Copper Ridge Health Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 24, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF759Nov 2, 2023

  Based 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. Findings included: Resident 63 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute and chronic respiratory failure, chronic kidney failure stage 4, type 2 diabetes, morbid obesity, essential hypertension, and hypothyroidism. Resident 63's medical record was reviewed on 11/2/23. […]

• No harm, potential for more than minimal, patternF760Nov 2, 2023

  Based 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. Findings included: Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, pain in thoracic spine, dementia, bipolar 2 disorder, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease stage 3, generalized anxiety disorder, major depressive disorder, and chronic pain. […]

• No harm, potential for more than minimal, patternF804Jan 12, 2022

  Based 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. Findings include: 1. On 1/10/22 at 1:48 PM, resident 77 was interviewed. Resident 77 stated that the food was Nasty. On 1/11/22 at 3:24 PM, resident 82 was interviewed. Resident 82 stated the food was not good. On 1/10/22 at 10:57 AM, resident 24 was interviewed. Resident 24 stated that the food was not very good. […]

• No harm, potential for more than minimal, patternF880Jan 12, 2022

  Based 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. Findings include: 1. On 1/11/22 at 12:01 PM, an observation was made of room [ROOM NUMBER]. There was a sign that revealed droplet precautions and a sign indicating to see the nurse before entering. […]