Copperfield Health & Rehabilitation

Inspectors wroteBased on observation, record review, and interviews with resident, staff, Psychiatric Nurse Practitioner, and Medical Director, the facility failed to ensure residents were free from abuse when Resident #6, who had a known history of aggressive behaviors toward others, physically abused 2 of 5 residents (Resident #10 and Resident #117) reviewed for abuse. On 11/24/25 Resident #6 hit Resident #10, a resident with severe cognitive impairment, in the face resulting in a bruised, swollen, and busted open and bleeding lip. On 1/10/26 Resident #6 spat on and punched Resident #10 in the face resulting in swelling to the right eyebrow and swelling, bruising, and a gash on her upper lip. Resident #10 did not have the cognitive capacity to express an adverse psychosocial outcome. A reasonable person would have experienced feelings such as fear, anxiety, isolation, and withdrawal. [...]

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to follow the planned menu for residents prescribed a mechanically altered diet during 2 of 2 lunch meal observations. This deficient practice affected 1 of 5 residents observed on mechanically altered diets (Resident #78) and 23 other residents who were prescribed a mechanically altered diet.

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date leftover food stored for use, discard food past its use-by-date and discard food showing signs of spoilage in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer. These practices had the potential to affect food served to residents.

Inspectors wroteBased on observation, record review, and interviews with resident, staff, and Nurse Practitioner (NP), the facility failed to administer oxygen as ordered by the physician for 1 of 3 residents reviewed for respiratory care (Resident #59).

Inspectors wroteBased on observation, record review, and responsible party, Lieutenant of Criminal Investigations and staff interviews the facility failed to protect a resident's privacy for 1 of 3 residents (Resident #2). Nurse aide (NA) # 1 and NA # 2 provided personal care to Resident # 2 while live streaming on a cell phone. The staff allowed a prison inmate who was watching the live stream to view the resident while the resident was naked from the waist up and while care was provided; the staff allowed this live streaming while other inmates were observed in the open area behind him. As Resident #2 was severely cognitively impaired, the reasonable person concept was applied. A reasonable person would have been traumatized and have feelings of worthlessness, powerlessness and dehumanization through people that were not caregivers viewing them naked and while care was provided without consent. [...]

Inspectors wroteBased on observation, record review, and family, Lieutenant of Criminal Investigations and staff interviews, the facility failed to protect a resident's right to be free from abuse for 1 of 3 residents (Resident #2). Nurse aide (NA) # 1 and NA # 2 provided personal care to Resident # 2 while live streaming on a cell phone, the resident was naked from the waist up, the staff and the prison inmate watching the live stream spoke with profanity and vulgarity without any regard for the resident; the staff did not explain care as it was provided to the resident; the staff were physically aggressive during care; the staff allowed an inmate who was watching the live stream to view the resident and speak to the resident; the staff allowed this live streaming while other inmates were observed in the open area behind him. [...]

Inspectors wroteBased on observation, record review, and responsible party, Lieutenant of Criminal Investigations and staff interviews, the facility failed to develop and implement abuse policies in the area of identification, protection and reporting for 1 of 3 residents (Resident #2). While Resident # 2 was being abused, neither of the two nurse aides (NA #1 and NA #2) in the room identified the abuse, intervened to stop the abuse, and neither of the two nurse aides reported the abuse immediately to licensed staff or administrative staff. Immediate jeopardy began on 10/4/24 when Resident #2 was abused without staff identification, intervention or reporting. Immediate jeopardy was removed on 12/5/24 when the facility implemented a credible allegation of immediate jeopardy removal. [...]

Inspectors wroteBased on record review, and interviews with staff, the facility failed to protect the resident's right to be free from misappropriation of controlled medications for 1 of 3 residents reviewed for misappropriation of a resident's property (Resident #6). The resident received her pain medication as scheduled.

Inspectors wroteBased on observations, record review, and interviews with Resident #65 and staff, the facility failed to provide nail care and hand hygiene for a dependent resident (Resident #65). This deficient practice affected 1 of 4 sampled dependent residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete a quarterly smoking assessments for 2 of 3 residents reviewed for smoking (Resident #31 and Resident #72).

Inspectors wroteBased on manufacturer's recommendations, observations, and staff interviews, the facility failed to date three opened bottles of artificial tears stored for use in 1 of 2 medication carts reviewed for medication storage (the B-hall medication cart).

Inspectors wroteBased on record review and staff interviews, the facility failed to notify Resident #27's Representative and Resident #28 in writing, of transfers to the hospital for 2 of 3 residents reviewed for hospitalization (Resident #27 and Resident #28).

Inspectors wroteBased on record review and staff interviews the facility failed to protect the residents right to be free of misappropriation of narcotic pain medication for 1 of 1 resident (Resident #1) reviewed for misappropriation of resident property.

Inspectors wroteBased on record reviews, resident, family, nurse practitioner (NP), physician (MD), and staff interviews, the facility failed to notify the MD of a resident who experienced pain following a fall for 1 of 3 residents investigated for notification of changes (Resident #94). Resident #94 sustained a fall on 6/2/2023 and reported the fall and right hip pain to Physical Therapist (PT) #1 on 6/3/2023. PT #1 reported the fall and the hip pain to a nurse. Resident #94 reported the fall and right hip pain when she was assessed by NP#2 on 6/5/2023. NP#2 ordered an x-ray of the right hip, which revealed a fractured femur (the long bone in the leg). Resident #94 was sent to the hospital on 6/6/2023 at 12:30 AM and had a partial hip replacement surgery on 6/7/2023. Immediately Jeopardy began on 6/3/2023 when Resident #94 reported the fall and right hip pain to PT #1 and the MD was not notified. [...]

Inspectors wroteBased on record reviews, and resident, family member, Physical Therapist (PT) #1, Nurse Practitioner #2, Director of Rehab Services, Physician (MD), and staff interviews, the facility neglected to protect a resident from the right to be free from deprivation of goods and services related to pain management and initiating medical care and treatment after a fall on 6/2/2023 for 1 of 4 residents investigated for abuse/neglect (Resident #94). Nurse Practitioner (NP) #2 completed Resident #94's admission assessment on 6/5/2023 and Resident #94 reported the fall on 6/2/2023 and pain in her right hip since the fall. An x-ray of the right hip revealed a right femoral neck fracture (type of hip fracture of the thigh bone). Resident #94 was sent to the hospital on 6/6/2023 and had a partial hip replacement surgery on 6/7/2023. [...]

Inspectors wroteBased on record reviews, resident, family, nurse practitioner, physician, and staff interviews, the facility failed to effectively manage pain for a resident after she experienced a fall and reported pain for 1 of 5 residents investigated for pain management (Resident #94). Resident #94 experienced pain that caused her to yell and scream. The pain affected her ability to go to the bathroom and she became incontinent. Immediately Jeopardy began on 6/3/2023 when Resident #94 reported hip pain to Physical Therapist (PT) #1 and nursing did not effectively manage her pain. Immediate Jeopardy was removed on 7/26/2023 when the facility implemented a credible allegation of Immediate Jeopardy removal. [...]

Inspectors wroteBased on observations, and interviews with staff, the facility failed to maintain the exterior facility grounds clean, free of broken equipment and trash and repair broken floor tiles in the kitchen. This failure occurred for one to nine months.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to maintain one of one freezer free of accumulated ice and remove pooled water on the kitchen floor. This failure occurred for approximately four months and had the potential to affect food served to residents.

Inspectors wroteBased on record review and staff interviews the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the 8/31/2021 infection control and complaint investigation survey, 2/14/2022 recertification and complaint investigation, 7/29/2022 complaint investigation survey. The facility had deficiencies previously cited in the areas of notification of change (F580), baseline care plans (F655) and kitchen sanitation (F812). F580 was cited on 8/31/2021 during a complaint investigation and infection control survey, on 2/14/2022 during a recertification and complaint investigation survey, and on 7/29/2022 during a complaint investigation survey; [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to maintain an effective pest control program as evidenced by observations of current pest activity in 3 of 3 resident rooms, on two of two units, and the conference room. The facility failed to utilize insect light traps and implement pest service recommendations for four months to prevent reoccurring pest activity.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to develop a baseline care plan within 48 hours of admission that addressed the needs of a resident with a history of frequent falls for 1 of 29 residents reviewed for baseline care plans (Resident #94).