Copper Rock Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse aides (NA) were not used for more than four months without completing required training and evaluations when the facility did not have an effective process in place to ensure certified nurse aide (CNA) training programs were completed timely for NAs resulting in one NA (NA K) working longer than four months in the facility without completing the CNA training course. The facility census was 77. Review showed the facility did not provide a policy regarding NA training. 1. Review of NA K's personnel file showed the following:-Date of hire of 08/25/25 (six months and sixteen days prior);-NA K enrolled in the nurse aide training program on 01/06/26;-Staff did not have documentation NA K completed the nurse aide training program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with a complete and fully functional call light system when the facility failed to have process in place to notify staff of sounding call lights when call lights notifications could not be heard on the hall and the facility staff did not use the cell phone pagers for notification of call lights. The facility census was 77. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care per standards of practice when staff failed to ensure an oxygen tank was turned on while in the dining room for one resident (Resident #18), failed to ensure the oxygen tank contained sufficient oxygen for one resident (Resident #75) while in the dining room, and failed to ensure the humidifying bottles were filled with water for three residents (Resident #75, #9, and #2) with oxygen concentrators in their room. The facility census was 77. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served was appetizing when staff served food that was not an appetizing temperature, failed to season food, and failed to cook food appropriately for 10 residents (Residents #17, #34, #15, #60, #28, #61, #66, #58, #5, and #38) of 25 sampled residents. The facility census was 77. Based on observation, interview, and record review, the facility failed to ensure food served was appetizing when staff served food that was not an appetizing temperature, failed to season food, and failed to cook food appropriately for 10 residents (Residents #17, #34, #15, #60, #28, #61, #66, #58, #5, and #38) of 25 sampled residents. The facility census was 77. Review of the facility policy The Dining Experience: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain effective and complete an infection prevention and control program when staff failed to follow appropriate Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for one resident (Resident #5) with an indwelling catheters (tubing placed to drain the bladder to outside the body). Staff failed to follow acceptable standards of care for performing hand hygiene and glove use during personal care for four residents (Residents #49, #3,#21, and #23). The facility census was 77. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure all residents had interventions in place and followed to ensure acceptable parameters of nutritional status were maintained when staff failed to assist two residents (Resident #18 and #75) during meals. A sample of 25 residents was reviewed for dietary concerns. The facility census was 77. 1. Review of Resident #18's face sheet (a quick-glance referral of the resident's information) showed the following:-admission date of 01/17/25;-Diagnoses included dementia, chronic systolic (heart failure), chronic kidney disease, stage 3 (kidneys losing the ability to filter blood, leading to waste build-up), and paroxysmal atrial fibrillation (irregular heart rhythm). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pain management program was in place for each resident when staff failed to address one resident's (Resident #23) complaint of pain. The facility census was 77. Review of the facility policy Pain Assessment and Management, revised April 2025, showed the following:-Purpose to help staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain;-Pain management included identifying signs and symptoms of and assessing existing pain; -recognizing situations and conditions with the potential for pain; -addressing the underlying causes of the pain; developing and implementing approaches to pain management based on accepted standards of practice; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the administrator of the facility had an active and valid administrator's license when the facility failed to confirm renewal of his/her license, and the administrator continued his/her normal job duties for a period of 20 days without a valid license. The facility census was 77. On 07/21/25, the facility's corporation became aware of the Administrator's license expiration. The facility removed the Administrator from his/her role and provided counseling. The facility's corporation appointed the [NAME] President (VP) of Operations, who had a current valid administrator's license, to the administrator role on 07/21/25. The corporation implemented audits of the licenses of all administrators with the corporation. The noncompliance was corrected on 07/21/25. [...]

Inspectors wroteBased on interviews and record review, the facility staff failed to implement their abuse/neglect policy to protect all residents during an abuse allegation investigation when staff allowed one staff member (Certified Medication Tech (CMT) A) continue to work independently after one resident (Resident #1) made an allegation of abuse involving the CMT. The facility census is 80. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents dependent on staff to for grooming and personal hygiene received baths/showers in a timely fashion for two dependent resident's (Resident #1 and #2). The facility census was 79. Review of the facility's policy titled, Bath, Shower/Tub, revised February 2018, showed the following: -Purpose to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin; -Document date and time the shower/tub bath was performed; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care per professional standards related to pressure ulcers (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) when the facility staff failed to obtain physician's orders for treatment and interventions of wounds and failed to update the care plan regarding skin breakdown intervention changes for one resident (Resident #3) out of seven sampled residents. The facility census was 79. Review of the facility's policy titled, Pressure Injury Risk Assessment, revised March 2020, showed the following: -Identify all risk factors and then determine which can be modified and which cannot, or which can be immediately addressed, and which will take time to modify; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective and accurate pain management program was in place when staff failed to ensure pain patches were on-hand for administration, when staff documented administration of pain patches that were not administered, and when staff failed to accurately document monitoring of the pain patch placement for one resident (Resident #1) out of 7 sampled residents. The facility census was 79. Review of the facility's policy titled, Documentation of Medication Administration Policy, revised April 2007, showed the following: -Administration of medication must be documented immediately after (never before) it is given; -Documentation must include at a minimum: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure all residents were free from significant medication errors when staff administered another resident's medication to one resident (Resident #1) resulting in an unsafe drop in blood pressure and hospitalization of the resident. Staff also failed to administer insulin as ordered and contact the physician regarding insulin not available for one resident (Resident #3) resulting in elevated blood sugar levels and hospitalization of the resident. A sampled of ten residents were reviewed in a facility with a census of 67. 1. Review of the facility policy titled Administering Medications, April 2019, showed the following: -Medications are administered in a safe and timely manner, and as prescribed; -The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions; [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to ensure food stored in the kitchen pantry, refrigerators, freezer and the kitchenette refrigerators for five of five halls were labeled, dated, sealed, and stored at the appropriate temperature. These failures had the potential to increase the prevalence and spread of foodborne illness and infection among all facility residents. Review of the facility's policy titled, Food Storage (Dry, Refrigerated, and Frozen,) dated 2020, showed the general storage dry storage guidelines were as follows: -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded; -Discard food that has passed the expiration date and discard food that has been prepared in the facility after seven days of storing under proper refrigeration; [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation for clinical indication of use for antibiotics with the potential to effect all residents in the facility. Review of the facility's Facility Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcomes Policy Statement, revised December 2016, showed the following: -Antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form; -The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship; -The Infection Preventionist (IP), or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity was provided to all residents when staff failed to keep urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) drainage bags covered for two residents (Resident #128 and #5) and when staff administered nasal medication in the dining room to one resident (Resident #31). A sample of 19 residents was reviewed. Review of the facility's policy titled, Dignity, dated February 2021, showed the following: -Each resident will be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation in each resident's medical record of the consulting pharmacist's recommendations after the monthly medication review was conducted for each resident in the facility and documentation of the attending physician's response to the consulting pharmacist's recommendations for four of four residents (Residents #38, #55, #31 and #2) reviewed for monthly medication regimen review in a sample of 19 residents. Review of the facility's Facility Medication Regimen Review Policy showed the following: -The Consultant Pharmacist will perform a medication regimen review (MRR) for every resident in the facility; -Routine reviews will be done monthly; -Consultant Pharmacist will document his/her findings and recommendations on the monthly drug/medication regimen review report; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the nutritional needs of all residents were met when staff failed to follow the recipe and failed to provide the correct serving size of pureed foods to four residents on pureed diets. Review of the Standardized Recipes policy, dated 2020, showed the following: -Standardized recipes will be used for all menu items, including pureed and therapeutic diets; -Each standardized recipe will include name of product; number of servings or yield; ingredients; measurement and/or weight of ingredients; procedures for assembling/method of production; size of pan needed; serving sizes; and modifications for therapeutic diets if applicable; -Recipes will be scaled to the number served; -The Registered Dietitian will approve recipe changes or new recipes utilized for a menu item. 1. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that 10 of the 10 residents (including Resident #20, #11, and #62) with a physician's order for a mechanical soft diet were served foods prepared in a mechanical soft form to meet their needs. Review of the facility's policy titled, Diet Summary, dated 2023, showed the following; -Dental soft (mechanical soft) diet is a consistency modified diet for individuals with limited or difficulty in chewing regular textured foods; -The diet follows the regular diet planned and provides foods that can be easily chewed; -The diet consists of food of nearly regular textures, but eliminates very hard, sticky, crunchy or hard to chew foods; -Foods should be moist and fork tender; [...]

Inspectors wroteBased on record review and interviews, the facility failed ensure one (Resident #2), of two residents reviewed for hospitalization, received written notice of transfer to the hospital that included the reason for the transfer, the location of the transfer, a statement of the resident's appeal rights, and the contact information for the office of the Ombudsman. Review of the facility provided a blank form named, Notice of Resident and Discharge, undated showed the form contained spaces to document the following: -Location of the transfer; -Reason for the transfer; -Resident's appeal rights; -Contact information for the State Long-Term Care Appeal Agency, the Missouri Protection and Advocacy Agency, and the Long-Term Care Ombudsman for the region. 1. Review of Resident #2's Profile tab of the electronic medical record (EMR) showed the following: -admission date of 02/11/20; [...]

Inspectors wroteBased on record review, and interviews, the facility failed ensure one resident (Resident #2), of two residents reviewed for hospitalization, received written notice of the bed hold policy upon transfer to the hospital. Review of the facility's Bed Hold Policy, undated, showed the policy did not address when the bed hold notice would be provided or by whom. 1. Review of Resident #2's Profile tab of the electronic medical record (EMR) showed the following: -admission date of 02/11/20; -Diagnoses include dementia, anxiety, and unsteadiness on her feet. Review of the resident's significant change of condition Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff) assessment, with an assessment reference date (ARD) of 11/28/23, located in the MDS tab of the EMR, showed the following: -Resident had severely impaired cognition; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative nursing services to maintain, improve, or prevent avoidable decline in range of motion (ROM) and mobility for one resident (Resident #4) of two residents reviewed for limited range of motion. Review of the facility's policy titled Restorative Nursing Services, dated July 2017, showed the following: -Residents will receive restorative nursing care as needed to help promote optimal safety and independence; -Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies); -Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care; [...]

Inspectors wroteBased on record review, and interview, the facility failed to ensure staff took steps to prevent accidents (falls) for all staff when staff failed to complete a root cause analysis, implement new interventions, or document the reason new interventions were not implemented for one resident (Resident #2), of four sampled residents, who had multiple falls. Review of the facility's policy titled, Fall Risk Assessment, dated March 2018, showed the following: -For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall; -Often, multiple factors contribute to a falling problem; -If the cause of the fall is unclear, or if the individual continues to fall despite attempted interventions, a physician will review the situation to help further identify causes and contributing factors; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff took steps to protect all resident with indwelling urinary catheters (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) from potential infection when staff allowed two resident's (Resident #5 and #128) catheter tubing and collection bag to be in contact with the floor. Three residents reviewed for catheters and urinary tract infection. Review of the facility's policy titled, Catheter Care, Urinary, dated September 2014, showed the following: -The purpose of this procedure is to prevent catheter-associated urinary tract infections; -Be sure the tubing and drainage bag are kept off the floor. 1. Review of the residents' Profile tab, in the electronic medical record (EMR), showed the following: -admission date of 03/26/21; [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that one of one nurse was competent with skills and knowledge to provide care for one of one resident (Resident #56) who used a Dexcom G7 Continuous Glucose Monitoring device (a method to track glucose levels throughout the day and night) out of a total sample of 19 residents. Review of the External Blood Glucose Monitoring Devices-Dexcom-Policy & Procedure, dated 01/2024, showed the following : -The Use of Dexcom Continuous Glucose Monitoring (CGM) Device in the long-term skilled nursing facility is crucial for ensuring the effective management of diabetes for residents requiring continuous glucose monitoring; -Nursing staff responsible for the application, maintenance, and interpretation of Dexcom CGM data will receive comprehensive training on device usage, troubleshooting, and data analysis; [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have documentation of increased behaviors to warrant the increased dosage of the antipsychotic medication for one resident (Resident #29) of six residents reviewed for unnecessary medications. Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring, dated March 2019, showed the following: -Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment; -If the resident is being treated for altered behavior or mood, the Interdisciplinary Team (IDT) will seek and document any improvements or worsening in the individual's behavior, mood, and function; -If antipsychotic medications are used to treat behavioral symptoms, the IDT will monitor their indications. 1. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure the skin assessment accurately reflected the current skin condition for one (Resident #5), of three residents, in the sample of 19 residents reviewed for presence of pressure ulcers or other skin conditions. Review of the facility's policy titled, Charting and Documentation, dated July 2017, showed the following: -The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care; -Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 1. Review of the Profile tab in Resident #5's electronic medical record (EMR) showed the following: -admission date of 03/26/21; -Diagnoses included disorder of the skin and subcutaneous tissue. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to report an allegation of resident to resident abuse involving two residents (Resident #1 and Resident #2) immediately to administration per their policy and failed to report the allegation to the Department of Health and Senior Services (DHSS) within the required two hours of the facility staff becoming aware of the allegation. The facility census was 78. Review of the facility's policy titled, Abuse investigation and Reporting, revised 07/2017, showed the following: -All reports of resident abuse, neglect, exploitation, misappropriation, mistreatment or injuries of unknown origin shall be promptly to reported to the local, state and federal agencies (as defined by the regulations) and thoroughly investigated; [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that an allegation of possible abuse was thoroughly and timely investigated, when a staff member failed to report and begin an investigation into a physical altercation between two residents (Resident #1 and Resident #2) that resulted in injury to one resident. The facility census was 78. Review of the facility's policy titled, Abuse investigation and Reporting, revised 07/2017, showed the following: - All reports of resident abuse, neglect, exploitation, misappropriation, mistreatment or injuries of unknown origin shall be promptly to reported to the local, state and federal agencies (as defined by the regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported; [...]

Inspectors wroteBased on interview, record review, and observation, the facility staff failed to perform a timely initial wound assessment for one resident (Resident #82) who returned from the hospital with a wound and wound orders. The facility failed to obtain a physician's order for wound treatment, failed to perform and document complete weekly skin assessments, and failed to update the care plan for one resident (Resident #13) when the resident developed a wound on the toe. The facility census was 82. Record review of the facility's policy titled Wound Care, dated October 2010, showed the following information: -The purpose of the procedure is to provide guidelines for the care of wounds to promote healing; -Staff should verify there is a physician's order for the procedure; [...]

Inspectors wroteBased on interview, record review, and observation, the facility failed to routinely complete full weekly wound assessments for two residents (Resident #28 and Resident #67) with pressure wounds and failed to ensure a dressing was maintained in place as ordered for one resident (Resident #28). The facility census was 82. Record review of the facility's policy titled Wound Care, dated October 2010, showed the following information: -The purpose of the procedure is to provide guidelines for the care of wounds to promote healing; -Staff should verify there is a physician's order for the procedure; -Staff should document all assessment data, such as the wound bed (bottom of the wound) color, size of the wound, drainage, obtained when inspecting the wound. Record review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated April 2018, showed the following: [...]