Copper Ridge Health Care

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 8 sampled residents (Resident 8). Specifically, facility staff failed to respond to a wander guard alarm, failed to communicate with one another, and failed to implement the facility's elopement procedure when Resident 8, a cognitively impaired resident with known exit-seeking behaviors, eloped from the building. Resident 8 was found by police approximately 1.5 hours later near a fast-food restaurant two miles away, having sustained a self-reported fall and facial bruising. This noncompliance placed Resident 8 at risk for serious injury, serious harm, serious impairment, or death, constituting an Immediate Jeopardy. It was determined the provider's noncompliance with the requirements of participation had caused a situation that constituted Immediate Jeopardy. [...]

Inspectors wroteBased on observation, interview, and record review, for 1 out of 43 sampled residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident did not have a physician order for their use of oxygen. Resident identifier: 29.

Inspectors wroteBased on interview and record review, for 1 out of 43 sampled residents, the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Resident identifier: 89Findings Included: Resident 89 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, spastic hemiplegia, immobility syndrome (paraplegic), and metabolic encephalopathy. Resident 89's medical record was reviewed on 9/7/25 through 9/10/25. A review of resident 89's progress notes revealed:On 6/24/25 at 5:35 PM, a nursing note documented, Resident was seen provider [sic] today, order received to get KUB [kidney, ureter, bladder x-ray] and UA [urinalysis]. Sample sent to lab and KUB performed, Results were related to provider. [...]

Inspectors wroteBased on interview and record review, for 1 out of 43 sampled residents, the facility did not arrange services with an outside agency in a timely manner. Specifically, a resident did not have a follow up appointment scheduled within the timeline ordered by the provider after a surgical procedure. Resident identifier: 18.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 25 medication opportunities, on 11/2/23, revealed 3 medication errors which resulted in a 12.00% medication error rate. Specifically, two blood pressure medications were not administered to a resident and a medication was administered at the wrong time. Resident identifier: 63.

Inspectors wroteBased on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 31 sampled residents, a resident's Humalog was administered when it should have been held, Lantus was not increased to 78 units, hold blood glucose (BG) parameters were not lowered to 160, and an as needed (PRN) Humalog order was not initiated. Resident identifier: 54.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide procedures that assure the accurate recording of narcotics. Specifically, for 2 out of 9 sampled residents, licensed nursing staff did not reconciliate narcotics in accordance with professional standards and principles. Resident identifiers: 32 and 67.

Inspectors wroteBased on interview and record review, the irregularities noted by the pharmacist during the drug regimen review must be reported to the attending physician and the facility's Medical Director (MD) and Director of Nursing (DON), and these reports must be acted upon. Specifically, for 1 out of 31 sampled residents, a pharmacy recommendation to discontinue a resident's medication was not acted upon when the MD agreed with the pharmacy recommendation. Resident identifier: 54.

Inspectors wroteBased on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 31 sampled residents, a resident's cardiac medication for hypertension was not held when the systolic blood pressure (SBP) was below the physician's ordered parameters. Resident identifier: 30.

Inspectors wroteBased on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 31 sampled residents, a resident taking psychotropic that were last increased on 12/16/21 and 6/14/21, had not received a GDR and the medication was not clinically contraindicated. Resident identifier: 54.

Inspectors wroteBased on observation and interview, the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, an insulin pen was not labeled with a resident identifier or an open date and was open and available for use. In addition, narcotics were repackaged into the narcotic cards.

Inspectors wroteBased on observation, interview and record review it was determined, for 7 of 31 sample residents, that the facility did not provide food and drink that was palatable, attractive, at at a safe and appetizing temperature. Specifically, residents complained of the food quality, a test tray was not palatable, and there were complaints of food quality in resident council. Resident identifiers: 9, 21, 24, 47, 57, 77 and 82.

Inspectors wroteBased on observation and interview it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were not using N95 masks for a resident with isolation precautions, staff were not wearing appropriate eye protection and staff taking soiled gowns through the hallway after leaving an isolation room.

Inspectors wroteBased on interview and record review it was determined, for 2 of 5 sampled facility staff, that the facility did not ensure that routine testing of staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff for COVID-19 at a frequency of two times per week during periods of high levels of community transmission, based on the positivity rate of the county the facility was located in, was not followed. Staff identifiers: Staff 1 and Staff 5.

Inspectors wroteBased on observation and interview it was determined the facility did not ensure that ventilation in the hallways was sufficient to keep foul odors from the hallways. Specifically, odors of urine and feces were observed in the hallways and resident common areas.

Inspectors wroteBased on interview, and record review it was determined, for 2 of 31 sample residents, the facility did not conduct periodic comprehensive, accurate, standardized reproducible assessment not less than once every 12 months. Specifically, resident's annual Minimum Data Set (MDS) assessments were not completed. Resident identifier: 1 and 2.

Inspectors wroteBased on observation it was determined the facility did not ensure hand rails were completely secured to the wall. Specifically, hand rails were not secured throughout the facility.