Copperfield Health & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Resident #78 was admitted to the facility on [DATE] with diagnoses including protein calorie malnutrition, lipoprotein deficiency (inherited metabolic disorder where a defective gene prevents the body from producing the enzyme needed to break down dietary fat), and dysphagia (difficulty swallowing). The significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #78 was severely cognitively impaired. The MDS was coded for Resident #78 receiving a mechanically altered diet. Review of the physician order dated 1/7/2026 indicated Resident #78 required a mechanically altered diet with thin liquids for diagnosis 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 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. The findings included:a. During an initial observation of the facility's kitchen with the Regional Dietary Manager and the Dietary Manager on 2/16/2026 at 9:52 AM, the walk-in freezer was noted to have the following concerns: - An opened unsealed package of chicken tenderloins with signs of frost bite spots and discolored grayish brown patches; - An opened, unlabeled, and unsealed package of chicken breasts with signs of frost bite spots and discolored grayish brown patches; - One opened, unlabeled, unsealed box of chocolate chip cookies with signs of frost bite spots and discolored grayish brown patches and; - One opened, unlabeled, unsealed package of biscuit dough with ice crystal formation. b. During an initial observation of the facility's kitchen with the Regional…

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 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). The findings included:Resident #59 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, chronic obstructive pulmonary disease (COPD), and chronic respiratory failure.Review of physician orders dated 10/02/2025 revealed an order for oxygen at 3 liters per minute via nasal cannula continuously for shortness of breath.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #59 was cognitively intact, received oxygen therapy and utilized a non-invasive mechanical ventilator.Observations of Resident #59's oxygen via nasal cannula connected to the bedside oxygen flowmeter revealed the oxygen was set at 2 liters per minute on 02/16/2026 at 11:00 AM, 02/17/2026 at 10:00 AM, and 02/18/2026 at 10:00 AM.An interview with…

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 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. Findings included: The facility's Abuse, Neglect, and Exploitation Policy, last updated on 10/22/24, was reviewed and it included misappropriation in part was the protection of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Resident #6 was admitted to the facility on [DATE] with a diagnosis of chronic pain. Resident #6 had an order for oxycodone 10 milligrams (mg) every 6 hours for chronic pain dated 2/13/24. A pharmacy packing slip dated 3/25/24 documented dispense date of 3/25/24 of 4 cards of oxycodone 10 mg and each card had 10 tablets for a total of 40 tablets. A review of 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 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. Findings included: Resident #65 was admitted to the facility on [DATE] with the diagnosis of limited range of motion. Resident #65's Minimum Data Set, dated [DATE] documented her cognition was intact. The resident required assistance from one staff member for bathing and personal grooming. The care plan for Resident #65 dated 9/13/24 included the resident required assistance with all activities of daily living. The intervention was nail care to be provided with showers or bathing. On 12/2/24 at 11:40 am an observation and interview was completed of Resident #65. The Resident was sitting in her bed in a hospital gown. The Resident's nails were noted to be uneven, long, and had black matter underneath the nails, especially the right hand. The resident stated she…

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 staff interviews, the facility failed to complete a quarterly smoking assessments for 2 of 3 residents reviewed for smoking (Resident #31 and Resident #72). The findings included: 1a. Resident #31 was admitted to the facility on [DATE] with diagnoses which included hypertension, muscle weakness, dementia, and blindness in one eye. Review of Resident #31's annual MDS dated [DATE] revealed the resident was coded for smoking. Review of Resident #31's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired and was totally dependent on staff for most activities of daily living (ADL). Resident #31 was coded for moderate visual impairment. The MDS indicated Resident #31's mobility device was a wheelchair use. Review of Resident #31's care plan revised on 12/4/24 revealed the resident was a smoker and was supervised because he was once non-compliant with smoking policy and witnessed smoking in his room. The goal was for Resident #31s smoking…

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 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). Findings included: A review of the manufacturer's recommendations for artificial tears stated after the bottle was opened it should have been discarded after 28 days. On 12/3/2024 at 11:00 am an observation of the B-hall medication cart with Nurse #5 revealed 3 bottles of artificial tears were found without an open date. Nurse #5 stated the bottles were in the boxes and the date was on the box on the previous evening. Nurse #5 stated either the bottle or the box should be dated when the bottle is opened. On 12/9/2024 at 11:06 am the Director of Nursing was interviewed by phone, and she sated the bottles of artificial tears that were opened in the B-hall medication cart should have been dated when they were opened. The Administrator was present during the interview and stated either the box or the bottle of the artificial tears should…

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 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. Findings included: A review of the facility's Abuse, Neglect and Exploitation policy dated 11/1/2020 indicated the facility would prohibit and prevent misappropriation of resident property. Resident #1 was admitted for a short stay for rehabilitation to the facility on 7/14/2023 after a hospitalization for encephalopathy and weakness. A review of Resident #1's Physician's Orders revealed he did not have an order for hydromorphone. An admission Minimum Data Set assessment dated [DATE] indicated Resident #1 was cognitively intact and required extensive assistance with bed mobility and transfers, and he did not require pain medication. Attempted to call Resident #1 during the survey and there was no answer at the number the facility had for him, and the phone did not receive…

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, 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. The findings included: 1. On 7/19/23 at 1:42 PM, an observation of the exterior facility grounds revealed two commercial dumpsters. One dumpster was open without a lid, filled with cardboard and no room for additional storage. The second commercial dumpster's lid was closed with room for additional storage. The following broken items were observed stored on the ground or propped against the facility: Multiple boards of sheet rock, propped against the facility. One broken shower chair stored on the ground. Four cement stairs stored on the ground. Five wooden pallets, broken, stored on the ground. One black leather chair, broken and stored on the ground. One used surgical face mask, stored on the ground. Four particle board headboards and footboards, broken, propped against the facility shed. One used glove, laying on the ground. Two recliner…

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 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. The findings included: 1. An observation of the walk-in freezer occurred on 7/17/23 at 11:45 AM. A metal storage rack approximately 11 inches in height was observed with milk crates stored on top. The milk crates were approximately 11 inches in height. Multiple cases of carrot coins, crinkle cut French fries and garlic bread were stored on top of the milk crates. Ice was observed on top of these cases of food items and the ice extended to the floor, approximately 22 inches and pooled on the floor around the base of the metal storage rack. The ice was also observed inside the cases of food items and on the food. The freezer compressor was observed with ice accumulation and water dripping. The Dietary Manager (DM) stated in an interview on 7/17/23 at 11:45 AM that compressor had been leaking for 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 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; F655 was cited on 2/14/2022 during recertification and complaint investigation survey and F812 was cited on 2/14/2022 during a recertification and complaint investigation and on 7/29/2022 during a complaint investigation. These deficiencies were cited again during the facility's current recertification and complaint investigation survey…

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 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. The findings included: 1 a. Observations of live pest activity occurred on the following: - On 7/17/23 at 12:33 PM, flies were observed flying around the covered lunch meal tray that was stored on the over bed table in room [ROOM NUMBER] on the A/B unit. - On 7/17/23 at 12:55 PM, multiple small flying insects were observed flying around the nightstand in room [ROOM NUMBER] on the C/D unit. - On 7/17/23 at 12:59 PM, flies were observed in room [ROOM NUMBER] on the C/D unit. - On 7/19/23 at 11:21 AM, multiple flies were observed on the C/D unit flying around the open food cart. - On 7/19/23 at 11:44 AM a spider was…

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 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). The findings included: Resident #94 was admitted to the facility on [DATE]. Diagnoses for Resident #94 included difficulty walking, frequent falls, and Parkinson's disease. A review of the medical record revealed no baseline care plan was in place for Resident #94 dated 6/2, 6/3, 6/4 or 6/5/2023. Resident #94 was discharged to the hospital on 6/5/2023. The discharge Minimum Data Set (MDS) assessment dated [DATE] documented Resident #94 had a fall since admission with a major injury. A review of the medical record revealed Resident #94 was readmitted to the facility on [DATE]. A review of the medical record for Resident #94 revealed a baseline care plan was created on 7/2/2023. An interview was conducted with Nurse #6 on 7/21/2023 at 12:10 PM.…

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.