Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Copper Ridge Care Center during CMS and state inspections, most recent first.
A resident with muscle weakness and difficulty ambulating did not receive physician-ordered restorative nursing ambulation services as planned. The care plan and RNA referral called for ambulation assistance 3 times weekly, but the RNA record showed long gaps with no documented services, only one documented session in one week, and later only two offers that were both refused with no further attempts. The RNA also stated that when pulled to CNA duties, residents did not receive restorative care, and the DON confirmed the ordered services were not provided.
Adaptive Drinking Equipment Not Provided as Needed: An RN was unfamiliar with a resident’s adaptive drinking needs and the facility’s available supplies, and he taped over a sipping port on the resident’s cup lid as a short-term measure. The resident had COPD, muscle wasting, dementia, and dysphagia, and the family member had requested a lid without a sipping port so water would not spill on the resident’s shirt. The DON confirmed the RN did not seek help from her and that the resident needed reassessment for a drinking device that fit his needs.
Two residents with physician orders for naloxone did not have this medication or related interventions included in their care plans. Both residents, one with cancer and impaired decision-making and another with lumbar spondylosis, had active naloxone prescriptions, but their care plans failed to address its administration. The ADON confirmed that naloxone should be included in care plans when ordered.
Nurses were unable to locate naloxone prescribed for three residents, despite active physician orders and facility policy requiring timely access. During interviews and observations, staff searched medication carts but could not find the medication, and the ADON confirmed that nurses are expected to know its location. The residents affected had significant medical conditions and varying levels of cognitive function.
A licensed nurse crushed and administered extended-release morphine tablets to a resident with cancer who was unable to make her own decisions, despite clear pharmacy and manufacturer instructions to swallow the medication whole. Facility policies and medication packaging both indicated the medication should not be crushed, and staff interviews confirmed this was a medication error.
A resident with severe cognitive impairment and multiple medical conditions did not receive IV ceftriaxone for a UTI until more than 4 hours after it was ordered, and the physician's order lacked an infusion rate. This resulted in a significant delay in treatment and incomplete documentation, as confirmed by the DON and facility records.
A resident on warfarin therapy experienced significant harm due to the facility's failure to follow physician's orders for PT/INR monitoring. A nurse's error in revising the lab order led to missed tests, resulting in critically high INR levels and severe complications, including internal bleeding and hospitalization. Interviews revealed issues with EHR order entry and communication among staff.
A resident was found with four and a half Norco tablets in their room, indicating a failure by the facility to adhere to its Medication Administration Policy. The resident, diagnosed with anxiety and major depressive disorders, was at risk for poor impulse control. The facility's policy required licensed individuals to administer medications, and residents could self-administer only if deemed capable. The Director of Nursing expected nurses to stay with patients during medication administration.
A resident with arthritis and type 2 diabetes was discharged home, but the MDS inaccurately recorded a discharge to a hospital. The MDS Coordinator admitted the error, and the DON stressed the importance of accurate coding. The Administrator, though not directly involved, expected accuracy in MDS assessments.
Staff in a facility failed to follow infection control practices by not wearing surgical masks properly and drinking water in a hallway with COVID-19 positive residents. A CNA was observed with a mask not covering her nose and drinking from an unlidded cup. Similarly, a TN and an LN were seen with masks not covering their noses. Staff confirmed awareness of proper mask usage and restrictions on eating or drinking in hallways.
A facility failed to honor a resident's rights when a caregiver requested a nurse to be present at a care conference meeting, but nursing was not notified or included. The resident had concerns about diabetes and bathroom assistance, and the meeting proceeded with only the social worker, physical therapist, and occupational therapist present.
A resident with depression and atrial fibrillation was served a chef's salad containing moldy cherry tomatoes. The dietary manager and Registered Dietician confirmed the incident, noting that staff failed to visually inspect the food before serving it, contrary to the facility's policy.
The facility failed to provide a resident with outside services when a request was made for the resident to be seen by her cardiologist, and a referral was not initiated. Despite the resident's history of hypertensive heart disease and diabetes, and a request made during a care conference meeting, the social worker was unable to find any documentation that a referral had been made.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
Physician ordered restorative nursing services were not provided for one resident who had been admitted with muscle weakness and difficulty walking. The resident’s quarterly MDS indicated a BIMS score of 14 out of 15, showing good memory, and that the resident required staff supervision while ambulating. The resident stated they were done with rehab but were still at the facility and denied receiving restorative nursing services, saying they had it twice. The care plan and restorative nursing referral indicated the resident was to receive RNA assistance to ambulate 50 to 100 feet three times a week or as tolerated to maintain strength and activity tolerance and prevent decline in functional mobility. The physician’s order also directed restorative nursing services three times a week for ambulation. Review of the RNA documentation showed no documented restorative nursing care from 10/22/25 to 11/10/25, only one documented service between 11/11/25 and 11/17/25, none from 11/18/25 to 11/24/25, and during the week of 11/25/25 to 12/1/25 the resident was offered services twice, refused both times, and no other attempts were made. The RNA confirmed that when assigned to CNA duties, residents did not receive restorative nursing care, and the DON confirmed the documentation showed the resident did not receive the physician ordered restorative nursing services.
Adaptive Drinking Equipment Not Provided as Needed
Penalty
Summary
The facility failed to meet the adaptive equipment needs of one resident who had diagnoses including COPD, muscle wasting, dementia, and dysphagia. During an observation, RN G was seen holding the resident’s black lid to his bedside water cup and taping clear desk tape over a sipping port on the lid. The resident’s family member asked about the resident’s drinking cup, and RN G showed the taped lid and later an adult sippy cup, asking whether either would work. The family member stated she had requested a drinking cup with a lid that did not have a sipping port so water would not spill on the resident’s shirt when he drank from the straw. During interview, RN G stated it was his first time on the hall, that he had not familiarized himself with the residents and their needs before his shift, and that he was unfamiliar with the adaptive supplies kept on hand. He stated he and the ADON agreed to use tape on the lid as a short-term solution and that he did not know who else to ask for help to locate an assistive device that would not leak. The DON confirmed RN G did not ask her for help and stated the expectation was that he would do so. The DON also confirmed the resident needed to be reassessed for a drinking device that fit his needs.
Failure to Include Naloxone in Care Plans for Residents with Physician Orders
Penalty
Summary
The facility failed to ensure that two residents with physician orders for naloxone had this medication included in their care plans. For one resident with a history of cancer and impaired decision-making capacity, the care plan for narcotic pain medication did not address naloxone administration, despite an active prescription. Similarly, another resident with lumbar spondylosis and the ability to make his own decisions also had a physician's order for naloxone, but his care plan lacked any intervention related to naloxone administration. Record reviews confirmed that both residents had current orders for naloxone, yet their respective care plans did not reflect this, omitting necessary interventions for opioid overdose reversal. The Assistant Director of Nursing acknowledged during an interview that naloxone should be included in the care plan when ordered by a physician. This omission was identified through interviews and review of facility policies, resident records, and care plans.
Nurses Unable to Locate Prescribed Naloxone for Multiple Residents
Penalty
Summary
The facility failed to ensure that nurses were competent in locating naloxone prescribed for three residents, each of whom had a physician's order for the medication. During observations and interviews, multiple licensed nurses were unable to identify the storage location of naloxone for these residents. In each instance, the nurses, sometimes accompanied by the Director of Staff Development, searched the medication carts but could not find the naloxone. The Assistant Director of Nursing confirmed that nurses are expected to know where naloxone is stored, yet this expectation was not met. The residents involved included individuals with significant medical needs: one with cancer and impaired decision-making capacity, another with lumbar spondylosis who was cognitively intact, and a third with a spinal fracture and moderate cognitive impairment. Despite having active physician orders for naloxone, the medication was not readily accessible or locatable by nursing staff at the time of surveyor inquiry, as required by facility policy and standard practice.
Significant Medication Error: Extended-Release Morphine Crushed and Administered
Penalty
Summary
A licensed nurse crushed and administered morphine sulfate extended-release tablets to a resident with cancer, despite clear instructions from the manufacturer and pharmacy that the medication should be swallowed whole and not crushed. The resident was not able to make her own decisions, as indicated by a Brief Interview for Mental Status score of 8 out of 15. The nurse documented in the nurse's note that the morphine was given crushed in yogurt. The medication administration record confirmed that the nurse administered the medication as prescribed, but in a crushed form. Facility policies and pharmacy guidelines specifically stated that medications should only be crushed when appropriate and safe, and that extended-release tablets labeled as 'do not crush' must not be altered. The medication packaging also included a warning label stating 'Swallow Whole. Do Not Chew Or Crush.' Interviews with facility staff, including the Assistant Director of Nursing and the Administrator, confirmed that morphine sulfate extended-release should not be crushed and that this constituted a medication error.
Delayed and Incomplete IV Antibiotic Administration
Penalty
Summary
The facility failed to ensure the timely and appropriate administration of intravenous (IV) antibiotics for a resident diagnosed with a urinary tract infection. The physician ordered IV ceftriaxone for the resident, who had a history of stroke with left-sided weakness and atrial fibrillation, but the order did not specify the infusion rate. As a result, the order was incomplete and did not meet professional standards of practice or the facility's own policy, which requires documentation of the total time infused. The resident's medication administration record showed that the first dose of IV ceftriaxone was administered nearly 15 hours after the order was placed, significantly exceeding the facility's expectation that antibiotics be given within 4 hours of the physician's order. Interviews with the Director of Nursing confirmed that the delay in administration and the lack of an infusion rate in the physician's order were not consistent with facility policy or professional standards. The family member of the resident was also unsure if the antibiotics had been started as required. The documentation review further revealed that there was no way for nursing staff to document the rate at which the IV ceftriaxone was infused, as required by policy.
Failure to Monitor Warfarin Therapy Leads to Resident Harm
Penalty
Summary
The facility failed to follow physician's orders for monitoring and adjusting warfarin therapy for a resident, leading to significant medication errors. Licensed Nurse A incorrectly revised the resident's physician's order for a PT/INR lab test, causing the order not to populate in the resident's Electronic Health Record (EHR). This oversight resulted in missed opportunities for timely intervention, ultimately leading to serious clinical harm, including emergency treatments and a prolonged hospitalization. The resident, who was admitted with a fractured femur, was on a regimen of warfarin, a high-risk medication requiring close monitoring. Despite multiple adjustments to the warfarin dosage by the attending physician, the necessary PT/INR tests were not conducted as ordered. The resident's PT/INR levels were critically high, leading to symptoms such as blood in the urine, nausea, vomiting, and abdominal pain. The resident's condition deteriorated, resulting in a transfer to the hospital where internal bleeding and other complications were diagnosed. Interviews with facility staff revealed a lack of clarity and communication regarding the entry and monitoring of lab orders in the EHR system. The Director of Nursing and other staff members acknowledged the oversight and the failure to conduct the PT/INR test as ordered. The resident expressed distress over the situation, indicating that her concerns were not adequately addressed by the nursing staff, which contributed to the delay in receiving appropriate care.
Medication Administration Policy Violation
Penalty
Summary
The facility failed to ensure that licensed nurses administered medication in accordance with their Medication Administration Policy for a resident. This deficiency was identified when four and a half Norco tablets, a narcotic pain medication, were found in a container in the resident's room. The resident, who had been admitted with diagnoses including anxiety disorder and major depressive disorder, was at risk for poor impulse control according to their care plan. The facility's policy stated that only licensed individuals could administer medications, and residents could self-administer only if deemed capable by the attending physician and care team. During an observation and interview, the resident revealed that they found pain pills in their bed and kept them in a container. A nurse's note indicated that a CNA had notified the nurse about the pills, which were subsequently found in the resident's room. The resident's physician had ordered Norco to be administered every six hours and additionally as needed every four hours. The Director of Nursing stated that nurses were expected to stay with patients during medication administration and remove medications if they needed to leave the room before administration was complete.
Inaccurate MDS Assessment at Discharge
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident at the time of discharge. The resident, who had a medical history of arthritis and type 2 diabetes mellitus, was admitted to the facility and later discharged home. However, the discharge MDS inaccurately indicated that the resident was discharged to a short-term general hospital. This discrepancy was identified during a review of the resident's records, which showed that the resident had actually been discharged home with home health services, as noted in the progress notes and discharge summary. The MDS Coordinator acknowledged the error, stating that the MDS was not coded accurately and was done so in error. The Director of Nursing (DON) emphasized the importance of accurate MDS coding, as it reflects the resident's story. The Administrator, while aware of the MDS process, was not directly involved but also expected accurate coding. This deficiency highlights a lapse in the facility's adherence to its policy requiring all individuals completing any portion of the MDS to attest to the accuracy of the information.
Improper Mask Usage and Drinking in COVID-19 Positive Hallway
Penalty
Summary
The facility failed to ensure safe infection control practices were followed, as observed during a survey. A Certified Nurse Assistant (CNA) was seen walking down a hallway with COVID-19 positive residents while improperly wearing a surgical mask that did not cover her nose. Additionally, the CNA was observed pulling the mask below her chin to drink water from an unlidded cup on three separate occasions. The CNA admitted to being unaware that drinking water while walking down the hallway was not allowed. Further observations revealed that the Treatment Nurse (TN) and a Licensed Nurse (LN A) were also not wearing their surgical masks properly, with the masks not covering their noses while at the nurse's station on the same hallway. Both TN and LN A confirmed the improper mask usage during interviews. The Director of Staff Development and the Infection Preventionist confirmed that staff had been educated on proper mask usage and that eating or drinking in hallways or at the nurse's station was prohibited.
Failure to Include Nursing in Care Conference
Penalty
Summary
The facility failed to honor resident rights for one resident when the resident's caregiver requested a nurse to be present at the care conference meeting, and nursing was not notified of the request. The facility's policy indicated that the Interdisciplinary Team (IDT) was responsible for the development of resident care plans and that nursing should be included in the IDT. However, during the care conference meeting, only the social worker, physical therapist, and occupational therapist were present, and nursing was not included despite the caregiver's request due to concerns about diabetes and bathroom assistance. The social worker confirmed that nursing should have been included in the care conference but was not informed of the request by the Director of Nursing (DON). The DON also confirmed that they were not informed of the request and were not present at the care conference meeting. The resident involved was admitted to the facility with diagnoses of hypertensive heart disease and diabetes and was their own responsible party. The caregiver had specifically requested nursing presence at the care conference due to concerns related to the resident's diabetes and bathroom assistance needs. Despite this request, the social worker did not inform the DON, and nursing was not included in the care conference meeting, which focused on care received from physical therapy and occupational therapy. This failure had the potential to prevent the resident and their representatives from participating fully in the resident's care planning.
Moldy Cherry Tomatoes Served to Resident
Penalty
Summary
The facility failed to provide a resident with food that was served in a safe manner when the resident was served a chef's salad containing moldy cherry tomatoes. The facility's policy and procedure for Food and Nutrition Services, revised on 10/1/17, indicated that food trays should be inspected to ensure the food appears palatable and is served at a safe temperature. However, this policy was not followed in this instance. Resident 2, who was admitted to the facility with diagnoses of depression and atrial fibrillation, reported being served moldy tomatoes. The dietary manager in training/lead cook confirmed the presence of moldy cherry tomatoes in the chef's salad after performing a visual inspection. The Registered Dietician also confirmed the incident after being shown a photo of the moldy tomatoes taken by the resident. The expectation was for staff to visually inspect food prior to serving it to residents, which was not adhered to in this case.
Failure to Initiate Referral to Cardiologist
Penalty
Summary
The facility failed to provide a resident with outside services when a request was made for the resident to be seen by her cardiologist, and a referral was not initiated. The facility's policy and procedure indicated that Social Services or a designee should coordinate most resident referrals and document them in the resident's medical record. However, this was not done for the resident who had a history of hypertensive heart disease and diabetes and was her own responsible party. During a care conference meeting, the resident's caregiver informed the social worker that the resident wanted to be seen by her cardiologist. Despite this request, the social worker was unable to find any documentation that a referral had been made. The social worker confirmed that there was no documentation in the resident's medical records to support that a referral had been initiated, leading to concerns about the resident's heart problems.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Redding
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestwood Wellness And Recovery Center | 1.1 mi | ★★★★★ | 2 | 0 |
| River Valley Healthcare & Wellness Centre, Lp | 1.1 mi | ★★★★★ | 8 | 0 |
| Redding Post Acute | 1.3 mi | ★★★★★ | 16 | 0 |
| Marquis Care At Shasta | 1.3 mi | ★★★★★ | 19 | 0 |
| Vibra Hospital Of Northern California D/p Snf | 2.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.