Copper Knoll Health & Rehab LLC

Inspectors wroteBased on record review and staff interview, the facility failed to ensure there was a Registered Nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This had the potential to affect all 65 residents residing in the facility. The census was 65.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure laundry was stored to prevent the spread of infection. This had the potential to affect all 64 residents who reside in the facility. The facility census was 64. Findings Included:Based on observation, interview and policy review, the facility failed to ensure laundry was stored to prevent the spread of infection. This had the potential to affect all 64 residents who reside in the facility. The facility census was 64. Findings Included:Observation on 12/31/25 at 8:35 A.M. with the Environmental Manager (EM) #39 of the 300 hall central bath with a linen cart with four shelves filled with linens, towels, washcloths, and other miscellaneous items had a front flap that was opened up and on top of the cart, leaving all of the items on the cart exposed. The bathtub was about one foot from the cart. [...]

Inspectors wroteBased on observation, interview, review of the safety data sheets, and policy review, the facility failed to ensure the resident environment was free of accident hazards. This affected four (#01, #16, #26 and #54) out of four residents reviewed and had the potential to affect all seven (#01, #16, #26, #33, #51, #54 and #64) independently mobile residents who reside in the memory care unit. The facility census was 64.

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure privacy of the electronic medical record. This affected two (#53 and #62) of six residents reviewed for privacy. The facility census was 64.

Inspectors wroteBased on medical record review, interview, and policy review, the facility failed to adequately monitor the administration of warfarin. This affected one (#56) of five residents reviewed for unnecessary medications. The facility census was 64.

Inspectors wroteBased on record review, facility staff interview and facility policy review, the facility failed to ensure allegations of abuse were reported in a timely manner. This had the potential to affect 62 of 62 residents.

Inspectors wroteBased on observation, staff interview, review of signage on the resident unit refrigerators, and policy review, the facility failed to ensure foods were safely stored. This had the potential to affect all 52 residents who received food from the kitchen. The facility census was 52.

Inspectors wroteBased on medical record review, observation and staff and resident interview, the facility failed to ensure the resident environment was sanitary. This affected eight residents (#01, #04, #12, #16, #44, #45, #46 and #103) of 52 residents' room environment observed. In addition, the facility failed to ensure the floors were in good repair. This had the potential to affect 31 of 31 residents who could independently ambulate. The facility identified 21 residents (#01, #09, #07, #22, #20, #14, #23, #47, #08, #41, #02, #36, #15, #19, #39, #06, #07, #09, #35, #11 and #38) who were unable to independently ambulate in the facility. The facility census was 52. Findings Include: 1. Review of the medical record revealed Resident #04 revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart failure, diabetes, chronic pain, and psychotic disturbance. [...]

Inspectors wroteBased on medical record review, staff interview, review of the minimum data set log, and review of the resident assessment instrument (RAI) manual, the facility failed to ensure resident assessments were completed quarterly. This affected three residents (#05, #20 and #32) of four residents reviewed for timely assessments. The facility census was 52. Findings Include: 1. Review of the medical record revealed Resident #05 was admitted to the facility on [DATE]. Diagnoses included dementia, diabetes, and depressive disorder. Review of the Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed the resident had impaired cognition. Review of the MDS log revealed Resident #05 should have had a quarterly MDS completed on 08/02/22 and it was completed on 09/06/22. The previous quarterly MDS was completed on 05/23/22. This was greater than 90 days between MDS completion dates. 2. [...]

Inspectors wroteBased on observation, staff interview, record review, and review of the facility's policy, the facility failed to ensure resident foods in the unit refrigerators were dated and/or labeled and thickened water was not expired. This had the potential to affect 39 of 40 residents who receive food from the kitchen (Resident #26 received nothing by mouth).

Inspectors wroteBased on record review, observation, review of the facility's policy and staff interviews, the facility failed to ensure activities were provided to meet the needs of Resident #25. This affected one (Resident #25) of three residents reviewed for activities. This had the potential to affect all seven residents (Resident #1, #3, #8, #11, #25, #32, and #33) residing on the memory care unit. The facility census was 40.

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to hold initial care planning conferences for new admissions to the facility. This affected one (#27) of one resident sampled for care planning conferences. The facility census was 40 residents.

Inspectors wroteBased on observation, review of manufacturer's recommendations and staff interview, the facility failed to dispose of outdated insulin and failed to date open vials of insulin with the date when opened. This affected one (#11) of eight residents identified by the facility who receive insulin. The facility census was 40 residents.

Inspectors wroteBased on record review, review of the facility's policy, and staff interview, the facility failed to accurately document resident supplements and administration of a resident's narcotics. This affected two (Resident #3 and #22) of four residents reviewed for nutrition and one (Resident #27) of five residents for unnecessary medications. The facility census was 40. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date of 08/12/19 with diagnoses including dementia and dysphagia. Review of the active physician orders revealed an order dated 08/15/19 for a magic cup (high calorie nutritional supplement) twice a day with lunch and dinner. Review of the April 2021 medication administration records (MAR) revealed Resident #3 received a magic cup with lunch and dinner until 04/23/21 when it was crossed out and marked as discontinued. [...]

Inspectors wroteBased on resident and staff interviews, and review of the facility's policy, the failed to ensure the resident's mail was delivered on Saturdays. This had the potential to affect all 40 residents residing in the facility.