Copley Health Center

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to ensure consistent and accurate advanced directives were maintained throughout the electronic and physical medical records. This affected five residents (#9, #14, #18, #96, and #128) of five residents reviewed for advanced directives. The facility census was 124.

Inspectors wroteBased on resident interviews, observation of lunch meal, observation of test tray, review of resident council minutes, and review of facility policy, the facility failed to ensure meals were served at a palatable temperature. This had the potential to affect all residents who received meals from the kitchen. The facility identified eight residents (#4, #23, #94, #96, #127, #131 #144, and #149) who were on nothing by mouth (NPO) diet and did not receive food from the facility's kitchen. The facility census was 124.

Inspectors wroteBased on observation, interview, record review, review of manufacturer information, and facility policy review, the facility failed to ensure strength of wound care solutions were specified in a physician order. This affected one Resident #15 of three residents observed for wound care. The facility census was 124.

Inspectors wroteBased on record review, policy review and interview, the facility failed to ensure transportation to and from scheduled eye surgery for Former Resident #120. This affected one (Former Resident #120) of three residents reviewed for transportation assistance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident wheelchairs were maintained in a clean and sanitary manner. This affected four residents (Resident #13, Resident #18, Resident #32, Resident #18, and Resident #105) of five residents observed for sanitary wheelchairs.

Inspectors wroteBased on observation, record review, review of the facility policy and procedure, and interview, the facility failed to ensure Resident #32 and #113's aerosol treatments were administered per the physician order. This affected two residents (Resident #32 and Resident #113) of three residents reviewed for medication administration records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure infection control was maintained during and after aerosol treatments for Resident #32 and #113. This affected two residents (Resident #32 and Resident #113) of three residents reviewed for infection control.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure tube feeding was administered according to physician orders. This affected two residents (#35 and #86) of three residents reviewed for enteral nutrition. The facility census was 122.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure each resident was treated in a respectful and dignified manner. This affected one (Resident #9) of three residents reviewed for toileting. The facility census was 111. Actual Psychosocial Harm occurred on 01/09/24 at 3:16 P.M. when Resident #9 was humiliated upon asking State Tested Nurse Aide (STNA) #581 to assist her to the bathroom to use the toilet and STNA #581 told Resident #9 to go to the bathroom in her incontinence brief. Interview of Resident #9 on 01/10/24 at 10:43 A.M. revealed when STNA #581 told her to go to the bathroom in her incontinence brief it made her feel bad and sad. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure appropriate care and services to prevent the devopement of an in house pressure ulcer and decline of the pressure ulcer to a Stage four pressure injury (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed). This affected one (Resident #76) of three residents reviewed for pressure ulcers. The facility census was 111. Actual Harm occurred on 11/12/23 when Resident #76, who was non-verbal, dependent on staff for turning and repositioning and had limitations in neck mobility was noted to have deterioration to a left ear wound in which there had been no previous documentation. [...]

Inspectors wroteBased on observation, record review, and interviews with staff and residents the facility failed to have sufficient staffing. This affected Residents #6, #10, #50, #36, #54, #59 and #105 and had the potential to affect all residents. The census was 111.

Inspectors wroteBased on resident interviews and record review the facility failed to promptly address concerns regarding palatability of food. This affected 105 residents who received meals from the kitchen. Six residents received nothing by mouth (#3, #18, #20, #53, #76 and #90). The census was 111.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure restorative therapy services were initiated and completed for Residents #20, #54, #80, #100 and #360 per discharge recommendations from therapy. This affected five (Residents #20, #54, #80, #100 and #360) of 14 residents who had restorative services recommended by therapy. The facility census was 111.

Inspectors wroteBased on observation and interview the facility failed to ensure monitoring of residents on oxygen for complications such as skin integrity issues, failed to ensure protective foam was applied to oxygen tubing to protect skin integrity, and failed to ensure current physician orders for the use of oxygen. This affected four (#6, #22, #40 and #45) of five residents observed for oxygen therapy. The facility census was 110.

Inspectors wroteBased on observation and interview the facility failed to ensure expired medications were discarded. This had the potential to affect 51 residents residing on the A and C halls. Facility census was 111.

Inspectors wroteBased on observation, interview, record review and review of the Centers for Disease Control (CDC) Considerations for Preventing Spread of Covid-19, the facility failed to maintain proper infection control procedures to prevent the spread of infection. This affected four residents (#7, #42, #65 and #88) and had the potential to affect eight residents (#17, #26, #42, #47, #52, #56, #71 and #102) residing on the D hall. The facility census was 110.

Inspectors wroteBased on interview, observation and record review, the facility failed to honor Resident #54's preferences regarding when she wanted to get out of bed and how long she remained out of bed. This affected one of resident reviewed for preferences.

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to ensure Resident #76 received the necessary services to maintain clean hair. This affected one (Resident #76) out of three residents reviewed for activities of daily living. The facility census was 111.

Inspectors wroteBased on observation and interview the facility failed to ensure prompt physician notification and timely care related to Resident #65's reddened and painful external genitals. This affected one (#65) of two residents observed for skin impairment. The facility census was 110.

Inspectors wroteBased on observation, interview, record review and policy review the facility failed to provide care and services to ensure Resident #59 was provided incontinence care timely and Resident #80's urine specimen was sent to the lab timely and urinary tract infection treated promptly. This affected one resident (Resident #59) of three residents reviewed for incontinence and one resident (Resident #80) of three residents reviewed for urinary tract infections. The facility census was 111.

Inspectors wroteBased on observation and interview the facility failed to provide a clean and sanitary environment. This affected Resident #18. The facility census was 110.

Inspectors wroteBased on observation, diet guide review, scoop size review and interview, the facility failed to ensure proper portion sizes of the pureed and regular/soft diets were served. This had the potential to affect 90 of 94 residents residing at the facility. Four residents (#34, #63, #66, and #69) were identified to receive nothing by mouth (NPO). The facility census was 94.

Inspectors wroteBased on observation, interview, record review, therapy discharge notes, and policy review the facility failed to ensure Resident #76 received restorative services necessary to maintain dexterity in his right hand. Actual harm occurred when Resident #76 was admitted back into the facility from the hospital, and the facility did not reorder the resident's splint or initiate restorative services as recommended by occupational therapy, resulting in a decline in the resident's ability to open his right hand. This affected one (Resident #76) resident of four reviewed for limited range of motion. The facility census was 96 residents.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure proper infection control practices were implemented during catheter care for Resident #34; failed to properly transport soiled linens in the hallway; and failed to follow proper infection control practice for a dressing change for Resident #93. This affected two (Residents #34 and #93) residents and had the potential to affect all 96 facility residents.

Inspectors wroteBased on observations, resident interviews, and staff interviews, the facility failed to ensure nail care and mouth care was provided to the residents. This affected nine (Residents #6, #26, #38, #41, #55, #71, #84, #88 and #93) of 11 reviewed for activities of daily living. The facility census was 96 residents.

Inspectors wroteBased on observation, review of the medical record, resident interview, and staff interview, the facility failed to maintain privacy during care for Resident #4 and #86, and failed to treat Resident #6 with dignity and respect during a dressing change. This affected three residents (Resident #4, #6 #86) of 24 reviewed for dignity and respect. The facility census was 96 residents.

Inspectors wroteBased on review of the medical record, resident interview and staff interview the facility failed to provide scheduled showers for Resident #43. This affected one resident (Resident #43) of one reviewed for choices. The facility census was 96 residents.

Inspectors wroteBased on Observation, review of the medical record and staff interview the facility failed to complete a dressing change as ordered for Resident #38. This affected one resident (Resident #38) of seven residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to ensure consistent catheter care was provided for one resident. This affected one (Resident #34) of nine residents who received catheter care at the facility. The facility cenus was 96 residents.

Inspectors wroteBased on observation, review of the medical record, and staff interviews, the facility failed to ensure the dression on the peripherally inserted central catheter (PICC), which was used for intravenous medications was changed as ordered. This affected one (Resident #79) of three residents reviewed for PICC dressing changes.