Copper Rock Healthcare

Based 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; -The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed; -Once the assessment is conducted a risk factor are identified and characterized, a resident centered care plan can be created…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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: name, strength of drug, dose, method of administration, date and time of administration, reason(s) why a medication was withheld, not administered, or refused, signature and title of person administering the medication, and resident response to the medication, if applicable. Review of the facility's policy titled, Medication and Treatment Orders, revised…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -Keep potentially hazardous foods out of the temperature danger zone (41 degrees Fahrenheit (F) to 135 degrees F); -Leftover contents of cans and prepared food will be stored in covered, labeled, and dated containers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -Therapy may require further review and possible changes if the organism is susceptible to narrower spectrum antibiotic; therapy was ordered for prolonged surgical prophylaxis; or therapy was started awaiting culture,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. 1. Review of the resident's admission Minimum Data Set (MDS - a federally mandated assessment completed by facility staff), with an Assessment Reference Date (ARD) of 08/23/23, located in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; -The Consultant Pharmacist will provide a written report to physicians for each resident with an identified irregularity; -If the Physician does not provide a pertinent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Review of the lunch menu, dated 01/24/24, showed the cooks were to serve the following pureed foods: beef stew, creamed peas, biscuit, and pear cake. Review of the 2024 Pureed Creamed Peas recipe, showed the ingredients included: 2.5…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -Meat is ground or chopped into bite-size pieces (½ inch or smaller) and should be mixed or served with gravy, broth, or another type of moistening agent; -Casseroles should contain bite-size chunks of meat, ground or tender meats that are less than ½ inch in size (this will generally fit though the tongs of a fork). 1. Review of Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; -Diagnoses included dementia, anxiety, and unsteadiness on feet. Review of the resident's significant change of condition Minimum Data Set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; -Resident had delusions and wandered occasionally. Review of the resident's Communication - with Physician notes, dated 01/13/24, located in the Notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. 1. Review of Resident #4's Profile tab of the electronic medical record (EMR) showed the following: -admission date of 03/13/21; -Diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined the cause cannot be found or is not correctable; - Based on the preceding assessment, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -Diagnoses included dementia, enlarged prostate with lower urinary tract symptoms, neurogenic bladder (urinary conditions in people who lack bladder control due to a brain, spinal cord, or nerve problem), urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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; -Residents and their designated caregivers will receive education on the purpose, function, and care of the Dexcom CGM device; -Nursing staff will regularly monitor and interpret Dexcom CGM data to ensure…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Review of Resident #29's quarterly Minimum Data Set (MDS - federally mandated assessment tool completed by facility staff), with an assessment reference date (ARD) of 12/20/23, located in the MDS tab of the EMR, showed the following: -admission date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Review of the resident's Care Plan, dated 05/03/23 and located in the Care Plan tab of the EMR, showed the following: -Resident had potential for altered skin integrity related to decreased mobility and compromised immune system; -On 05/3/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; -All alleged violations involving abuse will be reported by the facility administrator or his/her designee to the state licensing/certification agency responsible for surveying /licensing to the facility; -An alleged violation of abuse will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; -If an incident or suspected incident of resident abuse, the Administrator will assign the investigation to an appropriate individual; -The Administrator will provide any supporting documents relative to the alleged incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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; -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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: -The the nurse should describe and document a full assessment of pressure ulcers, including location, stage (the degree of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.