Copperfield Healthcare and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner in an environment that promotes maintenance or enhancement of his or her quality of life and recognizing each resident's individuality for 1 (Resident #1) of 4 residents reviewed resident rights. The facility failed to ensure CNA A treated Resident #1 with dignity and respect on [DATE] at 11:31 pm when discussing the need for incontinent care with the resident. This failure could place residents at risk for a diminished quality of life and a negative impact on the residents' psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate alternatives prior to installing a side or bed rail were used and if bed or side rails are used, the facility failed to ensure correct installation, use and maintenance of bed rails, including, but not limited to assessing the resident for risk of entrapment from bed rails prior to installation, reviewed the risks and benefits of bed rails with the resident or resident representative and obtained informed consent prior to installation for 11 of 11 residents (Resident #8, #15, #22, #25, #44, # 60, #84, #90, #134, #145, and #149) reviewed for mobility bars/bedrails. 1. -The facility failed to assess Resident #84 for mobility bars, educate the resident RP on the risk and benefits of mobility bars, obtain a physician order and a consent for mobility bars. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status and a need to alter treatment significantly for 1 of 8 residents (CR #1) reviewed for notification of changes. The facility failed to notify CR #1's physician when the resident's family member reported slurred speech and altered mental status on 08/24/25. On 08/25/25 CR #1 was transferred to the hospital where he was diagnosed with acute ischemic infarct (a type of stroke where blood flow to a part of the brain is interrupted, causing brain tissue to die). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents (CR #1) reviewed for quality of care. - The facility failed to act on 08/24/25 when CR #1's family member notified the nurse of slurred speech and altered mental status that indicated a stroke until 08/25/25. - On 08/25/25 CR #1 was transferred to the hospital where he was diagnosed with acute ischemic infarct (a type of stroke where blood flow to a part of the brain is interrupted, causing brain tissue to die). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment describing services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 residents (Residents #12, Residents #80 and Resident #84) reviewed for comprehensive care plans. - The facility failed to care plan Resident #80's incontinence care due to a neurogenic bladder disorder.-The facility failed to care plan Resident #12 for an intravenous mid-line.-The facility failed to care plan Resident #84 for mobility bars on her bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer Parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 (Resident #12) residents reviewed for parenteral fluids. The facility failed to obtain a physician order to discontinue Resident #12's mid-line that had been inserted on 08/05/25. The resident completed her IV antibiotic therapy on 08/28/25. The facility did not obtain an order to discontinue resident mid-line until 09/10/25. This failure placed Resident #12 at risk for unwanted infections and further decrease in quality of life. Resident #12Record review of Resident #12's face sheet, dated 09/11/25, revealed a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of any significant medication errors for 2 of 7 residents (Residents #2 and Resident #109) reviewed for significant medication errors. - The facility failed to ensure nursing staff administered pre-prandial (before a meal) insulin to Resident #2 safely by administering it more than 15 -minutes before meals on 25 occasions from 08/01/25 to 09/11/2025. - The facility failed to ensure nursing staff administered medication to Resident #109 as ordered when LVN K applied a Lidocaine patch to the resident's right knee without an order. These failures could place residents at risk of uncontrolled blood sugars, hypoglycemia (low blood sugars), hyperglycemia (high blood sugars), worsening of diabetes, medication errors and adverse reactions to medications.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 8 residents (Resident #25, Resident #38 and Resident #104) reviewed for environmental concerns. - The facility failed to ensure Resident #38's room door did not have a lock that required a key which resulted in the resident, who was bed bound with her ankle fixed with screws, being locked in the room and inaccessible for 15-20 minutes.- The facility failed to ensure Resident #25's dresser drawers did not swing open on their own, leaving the resident concerned that her head would be hit by the drawer.- The facility failed to ensure Resident #25 and Resident #104's bathroom door did not swing shut on its own. These failures could place residents at risk of falls, injuries, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide personal privacy when providing personal care for 2 (Resident #12, Resident #150) of 7 residents observed for personal care. -CNA AR failed to provide privacy for Resident #150 during incontinent care. -LVN M failed to provide privacy for Resident #12 during tracheostomy care. This failure placed residents at risk for their loss of dignity, respect, and psychological distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure MDS data was transmitted within 14 days of completion for 1 of 5 closed record reviews (CR #62), in that: -CR #62's MDS discharge assessment was not completed and submitted to CMS.This failure could place the resident at risk for receiving unnecessary services or inadequate care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 7 residents (Resident #11) reviewed for accidents and supervision. The facility failed to ensure a disinfectant Sani-wipes container was not placed at the bedside of Resident #11. This failure could place residents at risk for unwanted injuries and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 3 residents (Resident #72) reviewed for enteral feeding. The facility failed to ensure Resident #72's enteral feeding was turned off during bowel rest between 9AM and 11AM on 9/10/2025 . This failure could place residents at risk of health complications such as aspiration pneumonia or gastrointestinal injury. Record review of Resident #72's face sheet, captured 09/11/2025, reflected an [AGE] year-old male originally admitted on [DATE] and last re-admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference for 1 of 7 residents (Resident #12) reviewed for tracheostomy care. The facility failed to ensure -LVN M did not turn Resident #12's oxygen off for 2 minutes when providing resident tracheostomy (surgical opening that creates an opening in the trachea [(windpipe]) to allow air to enter and exit the lungs) care. This failure could place residents at risk for respiratory distress and hypoxia (deficiency of oxygen).

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (200 Hall Nurse Cart) and 1 of 8 residents (Resident #52) reviewed for medication storage. LVN K failed to ensure Resident #52's Tresiba Insulin Pen was not left unattended on top of the nursing cart on the 200 Hall. This failure could place residents at risk of misappropriation of medication and adverse reactions.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain and infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1of 3 staff reviewed for infection control. 1) RN E failed to practice hand hygiene before and after assisting Resident #84' with care. 2) RN E failed to sanitize the blood pressure device after taking Resident #3's blood pressure. 3)The facility failed to label and bag all personal care items in room [ROOM NUMBER]. Resident #12 resided in room [ROOM NUMBER]. These failures placed the residents at risk for cross contamination and infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (CR #1) of 5 residents reviewed for treatment of pressure ulcers. - The facility failed to notify the MD and receive orders for CR #1's sacral pressure ulcer from 1/24/25-1/27/25. There was no documentation of size until 1/27/25. The noncompliance was identified as PNC. The noncompliance began on 1/24/25 and ended on 2/24/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for worsening wounds, infection, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent (%) or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 3 of 14 residents (Residents #274, #77 and #14) reviewed for medication errors. -MA L did not administer the full dose of Trintellix (vortioxetine) HBr (a medication used to treat major depressive disorder) to Resident #274 as ordered by the Physician. -MA L administered Multi-Vitamin with Minerals to Resident #77 instead of Ocuvit eye + Multivitamin with Minerals (a medication used to help protect eye health) as ordered by the Physician. -RN T administered Lidocaine Patch 5 % (a medication used to help relieve pain) to Resident #14 instead of Aspercream 4% Lidocaine as ordered by the Physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 2 residents (Residents #71 and #1) reviewed for medical records accuracy, in that: Resident #71's June 2024 MAR documentation was incomplete. RN M failed to document or sign off on the administration of physician ordered Oxycodone with Acetaminophen (a controlled substance) for pain. Resident #1's April 2024 MAR documentation was incomplete. RN M failed to document or sign off on the administration of physician ordered Hydrocodone with Acetaminophen (a controlled substance) for pain. Facility staff failed to sign the correct narcotic count sheet for Resident #71's Oxycodone with Acetaminophen. RX301757108. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered admission baseline care plan within 48 hours of admission for 1 of 6 residents (Resident #22) reviewed for baseline care plans in that: - Resident #22 did not have a baseline care plan that addressed his diagnosis of pneumonia completed within 48 hours of admission. This failure placed newly admitted residents at risk of not receiving services to meet their needs. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, which included tracheostomy care and tracheal suctioning, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 2 of 3 residents (Resident #88 and Resident # 6) reviewed for oxygen therapy. The facility failed to ensure Resident #88's oxygen was set according to physician orders. The facility failed to ensure Resident #6's oxygen concentrator was functional, oxygen tank had oxygen and oxygen was set according to physician's order. These failures could place residents at risk of respiratory distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 26 opportunities, which involved 2 (Residents #77, and Resident #4) of 10 residents reviewed for medication errors. -LVN C left 5 ml of lactulose in the portion cup after the medication was administrated through a g - tube to Resident #77. -MA F administered eye drops to both eyes instead of in the left eye to Resident #4. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were secured and stored properly for two of four medication aide carts (100 and 300 Hall Medication aide Carts) reviewed for drug storage. -MA F failed to ensure a bottle or blister pack of Aspirin, Memantine HCL, Stool softener, loratadine, ClearLax 17 mg, multi-vitamins with minerals, Spironolactone 25mg were not left on top of 100 hall medication aide cart unattended on 05/17/23. -MA H failed to ensure 300 hall medication aide cart was locked when left unattended on 05/17/23. These failures could place residents at risk for possible drug diversions or accidental ingestion.

Inspectors wroteBased on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 6 of 8 Staff (MA I, MA H, LVN A, LVN C , LVN J, and Wound care nurse) reviewed for infection control. 1. The facility failed to ensure MA I followed proper hand hygiene and infection control procedures during medication administration for Resident # 301 and Resident #407. 2. The facility failed to ensure MA H followed proper hand hygiene during medication administration for Resident #36. 3. The facility failed to ensure LVN A followed proper hand hygiene and infection control procedure during medication administration for Resident #404. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure MDS data was transmitted within 14 days of completion for 1 of 22 residents (CR #49), in that: -CR #49's discharge assessment was started on 01/16/2023 but was not submitted to CMS until 05/18/2023. These failures placed residents at risk for receiving unnecessary services or inadequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for 2 of 20 (Resident #3 and #41) residents reviewed for accuracy of MDS assessment. Resident #3's and #41's MDS assessments accurately reflected the residents lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life due to an inability to eat regular texture foods.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1of 5 residents (Resident #401) reviewed for ADLs. The facility failed to ensure Resident #401 was provided personal grooming (shower and shaving) by facility staff. This failure could place residents at risk for discomfort, and dignity issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings, for 1 (Resident #77) of 3 resident that was reviewed for feeding tubes, in that: -The facility failed to ensure LVN C appropriately verified placement and amount of fluid to be used for Resident #77 during tube medication administration, lactulose 10gm/15ml, give 30 ml via g - tube one time a day. This failure could place residents at risk for adverse reactions, inadequate therapy, and a decreased quality of life. Resident #77 Record review of Resident #77's admission face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 2 of 10 residents (Resident #404 and Resident #77) reviewed for medication administration. -The facility failed to ensure LVN A followed proper medication administration of Enoxaparin (Lovenox ) injection to Resident #404. -The facility failed to ensure LVN C performed flushes as ordered during gastrostomy (G-tube) medication administration for Resident #77. These failures could place residents receiving medications at risk of adverse medication reactions.