Inspection Reports for
Copper Ridge Health and Rehab

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: residents #16, #24, #49, and #54 did not have call lights within reach, and resident #54 was at risk for elopement due to inadequate supervision and safety measures.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: resident #54 eloped by removing a window and exiting the facility, and the facility lacked effective policies and supervision to prevent elopements.

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility's policy on elopements did not specify procedures following incident reports, and visual checks for resident #54 were incomplete.

F 0584 Wall repairs: the facility failed to repair multiple wall damages in residents' rooms, including holes, gouges, and missing plaster and paint, which were not reported timely to maintenance.

F 0584 Housekeeping: the facility failed to maintain a clean environment, with thick brown substances and sticky spills observed in resident bathrooms and rooms.

F 0689 Call lights: residents with physical impairments did not have call lights within reach, limiting their ability to summon help.

F 0689 Elopement risk: the facility failed to prevent elopements and wandering of a resident at risk, including inadequate supervision and unsecured exits.

F 0689 Elopement risk: the resident at risk for elopement had insufficient monitoring and safety measures despite documented risks and care plans.

F 0880 Infection prevention: staff were not adequately educated or compliant with enhanced barrier precautions, failing to use required personal protective equipment for a resident on such precautions.

F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility failed to have the necessary bed and equipment on hand to accommodate a resident's height at admission.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody: a staff member removed a resident's oxygen during admission causing hypoxia and vomiting.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report the oxygen removal incident and follow-up investigation to the State Survey Agency within required timeframes.

F 0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted: the facility failed to have physician orders and necessary equipment on hand for a resident requiring high oxygen, and staff were unaware of the resident's respiratory care needs.

F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to ensure respiratory care was provided for a resident on high oxygen, removed oxygen causing hypoxia, and failed to follow physician orders for three residents receiving oxygen.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect: the facility failed to protect one resident from sexual abuse by another resident who had hypersexual behaviors and required one-to-one observation.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to include care plan interventions to keep a resident safe from unwanted sexual advances or abuse from another resident.

F 0554 Allow residents to self-administer drugs if determined clinically appropriate: the facility failed to assess and document self-administration ability for 4 of 6 sampled residents and lacked physician orders for self-administration.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise the care plan for catheter care according to physician orders for 1 of 26 sampled residents.

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason: the facility failed to provide adequate incontinence care and repositioning for 2 of 26 sampled residents, increasing risk of skin breakdown and discomfort.

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections: the facility failed to change a resident's catheter as ordered, increasing infection risk for 1 of 26 sampled residents.

F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to administer nebulizer treatments according to professional standards for 4 of 6 sampled residents, including failure to clean equipment, monitor residents during treatment, and document vital signs.

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs: the facility failed to remove expired medications and supplies and failed to keep supplies off the floor in multiple medication rooms and carts, increasing risk of use of expired products.

F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure appropriate hand hygiene during catheter and wound care for 2 of 26 sampled residents, including failure to perform hand hygiene between glove changes and before moving from contaminated to clean body sites.

F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to revise a resident's care plan to reflect an intervention regarding gravity enteral tube feeding complications.

F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: a licensed staff member failed to properly administer enteral tube feedings and the facility failed to clarify the feeding order, resulting in the resident receiving an incorrect amount of formula and a decline in status leading to death.

F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: a licensed staff member failed to seek necessary education or guidance for enteral feeding administration for a resident new to the unit, contributing to the resident's decline and emergency room transfer.

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report allegations of abuse to the State Survey Agency for two residents, including verbal abuse and inappropriate comments by staff.

F 0637 Assess the resident when there is a significant change in condition: the facility failed to initiate a Significant Change MDS for a resident who had a fall with a fracture and changed from extended assist to dependent assist for transfers.

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to prevent the development of three Stage II pressure ulcers in a resident who became more dependent after a fracture.

F 0695 Provide safe and appropriate respiratory care for a resident when needed: the facility failed to maintain clean and properly functioning respiratory equipment for two residents, including soiled nebulizer tubing and taped CPAP machine.

F 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures: the facility failed to ensure physicians provided rationale for pharmacist recommendations for two residents.

F 0880 Provide and implement an infection prevention and control program: the facility failed to ensure proper hand hygiene and infection control practices during glucose monitoring, insulin administration, and wound care for multiple residents.

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: the facility failed to provide updated pneumococcal vaccines for six residents, increasing risk of pneumonia.