Copperfield Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Copperfield Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF583Dec 11, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF600Dec 11, 2024

  Based 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… […]

• Immediate jeopardy, isolatedF607Dec 11, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF580Jul 28, 2023

  Based 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. […]

• Immediate jeopardy, isolatedF600Jul 28, 2023

  Based 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). […]