Copper Ridge Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility had a policy, but failed to implement a process to ensure food safety, including checking food expiration dates and monitoring refrigerator temperatures of resident personal refrigerators for 3 (#s 4, 14, and 51) of 34 sampled and supplemental residents.

Inspectors wroteBased on interview and record review, the facility failed to provide notification to a physician regarding a resident's severe weight loss, resulting in a lack of physician assessment and involvement, which did not allow the physician the opportunity to recommend or implement interventions for 1 (#3) of 16 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete an Annual and Significant Change in Status Minimum Data Set (MDS) assessment for a resident's pre-admission screening and resident review (PASARR), for 2 (#s 7 and 11) of 34 sampled and supplemental residents.

Inspectors wroteBased on interview and record review, the facility failed to promptly obtain a new PASARR (Preadmission Screening and Resident Review) Level One screen, upon re-admission from the hospital for a resident who had a significant change in mental status, for 1 (#68) of 16 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to revise resident care plans to reflect the Provider Orders for Life Sustaining Treatment (POLST) status for 2 (#s 50 and 74) of 34 sampled and supplemental residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician personally conducted an initial comprehensive visit within the first 30 days after admission for 1 (#3) of 16 sampled residents. The failure increased the risk of missed resident care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was not a 5% or greater medication error rate. The observed medication error rate was 10.34% for 2 (#s 13 and 38) of 34 sampled and supplemental residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the designated infection preventionist had completed specialized training in infection prevention. The failure placed residents at risk for inconsistent infection prevention and control practices due to the lack of specialized training for the infection preventionist.

Inspectors wroteBased on observations, interviews, and record reviews, the facility staff failed to ensure each resident had access to call lights for 4 (#s 16, 24, 49, and 54); and failed to prevent elopements for 1 (#54) of 22 sampled residents. These deficient practices placed residents at risk of falls, injuries, elopements, or a negative outcome if a medical crisis occurred, and the resident could not call for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff were educated on policies and procedures for the use of personal protective equipment, for a resident on enhanced barrier precautions, for 1 (#57) of 16 sampled residents for enhanced barrier precautions. This deficient practice increased the risk of infection for all residents related to staff not adhering to proper EBPs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain areas of the building in need of repair for 3 (#s 11, 19, and 27) of 22 sampled residents; and, failed to maintain a clean environment related to housekeeping services, for 1 (#57) of 22 sampled residents. Residents were concerned about lack of repairs and unclean areas identified.

Inspectors wroteBased on interview and record review, the facility failed to collect and act on admission information necessary to provide a safe, comfortable, and homelike environment accommodating a resident's physical size, for 1 (#1) of 6 residents sampled.

Inspectors wroteBased on observation, interview, and record review, a staff member removed a resident's oxygen for the provision of care, knowing it was necessary to maintain the resident's oxygen levels, and the resident showed signs of signs of hypoxia prior to being placed back on the oxygen, for 1 (#5) of 5 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of neglect where a resident's oxygen was removed for care, which resulted in the resident exhibiting symptoms of hypoxia during the admission process. The facility did not report the incident to the State Survey Agency within 24 hours, and failed to report a follow up investigation within 5 working days, as required, for 1 (#5) of 5 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 (#5) of 5 sampled residents received appropriate respiratory services on admission, and failed to have physician orders and necessary equipment on hand, and staff were not aware of or educated on the resident's respiratory care needs or risks related to them, and this resulted in neglect of care when a staff member removed the resident's oxygen, and then the resident showed signs of hypoxia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided for a new resident admitted on a high rate of oxygen, and this the oxygen was removed by a staff member, which resulted in signs of hypoxia for 1 (#5). The facility also failed to ensure physician orders were followed for 3 (#s 1, 2, and 4) of 5 sampled residents receiving oxygen. This deficient practice showed a potential concern for neglect and serious adverse effects to residents receiving oxygen services.

Inspectors wroteBased on observation of a facility security video, interview, and record review, the facility failed to protect 1 resident (#3) who could not consent to sexual contact from 1 resident (#2), of 7 sampled residents for abuse.

Inspectors wroteBased on interview and record review, the facility failed to care plan interventions to keep a resident safe from unwanted sexual advances or abuse from another resident, for 1 (#3) of 7 sampled residents for abuse.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to remove and dispose of expired medications and medical supplies in three medication rooms, three medication carts, and one wound supply cart; and, failed to properly store medical supplies, keeping the supplies off the floor in one medication room. These failures increased the risk of expired medications and medical supplies being used for any resident at the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to administer respiratory treatments in accordance with professional standards of practice for 4 (#s 22, 33, 36, & 49) of 6 sampled residents for respiratory services.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure residents were assessed and found safe to self administer their own medications, prior to doing so; and, the facility failed to document the assessments in the EHRs, for 4 (#s 22, 33, 36, & 49) of 6 sampled residents for self administration of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise comprehensive care plan interventions for catheter care for a resident that is at risk of infection for 1 (#9) of 26 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide incontinence care and repositioning for dependent residents, which had the potential to increase skin breakdown, and may cause discomfort for the residents, for 2 (#s 2 and 14) of 26 sampled residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to change a residents catheter, this had the potential to increase the risk of infection for 1 (#9) of 26 sampled residents. During an observation and interview on 3/25/24 at 3:31 p.m., resident #9's room smelled of strong urine. Resident #9 stated she had a catheter due to her wounds. The catheter tubing was cloudy and had chunks of white debris in it. Resident #9 could not remember if her catheter had ever been changed. During an interview on 3/27/24 at 8:45 a.m., staff member G stated catheters are changed based on the physician's order in the residents Medication Administration Record. Record review of resident #9's catheter order, dated 1/2/24, showed, Foley cath: 18fr. Inflate balloon to 30 cc for stage IV pressure sore to sacrum. Change for occlusion, leakage, dislodgement or s/s of infection. As needed. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff used appropriate hand hygiene during catheter care or wound care, for 2 (#s 9 and 37) of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review, a licensed staff member failed to properly administer enteral tube feedings, for 1 (#1) of 2 sampled residents; and the facility nursing staff failed to have the enteral tube feeding order clarified further on receipt. The failure resulted in the resident being given the incorrect amount of tube feeding formula and the resident had a decline in status.

Inspectors wroteBased on observation, interview, and record review, a licensed staff member failed to seek out necessary education or guidance to ensure competency for the skills and knowledge necessary for the administration of enteral tube feedings for a resident who was new to the unit, and who had complications with tube feedings, for 1 (#1) of 7 sampled residents. This deficiency resulted in the resident having a decline in status, and the resident was sent to the emergency room for further evaluation.

Inspectors wroteBased on interview and record review the facility failed to revise a resident's care plan to reflect an intervention with regards to gravity enteral tube feeding complications, for 1 (#1) of 7 sampled residents.