Copper Rock Healthcare

In the surveyor’s words

From the most serious findings on record at Copper Rock Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF760Aug 19, 2024

  Based on record review and interview, the facility failed to ensure all residents were free from significant medication errors when staff administered another resident's medication to one resident (Resident #1) resulting in an unsafe drop in blood pressure and hospitalization of the resident. Staff also failed to administer insulin as ordered and contact the physician regarding insulin not available for one resident (Resident #3) resulting in elevated blood sugar levels and hospitalization of the resident. A sampled of ten residents were reviewed in a facility with a census of 67. 1. […]

• Actual harm, isolatedF700Nov 2, 2021

  Based on observation, interview, and record review, the facility failed to obtain written consent for side rail use, failed to complete a documented side rail assessment, and failed to complete a risk versus benefits side rail assessment for one resident (Resident #1) who got entangled in the side rail when falling out of bed and suffered fractured bone. The facility failed to obtain written consent for side rail use, failed to complete a documented side rail assessment, and failed to complete a risk versus benefits side rail assessment for three additional residents (Resident #2, #3, and #4). […]

• No harm, potential for more than minimal, widespreadF728Mar 13, 2026

  Based on observation, interview, and record review, the facility failed to ensure nurse aides (NA) were not used for more than four months without completing required training and evaluations when the facility did not have an effective process in place to ensure certified nurse aide (CNA) training programs were completed timely for NAs resulting in one NA (NA K) working longer than four months in the facility without completing the CNA training course. The facility census was 77.Review showed the facility did not provide a policy regarding NA training. 1. […]

• No harm, potential for more than minimal, widespreadF919Mar 13, 2026

  Based on observation, interview, and record review, the facility failed to provide residents with a complete and fully functional call light system when the facility failed to have process in place to notify staff of sounding call lights when call lights notifications could not be heard on the hall and the facility staff did not use the cell phone pagers for notification of call lights. The facility census was 77. Review of the facility policy titled, Call System, Residents, dated November 2025, showed the following:-Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station;-Each resident is provided with a means to call staff directly from his/her bed, from toileting/bathing facilities… […]

• No harm, potential for more than minimal, widespreadF837Dec 11, 2025

  Based on interview and record review, the facility failed to ensure the administrator of the facility had an active and valid administrator's license when the facility failed to confirm renewal of his/her license, and the administrator continued his/her normal job duties for a period of 20 days without a valid license. The facility census was 77.On 07/21/25, the facility's corporation became aware of the Administrator's license expiration. The facility removed the Administrator from his/her role and provided counseling. The facility's corporation appointed the [NAME] President (VP) of Operations, who had a current valid administrator's license, to the administrator role on 07/21/25. The corporation implemented audits of the licenses of all administrators with the corporation. […]