Copper Ridge Care Center

In the surveyor’s words

From the most serious findings on record at Copper Ridge Care Center, in the surveyor’s own words.

• Actual harm, isolatedF760Dec 13, 2024

  Based on interview, record, and policy review, the facility failed to follow physician's orders and complete monitoring and adjustment of warfarin (also called Coumadin, a high-risk medication used to prevent blood clots by thinning the blood and has a significant risk for bleeding complications), for one of four residents sampled for warfarin use (Resident 1), when Licensed Nurse (LN) A incorrectly revised Resident 1's physician's order for a lab test for a prothrombin time and International Normalized Ratio (PT/INR, the laboratory testing parameter utilized to monitor warfarin therapy. The PT is the number of seconds required for the blood to clot, and the INR is the standardized ratio of the PT), and caused the order not to populate on to Resident 1's Electronic Health Record (EHR). […]

• No harm, potential for more than minimal, patternF812Feb 17, 2022

  Based on observation and interview the facility did not store cooking utensils in a sanitary manner when serving scoops were observed to be stored in a drawer containing dark colored water and food particles. The failure to maintain cleanliness in storage of serving utensils has the potential to cause the spread of food borne illness leading to adverse resident clinical outcomes. Findings: During a concurrent kitchen observation and interview, on 2/15/22 at 8:32 AM with the dietitian, three of four utensil drawers were observed to have food particulate matter within. One drawer was observed to have dark fluid accumulated in contact with food serving scoops. The dietitian commented that, This is unusual. I don't know how that got in there. […]

• No harm, potential for more than minimal, patternF880Feb 17, 2022

  Based on observation, interview, and record review, the facility failed to prevent the spread of infection when: 1. a staff member entered an isolation room of a resident who was under observation for exposure to the COVID-19 virus without donning (putting on) appropriate Personal Protective Equipment (PPE); 2. two of three pill cutters had not been cleaned between uses; 3. one of three glucometers (a device used to measure blood sugar) was not cleaned according to manufacturer's guidelines between uses. This failure had the potential to spread germs from resident to resident or staff which could have caused illness or outbreaks of infectious disease. Findings: 1. […]

• No harm, potential for more than minimal, isolatedF676Dec 5, 2025

  Based on interview and record review the facility failed to ensure Physician ordered restorative nursing services (a program that helped residents maintain or improve their highest possible level of physical function) was provided to one out of 24 sampled residents (Resident 15). This failure had the potential for a decline in functional status and to negatively impact psychosocial well-being.Findings:A review of the facility's undated policy and procedure (P&P) titled, Restorative Nursing Program, indicated, residents would receive restorative nursing care as needed to maintain safety and independence in their functional ability. […]

• No harm, potential for more than minimal, isolatedF810Dec 5, 2025

  Based on observation, interview, and record review, the facility failed to meet resident adaptive equipment needs for one of 24 residents (Resident 33) when Registered Nurse (RN) G was not aware of Resident 33's adaptive equipment needs and unable to provide information on where to find adaptive equipment for Resident 33 to meet his needs. This failure had the potential to affect Resident 33's ability to drink fluids independently. Findings:During a review of facility job description titled Job Description: Registered Nurse dated 2/2024, indicated RN was to, review nurses' notes to ensure they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such are provided in accordance with the resident's wishes, RN was… […]