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 21, 2023 | E · Potential for harm, repeated | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Aug 21, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Aug 21, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| May 25, 2023 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| May 25, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 25, 2023 | E · Potential for harm, repeated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| May 25, 2023 | E · Potential for harm, repeated | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| May 25, 2023 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| May 25, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 25, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (5 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 10 | 0 | F |
| 2024 | 6 | 0 | E |
| 2025 | 7 | 2 | K ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $49,901.
| Date | Type | Amount / length |
|---|---|---|
| May 7, 2025 | Fine | $34,776 |
| Jan 18, 2025 | Fine | $15,125 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.37 | 3.46 | 3.95 | top 45% in Texas; bottom 30% in the U.S. |
| Registered Nurse hours | 0.29 | 0.44 | 0.69 | bottom 26% in Texas; bottom 9% in the U.S. |
| Weekend total nurse staffing | 3.07 | 3.04 | 3.50 | top 37% in Texas; bottom 34% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.21 | 0.34 | 0.48 | bottom 24% in Texas; bottom 13% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 55.3 | 45.8 | — |
| RN turnover (%) | 0.0 | 54.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.30, RN 0.28, weekend 3.00. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Byrom, David | Individual | 5% or Greater Indirect Ownership Interest | — | 01/01/2014 |
| Byrom, David | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/01/2014 |
| Byrom, David | Individual | Corporate Director | NOT APPLICABLE | 01/01/2014 |
| Byrom, David | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2014 |
| Coryell County Memorial Hospital Authority | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2014 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What mental health services do you offer on-site, and how do you care for residents with depression, anxiety, or a history of trauma?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Avir at Caldwell | 2.6 mi | Caldwell, TX | ★☆☆☆☆ | 1/5 |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 676227.