Copper Ridge Care Center

Inspectors wroteBased on interview and record review the facility failed to ensure Physician ordered restorative nursing services (a program that helped residents maintain or improve their highest possible level of physical function) was provided to one out of 24 sampled residents (Resident 15). This failure had the potential for a decline in functional status and to negatively impact psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet resident adaptive equipment needs for one of 24 residents (Resident 33) when Registered Nurse (RN) G was not aware of Resident 33's adaptive equipment needs and unable to provide information on where to find adaptive equipment for Resident 33 to meet his needs. This failure had the potential to affect Resident 33's ability to drink fluids independently.

Inspectors wroteBased on interview and record review the facility failed to ensure that two of four Residents sampled (Resident 1 and Resident 2) had care plans (a document that outlines a patient's health care needs and the actions and interventions required to address them) for naloxone (a medication that rapidly reverses the effects of an opioid [a strong medication that blocks pain and poses a risk of death by overdose] overdose [when a dose of an opioid is too high, and causes the person's breathing and heartbeat to slow down or stop]). These failures had the potential to result in delayed identification of and interventions for an opioid overdose for Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that three of four residents sampled (Resident 1, Resident 2, and Resident 4) who had naloxone (a medication that rapidly reverses the effects of an opioid [a strong medication that blocks pain and poses a risk of death by overdose] overdose [when a dose of an opioid is too high, and causes the person's breathing and heartbeat to slow down or stop]) prescribed had nurses competent on where their naloxone was stored. This failure had potential to result in delayed treatment of an opioid overdose and death for Resident 1, Resident 2, and Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of four residents sampled (Resident 1) was safe from a significant medication error when Licensed Nurse (LN D) crushed Resident 1's morphine sulfate (an opioid which blocks pain and poses the risk of death by morphine overdose [when a dose of an opioid is too high, and causes the person's breathing and heartbeat to slow down or stop]) extended release (a type of medication that is designed to release its ingredients slowly rather than all at once) and gave it to Resident 1. This failure had the potential to result in Resident 1 having a morphine overdose and dying.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) received her intravenous (IV, a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) antibiotic called ceftriaxone (a medication used to treat bacterial infections) in a manner consistent with professional standards of practice and in accordance with the facility's policy to treat her urinary tract infection (infection of the kidneys and bladder) when: 1. Resident 1 did not receive her IV ceftriaxone until more than 4 hours after the physician ordered it. 2. The physician's order for the IV antibiotic ceftriaxone did not have an infusion rate (how fast an IV medication is given). These failures resulted in: 1. A delay in treatment of Resident 1's urinary tract infection. 2. [...]

Inspectors wroteBased on interview, record, and policy review, the facility failed to follow physician's orders and complete monitoring and adjustment of warfarin (also called Coumadin, a high-risk medication used to prevent blood clots by thinning the blood and has a significant risk for bleeding complications), for one of four residents sampled for warfarin use (Resident 1), when Licensed Nurse (LN) A incorrectly revised Resident 1's physician's order for a lab test for a prothrombin time and International Normalized Ratio (PT/INR, the laboratory testing parameter utilized to monitor warfarin therapy. The PT is the number of seconds required for the blood to clot, and the INR is the standardized ratio of the PT), and caused the order not to populate on to Resident 1's Electronic Health Record (EHR). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Licensed Nurses administered medication in accordance with their Medication Administration Policy for one of four sampled residents (Resident 1), when 4 and a half Norco tablets (a narcotic pain pill), were found in a container in Resident 1 ' s room. This failure had the potential to lead to possible overdose (when a person takes more than the recommended amount of a medication which can lead to serious harm or death), drug diversion (the illegal distribution, or abuse of prescription drugs, or their use for purposes not intended by the prescriber), and possible exposure of other residents to potentially hazardous substances.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for the disposition of a resident at the time of discharge for 1 (Resident #102) of 23 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices were followed when staff did not properly wear a surgical mask (face covering) and a Certified Nurse Assistant (CNA) drank water while walking down a hallway that contained COVID-19 positive residents. This failure had the potential to spread COVID-19 to other residents, potentially leading to a decline in health status.

Inspectors wroteBased on interview and record review, the facility failed to honor resident rights for one out of three sampled residents (Resident 1) when Resident 1's caregiver (CG) requested a nurse to be present at the care conference meeting (a group of medical professionals that met to discuss resident care and care planning with the resident, family members, or caregivers), and nursing was not notified of the request. This failure had the potential for Resident 1 and Resident 1's representatives to not be allowed to participate in resident care planning.

Inspectors wroteBased on interview and record review, the facility failed to provided one out of three sampled residents (Resident 2) with food that was served in a safe manner when Resident 2 was served a chef's salad that contained moldy cherry tomatoes. This failure had the potential for spoiled food to be eaten and could cause illness.

Inspectors wroteBased on interview and record review the facility failed to provide one out of three sampled residents (Resident 1) with outside services when a request was made for Resident 1 to be seen by her cardiologist (doctor that specialized in the heart) and a referral was not initiated. This had the potential for a decline in resident health status.

Inspectors wroteBased on observation and interview the facility did not store cooking utensils in a sanitary manner when serving scoops were observed to be stored in a drawer containing dark colored water and food particles. The failure to maintain cleanliness in storage of serving utensils has the potential to cause the spread of food borne illness leading to adverse resident clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the spread of infection when: 1. a staff member entered an isolation room of a resident who was under observation for exposure to the COVID-19 virus without donning (putting on) appropriate Personal Protective Equipment (PPE); 2. two of three pill cutters had not been cleaned between uses; 3. one of three glucometers (a device used to measure blood sugar) was not cleaned according to manufacturer's guidelines between uses. This failure had the potential to spread germs from resident to resident or staff which could have caused illness or outbreaks of infectious disease.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that outdated drugs were removed from the medication storage room when an expired bag of medication was found in the medication refrigerator in the main medication storage area. This could have led to a resident receiving an ineffective dose of medication that had expired. During a concurrent observation and interview, on [DATE] at 10:20 am, in Medication Storage room [ROOM NUMBER] with Assistant Director of Nursing (ADON), Pharmacist (Pharm), and pharmacy manager (Pharm Manager), a bag of Engerix B (a vaccine for Hepatitis, a blood infection) 20 mcg/ml (microgram per milliliter) was noted to have an expiration date of 12/21. ADON stated that this should have been removed, and did remove it immediately. Pharm stated that it was their job (contracted pharmacy vendor) to check for out dated medications monthly. [...]