Copper Ridge Nursing and Assisted Living Center

Inspectors wroteBased on observations, interviews, review of facility investigations and medical record review, it was determined that the facility failed to adequately supervise Resident #34 from behaviors that subjected him/her to the risk of serious injuries. This was found to be evident for 1 (Resident #34) of 3 residents reviewed for behaviors. The Maryland Office of Health Care Quality (OHCQ) determined that the concern met the Federal definition of Immediate Jeopardy, and the facility was notified in writing of this determination at 2 PM on 6/17/26.

Inspectors wroteBased on observation, interview and record reviews, it was determined that the facility failed to to provide necessary services to maintain good personal hygiene for dependent Residents timely. This was evident for 2 (Resident #74 & #68) of 5 residents reviewed for activities of daily living during the annual survey.

Inspectors wroteBased on observations, record reviews, and staff interviews, it was determined that the facility failed to administer medications according to procedures that ensure accurate dispensing and ensure medications were administered to a resident as ordered. This was evident for 1 (Resident #31) out 4 residents observed for medication administration and 1 (Resident #68) out of 2 complaints related to medication administration.

Inspectors wroteBased on review of facility and medical records and interview with staff it was determined the facility staff failed to provide adequate supervision to prevent a cognitively impaired resident from eloping from the facility. This was evident for 1 (#7) of 2 residents reviewed for accidents.

Inspectors wroteBased on review of facility files and interview with staff it was determined the facility staff failed to ensure all direct care staff received mandatory training for Effective Communication. This was evident for 4 (#8, #9, #10, and #11) of 4 direct care staff reviewed for Training Requirements during the extended survey.

Inspectors wroteBased on review of facility files and interview with staff it was determined the facility staff failed to ensure all staff received mandatory training on the elements and goals of the Quality Assurance Performance Improvement (QAPI) program. This was evident for 4 (#8, #10, #3 and #4) of 6 staff reviewed for Training Requirements during the extended survey.

Inspectors wroteBased on review of facility documents and staff interview it was determined the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made. This was evident for 2 (#3, #1) of 3 residents reviewed for an injury of unknown source and 1 (#2) of 1 residents reviewed for misappropriation of resident property.

Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined that the facility failed to conduct yearly performance reviews at least every 12 months. This was found to be evident for 4 (#8, #13, #14, #15) of 4 GNA employee files reviewed.

Inspectors wroteBased on review of facility files and interviews with staff it was determined the facility staff failed to ensure all staff received mandatory training for the Infection Control program. This was evident for 1 (#4) of 6 staff reviewed Training Requirements during the extended survey.

Inspectors wroteBased on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to conduct care plan meetings of the interdisciplinary team for residents at the time of the quarterly revision of their care plan. This was evident for 4 (Resident #7, #12, #29, and #63) out of 6 residents reviewed for care plans during this recertification/complaint survey.

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined the facility failed to ensure: 1) a psychotropic medication prescribed as needed (PRN), had an end date that was limited to 14 days, and 2) residents were free from unnecessary medications. This was evident for 2 (Residents # 29, #22) out of 5 residents reviewed for unnecessary medications during the facility's recertification/complaint survey.

Inspectors wroteBased on review of the medical record and interview with facility staff, it was determined the facility failed to provide written notice of the bed hold policy to the resident/resident representative when the resident was transferred to the hospital. This was evident for 1 (Resident #6) out of 2 residents reviewed for hospitalization during the recertification/complaint survey.

Inspectors wroteBased on review of medical records and interview with facility staff, it was determined that the facility failed to ensure that residents were provided with summaries of their baseline care plans including a list of their medications. This was evident for 1 (Resident #6) out of 30 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility failed to follow physician orders for a resident. This was evident for 2 (Residents #6 and #22) out of 30 residents reviewed during the facility's recertification/complaint survey.

Inspectors wroteBased on a review of resident medical records and interviews with facility staff, it was determined that the facility failed to ensure drug records were maintained in a manner that allowed for reconciliation of dispensed and administered medication. This was evident for 2 (Resident #29 and #165) out of 3 residents reviewed for administration of controlled medication during this recertification/complaint survey.

Inspectors wroteBased on medical record review and interviews with facility staff, it was determined that the facility failed to document/respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #1) out of 5 residents reviewed for unnecessary medication use during this recertification/complaint survey.

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility nursing staff failed to ensure medications were administered or withheld according to physician's orders. This was evident for 2 (Resident #3 and #28) out of 30 residents in the survey sample.

Inspectors wroteBased on clinical record review, resident interview, and staff interview, it was determined that the facility staff failed to ensure a resident received routine dental services. This was evident for 1 (Resident #3) out of 30 residents in the survey sample.

Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to discard protein drinks past their use by date. This was evident for 2 out of 3 unit-based kitchens observed during the recertification/complaint survey.

Inspectors wroteBased on record review and staff interviews, the facility failed to adequately monitor and track residents receiving antibiotics. This deficiency was evident for 2 (Resident #22 and #166) out of 4 residents reviewed for antibiotic use and the facility's antibiotic stewardship program during the recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to adequately screen residents for eligibility and document their pneumococcal and influenza (Flu) vaccination status. This deficiency was evident for 2 (Resident #29 and #54) out of 5 residents whose immunization records were reviewed during this recertification/complaint survey.

Inspectors wroteBased on medical record review, staff employee file review, and staff interview, it was determined the facility failed to maintain document related to residents' and staff' COVID-19 vaccination status. This was evident for 2 (Resident #3 and #54) out of 5 residents, and 1 (Staff #16) out of 5 staff reviewed for COVID vaccination records during this recertification/complaint survey.

Inspectors wroteBased on observation and interviews, it was determined that the facility failed to ensure that all residents were adequately equipped with the ability to call for assistance, if needed, through a communication system. This was evident for 1 (Resident #58) out of 4 resident rooms assessed for call light accessibility during the recertification/complaint survey.

Inspectors wroteBased on a review of facility investigative materials, resident medical records, and interviews with facility staff, it was determined the facility failed to ensure that a resident remained free of verbal abuse. This was evident for 1 (Resident #33) out of 4 residents reviewed for abuse during this recertification/complaint survey. The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facility's plan and actions were verified during this survey, leading to a determination of past noncompliance, with a compliance date of 6/12/2024.

Inspectors wroteBased on reviews of the facility's investigation, the facility reported incident, and staff interview, it was determined that the facility failed to protect a resident from abuse. This was evident for 3 (#115 ,#116 #117) out of 9 residents selected for abuse review during the annual recertification survey.

Inspectors wroteBased on a review of the medical record, observation, and interviews with staff, it was determined that the facility staff failed to 1) develop a comprehensive care plan for a resident (#26) receiving an antidepressant medication, and 2) develop a plan of care for pain management that had included non-pharmacological interventions. This is evident for 2 (Resident #26, #263) of 46 resident's selected for investigative review in the annual survey.

Inspectors wroteBased on observations, review of daily staffing records, and staff interview, it was determined the facility failed to post the total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing aides per shift and failed to have the staff data requirements available in an accurate, clear and readable format. It was identified that the facility did not have staffing information readily available in a readable format for residents and visitors for the survey.

Inspectors wroteBased on review of facility records and an interview with staff, it was determined the facility failed to revise and document an accurate up-to-date facility-wide assessment. This was evident during review of the sufficient and competent nurse staffing task of the annual survey. This has the potential to affect all residents within the facility.

Inspectors wroteBased on observation and staff interview, it had been determined that the facility had not implemented infection control practices to prevent the spread of COVID 19 as evidenced by facility staff to wear mask that covered their mouth and nose at all time while in resident care area.

Inspectors wroteBased on observation rounds, it was determined the facility failed to maintain dignity for a resident when a staff member wrote the date and time on a pain patch after applying it. This was evident for 1 (#21) of 46 sampled residents.

Inspectors wroteBased on record review and interview, it was determined that the facility staff failed to ensure that residents were able to exercise their right of self-determination, as evidenced by denying a resident a food preference due to the resident's diagnosis. This was evident for 1 (#19) of 43 residents reviewed.

Inspectors wroteBased on reviews of administrative documents and staff interview, it was determined that a facility staff member failed to 1) report an allegation of physical abuse immediately to the facility administrator and initiate an investigation into the allegation of abuse and 2) report an allegation of abuse to the State Agency within a timely manner. This was evident for 2 (Resident #115, #262) of 10 residents reviewed for abuse during an annual recertification survey.

Inspectors wroteBased on interviews with residents and facility staff, it was determined that the facility failed to 1) give residents a list of their admission medications with a copy of their baseline care plans, and 2) develop and implement baseline care plans and 2) provide a summary of the baseline care plan to newly admitted residents. This was evident for 5 (#21, #26, #51, #261, #262) of 46 residents reviewed during the investigation phase of the survey. The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive.

Inspectors wroteBased on medical record review, it was determined the facility failed to 1) update the care plans to reflect the removal of a Foley catheter for the residents (#26, #51), and 2) have a care plan meeting in August 2021 for resident #28. This was evident for 3 out 46 residents reviewed for the annual survey.

Inspectors wroteBased on interview and observation of resident # 35, it was determined that facility failed to turn and reposition a resident who could not do so independently. This was evident for 1 (#35) out of 1 resident.

Inspectors wroteBased on complaint, a facility reported investigation, and interview with the ombudsman and facility staff, it was determined that 1) RN staff #11 failed to replace an empty oxygen tank for resident #213 that was empty, and 2) the nursing staff failed to administer an injectable anticoagulant timely. This was evident for 2 (Residents #213, #114) of 46 residents reviewed during an annual recertification survey.

Inspectors wroteBased on observation and interview with GNA, facility failed to have sufficient staff on the Eastern Shore unit on 9/13/21 7-3 shift. This was evident for 34 out of 34 residents.

Inspectors wroteBased on reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to 1) conduct a yearly performance review on 2 (#40, # 43) out of 5 geriatric nursing assistant staff for the year of 2021, and 2) ensure that 2 (#40, # 43) out of 5 geriatric nursing assistants (GNA) staff completed a minimum of 12 hours of education per year.

Inspectors wroteBased on reviews of administrative records and staff interview, it was determined that the nursing administrative staff failed to ensure that 5 ( GNAs #22, 40, 41, 42, 43) out of 5 geriatric nursing assistants (GNA) staff received and completed minimum training for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder.

Inspectors wroteBased on observation, staff interview, and facility documentation review, it was determined the facility failed to discard medications after the expiration date. This was evident for 1 of 2 nursing units observed.

Inspectors wroteBased on interviews of residents and facility staff, it was determined the facility failed to follow residents' meal tickets and provide foods that were consistent with the resident diet plan and provide meals on time. This was found to be evident for 2 (Resident #10, #261) out of 46 residents investigated for food concerns during the facility's annual survey.

Inspectors wroteBased on complaint, observation, and staff interview, it was determined that the facility staff failed to provide a resident with a meal within the required time frame. This was evident for 2 (Resident #35, #114) of 2 residents who were totally dependent upon staff to feed them. This was observed during dining observations during an annual recertification survey.

Inspectors wrote4) On 9/21/21 at 10:56 AM, a review of Resident #263's medical records revealed on the Treatment Administration Record (TAR) for 5/2021, an order initiated on 5/3/21, that read, Sacrum: cleanse with wound cleaner then apply calcium alginate with silver and cover with foam dressing. Every day shift for wound healing. Further review of Resident #263's medical record revealed that staff had failed to document the assessment of this wound or a notification to the physician and resident representative regarding the wound. On 9/21/21 at 2:00 PM, an interview with the Assistant Director of Nursing (ADON) revealed that she was unable to locate any skin sheets or documentation regarding Resident #263's sacral wound. 3) On 9/22/21 at 12:05 PM, an investigation was conducted for resident # 28 who had a history of aggressive behavior towards other residents and staff. [...]

Inspectors wroteBased on record review and interview, it was determined that the facility staff had failed to conduct quality assurance meetings on a quarterly basis. This was evident for 2 of 4 Quality Assurance meetings.

Inspectors wroteBased on record review and staff interview, it had been determined that the facility failed to have a process in place to prevent the spread of infection by ensuring 1) that residents had been offered both pneumococcal vaccinations as recommended by the Centers for Disease Control and 2) that staff had provided immunization records in writing at the time of hire. This was evident for 3 (#19, #35, and #31) of 5 residents reviewed for immunizations and 5 (#40, #41, #42, #43, and #22) of 5 staff reviewed for immunization records.

Inspectors wroteBased on the review of employee records and staff interview, it was determined that the facility failed to have documentation that Geriatric Nursing Assistance's (GNA) were given 1) in-service training no less than 12 hours per year, 2) dementia management training and abuse prevention training, 3) a yearly performance review, and 4) training for GNA's that provided services to residents with cognitive impairments. This was evident for 5 of 5 GNA employee records (Staff #22, #40, #41, #42 and #43) that took place during the sufficient and competent nursing staffing task reviewed during an annual recertification survey.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to have a system in place to 1) ensure that required documentation regarding a resident's transfer and appeal rights were provided to residents when transferred to the hospital; and 2) to inform the Ombudsman of transfers and discharges. This was found to be evident for 1 out of 1 resident (Resident #61) reviewed for hospitalization but has the potential to affect any resident transferred out of the facility.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to 1) ensure staff documented the reason why a resident did not attend the interdisciplinary team care plan meeting and 2) update and revise a care plan for a resident with identified changes in need related to mobility status. This was found to be evident for 2 out of 29 residents (Resident #61 and #17) reviewed for care plan participation and revision during the investigative stage of the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to prevent the development of a pressure ulcer for a functionally and cognitively impaired resident (Resident #27). This was evident for 1 of 1 residents selected for pressure ulcer review in the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to complete a physician ordered lab on a Resident (#21) This was evident in 1 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure laboratory test results were kept in the resident's medical record for review by medical practitioners. This deficient practice was found to be evident for 1 out of 29 residents (Resident #34) reviewed during the investigative stage of the survey and resulted in the re-ordering of a lab test.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure documentation of certifications of incapacity to make health care decisions were completed prior to allowing health care agents to make decisions for the resident. This was found to be evident for 1 out of the 29 residents (Resident #45) reviewed during the survey.

Inspectors wroteBased on record review and staff interview it was determined that the facility failed to put a system in place to ensure proper infection surveillance policies and procedures are in place by not implementing a plan to monitor the duration/outcome of antibiotic therapy. This deficient practice has the potential to affect all residents, staff, and visitors in the facility.

Inspectors wroteBased on record and staff interview it was determined that the facility failed to put a system in place to ensure that there is documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization (and the administration or the refusal of or medical contraindications to the vaccines.) This deficient practice has the potential to affect all residents, staff and visitors in the facility.