Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Copper Rock Healthcare during CMS and state inspections, most recent first.
A nurse aide worked on the floor and provided resident care after being hired more than 120 days earlier, despite not having documentation of completed CNA training. Records showed the aide was enrolled in training later, remained scheduled as an aide, and was observed assisting residents with personal care, meals, and showering. The DON and Administrator stated aides should be certified within 120 days of hire, but the aide continued working while restarting classes.
Call Light System Not Fully Functional or Reliably Monitored: A resident could not reach the call light from a wheelchair and said staff never came when called, another resident said staff were slow to answer, and a third resident reported long waits for response. Survey observations showed call light alarms were not reliably audible or visible in the halls or at the nurses' stations, and staff interviews confirmed some aides did not carry the call-light phones, some phones were not working, and staff often had to walk the halls to find which room was calling.
Respiratory Care Not Provided as Ordered: Staff failed to ensure oxygen was turned on for one resident in the dining room, failed to ensure another resident’s portable oxygen tank had sufficient oxygen in the dining room, and left humidifier bottles empty for three residents using oxygen concentrators. Residents involved had diagnoses including COPD, CHF, chronic respiratory failure, and shortness of breath, and observations showed oxygen tanks in the red low-to-empty zone, regulators set at zero, and humidifier bottles with no water despite orders for continuous oxygen and humidification.
A facility failed to ensure meals were palatable and served at appetizing temperatures. Residents repeatedly complained in council meetings and grievances about cold food, poor presentation, missing menu items, and unseasoned or poorly prepared meals. During meal observations, hall trays sat on a cart long enough to cool, and test trays showed chicken, rice, broccoli, pasta, and green beans that were dry, undercooked, cold, or unseasoned. Staff interviews confirmed delays in tray delivery, a nonworking warming cart, and ongoing concerns about food quality.
An infection prevention and control deficiency occurred when staff did not follow EBP and hand hygiene requirements during resident care. An LPN and hospice nurse cared for a resident with a suprapubic catheter and wound without wearing gowns despite an EBP sign requiring gown and glove use, and staff touched catheter tubing, drainage equipment, and a wound dressing while only wearing gloves. Similar hand hygiene and glove-use lapses were observed during incontinent care and personal care for several other residents with catheters, feeding tubes, wounds, and bowel/bladder incontinence, including repeated removal of gloves without washing or sanitizing hands and contact with room surfaces and resident items between care tasks.
Failure to assist residents with meals and monitor intake. Two residents with dementia and other significant diagnoses were observed sitting in the dining room with untouched or poorly accessed meals while staff did not provide the ordered meal assistance, encouragement, or supervision. One resident was taken back to the room without being offered help, and the other was seen eating pureed food with a fork or butter knife despite an order for staff to offer assist with meals and a care plan calling for meal support.
Pain was not effectively managed for a resident with stroke, left hemiplegia, arthritis, and chronic left arm/shoulder pain. Staff observed and heard the resident yell out, grimace, and say “Ow” during morning care and Hoyer transfers, but the pain complaints were not documented and PRN ibuprofen was not recorded as given. Interviews showed staff recognized the resident had frequent pain, yet the record did not reflect timely pain documentation or medication use.
The facility allowed its administrator to continue performing job duties for 20 days after the expiration of their state license, due to incomplete renewal paperwork and insufficient CEUs. The administrator's license was not confirmed as renewed, and the facility did not ensure compliance with its policy requiring a current administrator license.
Two residents who were dependent on staff for all ADLs, including personal hygiene, experienced significant lapses in receiving scheduled showers, with one going up to 17 days and another up to 13 days without bathing. Staff failed to document missed showers, refusals, or interventions as required by facility policy, and care plans did not address shower preferences or refusal patterns. Interviews revealed inconsistent practices and communication among CNAs, LPNs, and the DON, with family members also reporting difficulties in ensuring regular hygiene care.
A resident admitted with multiple stage 2 pressure ulcers and a surgical incision with a wound vac did not receive timely wound care or physician orders for treatment. Staff failed to document or initiate wound care interventions, and the care plan did not address the wounds. Despite the resident reporting pain and notifying staff, no treatments were started until several days after admission, contrary to facility policy.
A resident with chronic pain did not receive scheduled fentanyl patches as ordered due to staff failing to maintain an adequate supply, improper use of the emergency kit, and inaccurate documentation of medication administration and patch monitoring. Nursing staff documented administration of patches that were not applied and did not notify the physician or follow facility policy when medication was unavailable.
Two residents were hospitalized due to significant medication errors at a facility. One resident received another's medication, causing a drop in blood pressure, while another did not receive insulin as ordered, leading to high blood sugar levels. Staff failed to verify identities and notify physicians of discrepancies, and no investigations were conducted.
Nurse aide worked beyond 120 days without completing CNA training
Penalty
Summary
The facility failed to ensure nurse aides were not used for more than four months without completing required training and evaluations. Review of records showed nurse aide K was hired on 08/25/25, enrolled in the nurse aide training program on 01/06/26, and there was no documentation that the training program had been completed. The facility also did not provide a policy regarding nurse aide training, and staff interviews showed the DON and Administrator understood aides should be certified within 120 days of hire. Daily rosters showed nurse aide K was scheduled to work on the floor as an aide on 03/08/26, 03/09/26, 03/11/26, and 03/13/26. Observations confirmed nurse aide K providing resident care, including assisting residents with personal cares, meals, showering, and personal hygiene. During interview, nurse aide K stated he/she had been hired as a NA, took initial testing in December 2025 but did not pass, then restarted classes in January 2026 and continued to work on the floor as a nurse aide. The DON stated staff should be certified within 120 days of hire and was not aware they could not restart class and continue working past that time, while the Administrator stated that after 120 days the NA should be put back in class and should not be working as an NA.
Call Light System Not Fully Functional or Reliably Monitored
Penalty
Summary
The facility failed to provide a complete and fully functional call light system in resident bathrooms and bathing areas, and also failed to have a process in place to notify staff of sounding call lights when the notifications could not be heard on the hall. The facility policy stated residents should have a means to call staff from the bed and toileting/bathing areas, that the system remain functional at all times, and that calls be answered as soon as possible, but no later than 5 minutes. The census was 77. During observation, one resident in a wheelchair said he/she could not reach the call light because it was on the other side of the bed, and the resident stated staff never came when he/she called. Another resident, who could not talk and used a phone to communicate, said staff were slow to answer the call light. A third resident reported call light response times ranging from 10 to 15 minutes, and sometimes 45 minutes to one hour. These resident statements were made while the surveyor observed the residents in their rooms and using their own phones or asking for help reaching the call light. Survey observations showed call light alarms were not consistently audible or visible where staff were working. At times there was no call light panel visible at the nurses' station, only a slight buzzing noise, and staff said they relied on cell phones for call light notifications. Multiple observations showed call lights sounding at the nursing station while no staff were at the desk, call lights could not be heard in the halls near resident rooms, and ceiling-mounted call lights were not visible from hall entryways because of wooden beams. Staff interviews confirmed that some aides did not carry the phones, some phones were not working or were reconnecting to wi-fi, and staff were using different methods such as watching for lights in the hall or walking the halls to find which room had activated the call light.
Respiratory Care Not Provided as Ordered
Penalty
Summary
The facility failed to provide respiratory care per standards of practice for residents receiving oxygen therapy. The report identified that staff did not ensure a portable oxygen tank was turned on for a resident with CHF and atrial fibrillation when the resident was in the dining room, and did not ensure another resident’s portable oxygen tank had sufficient oxygen while in the dining room. The report also identified that humidifying bottles were left empty for three residents who had oxygen concentrators in their rooms. Resident #75 had diagnoses including COPD, shortness of breath, asthma, and CHF, with severe cognitive impairment and an order for oxygen at 2 to 3 liters continuously. On 03/08/26, the resident was observed in the dining room for lunch with the oxygen tank set at 2 L and the tank in the red low-to-empty zone. Later that day, staff changed the tank after a family member asked them to check it. On 03/09/26 and 03/11/26, the resident was observed in bed with oxygen set at 3 L, and the humidifier bottle was empty on both occasions. The resident’s family member stated there had been times hospice staff contacted him/her and said the resident’s oxygen level was low and the oxygen was not turned on. Resident #9 had chronic respiratory failure with hypoxia, COPD, CHF, and shortness of breath, with an order for oxygen at 2 to 6 liters continuously and humidification as needed. The resident was observed on multiple occasions seated in the room with the oxygen concentrator set at 3 L and no water in the humidifier bottle. During one observation, the resident stated there should be water in it and that staff were supposed to do that. Resident #18 had CHF and atrial fibrillation, with severe cognitive impairment and an order for oxygen at 2 L continuously. On 03/08/26, the resident was observed in the dining room with the oxygen tank regulator set at zero while the tank was partially full. When the resident’s family member reported the resident appeared sleepy and asked for oxygen saturation to be checked, the CMT found the oxygen saturation low and noted the tank regulator had not been turned on. Resident #2 had chronic respiratory failure with hypercapnia and hypoxia, COPD, and shortness of breath, with an order for oxygen at 3 liters continuously. During wound care, the resident was observed with the oxygen concentrator set at 3 L and no water in the humidifier bottle.
Food Served Cold, Unseasoned, and Poorly Prepared
Penalty
Summary
The facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for 10 sampled residents. The deficiency was based on observations, interviews, and record review showing that meals were served cold, food was not seasoned, and some items were not cooked appropriately. The facility policy stated the dining services manager or designee was to be present at meals to ensure food was plated attractively, palatable, served at appropriate temperatures, and prepared according to safe food handling practices. Resident council minutes and grievance records documented repeated resident complaints about cold food, poor presentation, missing menu items, and side items not being served separately. Residents reported that food temperatures and presentation were worse on weekends, that salad was drenched in dressing, that requested items were not provided, and that some meals were served in a way residents could not eat. One resident on a mechanical soft diet was served un-chopped lettuce and poor-quality soup, and other residents complained that requests for items such as mayonnaise or preferred foods were not fulfilled. During meal observations, the last hall trays were delayed while trays were plated and placed on a rolling cart before being delivered to residents in their rooms. Test trays showed food temperatures below appetizing levels and food quality concerns: sweet and sour chicken was dry and tough, rice was dry and undercooked, broccoli was cold and mushy, chicken-bacon penne pasta was dry and pasty, and green beans were unseasoned. Interviews with residents and staff consistently described cold food, lack of seasoning, poor taste, and trays sitting long enough on carts to cool before delivery. Staff also reported that the warming cart was not working, that trays were not being served quickly enough, and that the cook had not seasoned food.
Infection Control Failures During EBP and Personal Care
Penalty
Summary
The facility failed to maintain an effective and complete infection prevention and control program when staff did not follow Enhanced Barrier Precautions (EBP) and hand hygiene practices during resident care. The facility policy stated that EBP required gown and glove use during high-contact care activities for residents with wounds or indwelling medical devices, including urinary catheters, and that PPE should be applied before those activities. The hand hygiene policy stated that staff were expected to perform hand hygiene before and after glove use and during resident care activities involving contact with residents or contaminated surfaces. Resident #5 had diagnoses including neuromuscular dysfunction of the bladder and cystostomy status, and the quarterly MDS identified an indwelling catheter. The care plan required EBP because of a central line, suprapubic catheter, and open wound. During observation, an LPN entered the room where an EBP sign on the door stated that gown and gloves were required for personal care. The LPN and a hospice nurse wore gloves but did not put on gowns while preparing supplies and assessing the suprapubic catheter tubing, drainage bag, and a bandage on the resident's calf. The staff touched the catheter tubing and drainage bag, decided not to change the catheter, and continued care without using gowns. Hand hygiene and glove-use failures were also observed during personal care for four other residents. For one resident with multiple sclerosis, neuromuscular bladder dysfunction, an indwelling catheter, and a feeding tube, staff performed perineal care and repositioning while changing tasks without hand hygiene, including removing gloves and then placing a clean brief and blanket without washing hands. For another resident with spinal cord disease, paraplegia, an indwelling urinary catheter, and bowel incontinence, an LPN performed cleansing and wound-related care, touched room surfaces and supplies, and repeatedly removed gloves without washing or sanitizing hands between tasks. For a resident with vascular dementia, severe dependence, and bowel and bladder incontinence, aides performed incontinent care, removed gloves without hand hygiene, touched furniture, and handled the resident after care. For a resident with stroke, hemiplegia, a gastrostomy tube, and bowel and bladder incontinence, aides used gloves for urinal and hygiene care but removed gloves and left the room without washing or sanitizing hands. Staff interviews confirmed that EBP required gown and glove use for residents with wounds or indwelling devices and that hand hygiene was expected before donning gloves, after removing gloves, and during personal care.
Failure to Assist Residents With Meals and Monitor Intake
Penalty
Summary
The facility failed to ensure that residents who required meal assistance received it and that their nutritional intake was monitored during meals. Resident #18 had diagnoses including dementia, chronic systolic heart failure, chronic kidney disease stage 3, and paroxysmal atrial fibrillation, and the quarterly MDS showed severe cognitive deficit. The care plan directed staff to monitor intake at meals and provide an adaptive cup with lid to assist with fluid intake and independence. During breakfast observation, the resident sat in a wheelchair with eyes closed and an untouched plate of food in front of him/her, did not attempt to eat, and staff did not approach to encourage or assist with eating. The resident remained untouched at the table for an extended period and was then taken back to the room without being offered help with the meal; the plate was later removed and discarded. Resident #75 had diagnoses including COPD, shortness of breath, asthma, dementia, anorexia, chronic pain, and dysphagia. The care plan identified the resident as at risk for impaired nutrition related to poor appetite and low body weight and directed staff to assist with meals, feeding, and set-up as needed, ensure proper positioning, and serve the ordered diet and adaptive equipment. The MDS showed severe cognitive impairment, dependence on staff for eating, and a mechanically altered diet. The physician orders included a fortified pureed diet and an order for staff to offer assist with meals. Despite this, observations showed the resident eating pureed food with a fork or butter knife, including poking through plastic wrap to access pudding, while staff did not assist. Additional meal observations showed the resident seated with eyes closed and untouched pureed food in front of him/her while staff did not rouse, assist, or remain nearby. On one occasion, the resident repeatedly remained at the table with no intake while staff walked away or asked if the resident was done eating without providing assistance. Family stated the resident could not feed him/herself and needed help with meals, and staff interviews confirmed that residents with meal-assistance orders should be seated with staff for the whole meal, monitored, encouraged, and assisted. The DON and Administrator also stated that residents needing assistance should be observed and helped during meals, and that residents should not be eating pureed food with a fork.
Pain Not Addressed or Documented for Resident With Chronic Left-Sided Pain
Penalty
Summary
The facility failed to ensure an effective pain management program was in place for a resident with stroke, left hemiplegia, left shoulder and left hand pain, and arthritis. The resident’s care plan identified occasional pain and directed staff to monitor and report signs of non-verbal pain, complaints of pain, changes in routine, sleep, range of motion, and resistance to care. The resident’s MDS showed moderately impaired cognition, occasional pain that sometimes affected sleep and daily activities, and mild pain. On 02/22/26, staff documented that for the past two mornings the resident had swung arms at staff and stated, “I am going to hurt you,” and, “If you are going to hurt me, I am going to hurt you!” during morning ADLs and Hoyer lift transfers. The note stated staff were being gentle, but it did not document addressing the resident’s comments about pain. The MAR for that date did not show administration or offering of PRN ibuprofen for pain. On 03/09/26, during observation, CNA B stated the resident had been in pain that day and had been yelling out with pain in the left arm, but had not told anyone. During the transfer and repositioning, the resident said “Ow” several times, grimaced, kept eyes closed, and stated “No” when asked if comfortable. The resident’s March 2026 MAR did not document pain for that day and did not show ibuprofen was administered as needed. Staff interviews indicated the resident frequently yelled out in pain, staff expected pain to be reported to the nurse or medication technician, and the DON and Administrator stated staff were to notify the nurse when pain was noted, but the resident’s pain complaints were not documented or treated in the records reviewed.
Administrator Served Without Valid License
Penalty
Summary
The facility failed to ensure that its administrator maintained an active and valid administrator's license, resulting in the administrator performing normal job duties for a period of 20 days without proper licensure. The administrator's license expired on 06/30/25 due to failure to complete the necessary paperwork and education for timely renewal. The administrator submitted the renewal application online on the expiration date but did not mail the required fee on time, and the renewal was further delayed due to insufficient continuing education units (CEUs). The facility did not confirm the renewal status and allowed the administrator to continue in the role during this period. The deficiency was identified when the facility's corporation became aware of the expired license on 07/21/25. During this time, the administrator continued to manage the facility, which had a census of 77, without the legally required credentials. The facility's governing body did not ensure compliance with its own policy, which mandates that the administrator must possess and maintain a current state license to operate the facility.
Failure to Provide Timely Showers and Document Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living, specifically grooming and personal hygiene, received baths or showers in a timely manner. Two residents with significant medical conditions, including cerebral infarction, osteoarthritis, and paralysis, were identified as being dependent on staff for all ADLs except eating and were frequently incontinent of bowel and bladder. Both residents were scheduled to receive showers twice weekly, but documentation showed significant lapses, with one resident going up to 17 days and another up to 13 days without a shower. There was no documentation of showers being offered or completed on other days, nor was there documentation regarding missed showers or extended periods without bathing. The facility's policy required staff to document the date, time, and details of showers or baths, including refusals and interventions taken, and to notify supervisors and physicians as appropriate. However, the care plans for both residents did not address shower frequency preferences or patterns of refusal, and staff failed to document refusals or missed showers as required. Interviews with staff revealed inconsistent awareness and practices regarding shower refusals, documentation, and notification of nursing staff or families. Some staff were unaware of recent refusals, and others indicated that nurses were not informed about which residents received showers or refused them. Further interviews with nursing and administrative staff confirmed that there were designated shower aides, but coverage was limited, and sometimes residents did not receive even one shower per week. The Director of Nursing and Administrator both stated that residents should receive two showers per week unless refused, and refusals should be documented. However, neither was aware of residents going more than 10 days without a shower, and documentation did not support that refusals were consistently recorded. Family members also reported having to request showers and being asked to provide them themselves, indicating a lack of consistent care and communication.
Failure to Provide Timely Pressure Ulcer Care and Obtain Physician Orders
Penalty
Summary
Facility staff failed to provide care in accordance with professional standards for pressure ulcers for one resident. Upon admission, the resident had multiple stage 2 pressure ulcers on the buttocks and coccyx, as well as a surgical incision with a wound vac. The facility's own policies required prompt risk assessment, documentation, physician notification, and establishment of wound care interventions. However, staff did not obtain physician orders for wound treatments or the wound vac, nor did they document or initiate any wound care for the identified pressure ulcers. The baseline care plan did not address care or treatment for the wounds, and there were no specific wound care instructions from the discharging hospital. Review of the resident's records showed that the wounds were present on admission, but staff failed to document wound treatments or obtain orders for several days. Progress notes and treatment administration records lacked any documentation of wound care or interventions for the pressure ulcers or the wound vac. Multiple staff interviews confirmed that while some were aware of the wounds, no treatments had been initiated, and there was confusion regarding documentation and responsibility for obtaining orders. The DON and Administrator both stated that they expected staff to assess, document, and initiate treatment for wounds upon admission, but this did not occur. The resident reported ongoing pain from the wounds and stated that staff had been informed of the wounds since admission, but no action was taken. Observations confirmed the presence of untreated wounds with partial thickness skin loss and slough tissue. It was only after several days that a physician order for topical zinc oxide was obtained. The facility failed to follow its own policies for wound assessment, documentation, and timely intervention, resulting in a lack of appropriate care for the resident's pressure ulcers.
Failure to Ensure Accurate Pain Management and Medication Documentation
Penalty
Summary
Facility staff failed to ensure an effective and accurate pain management program for a resident requiring scheduled opioid pain management. Staff did not maintain an adequate supply of fentanyl transdermal patches, resulting in multiple instances where the resident did not receive the prescribed medication as ordered. Documentation showed that staff recorded administration of fentanyl patches even when no patches were available or applied, and failed to accurately document the location and status of the patches on the resident. There were also discrepancies between the Medication Administration Record (MAR), Controlled Drug Receipt Records, and progress notes, with staff documenting the presence of patches that were not actually in place. The resident involved had diagnoses including cerebral infarction, osteoarthritis, and unspecified pain, and was on a scheduled pain medication regimen. Despite clear physician orders and care plan instructions for pain management, staff did not reorder fentanyl patches in a timely manner, leading to gaps in administration. When patches were unavailable, staff did not consistently utilize the facility's emergency kit or notify the physician about missed doses or the presence of an outdated patch. Staff also failed to follow facility policy regarding the destruction of narcotic patches and did not document follow-up actions related to drug interaction alerts. Interviews with nursing staff and facility leadership confirmed that staff were aware of the lack of available fentanyl patches and the presence of an expired patch on the resident, but did not take appropriate steps to resolve the issue or ensure accurate documentation. The Director of Nursing and other staff acknowledged that policies for medication administration, documentation, and reordering were not followed. These failures resulted in the resident not receiving prescribed pain management and inaccurate medical records.
Medication Errors Lead to Hospitalization of Two Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in two residents being hospitalized. In the first incident, a Certified Medication Tech (CMT) mistakenly administered another resident's medication to a resident, leading to a dangerous drop in blood pressure and subsequent hospitalization. The error occurred when the CMT, who was behind schedule, handed the wrong medication to the resident without verifying their identity. The facility did not conduct an investigation into this medication error. In the second incident, the facility failed to administer insulin as ordered to a resident with diabetes, leading to elevated blood sugar levels and hospitalization. The insulin was unavailable, and staff did not notify the physician about the missing medication. The resident's blood sugar levels remained high, and the resident exhibited a decline in mental status, prompting a transfer to the emergency department. The facility did not investigate this medication error either. Interviews with staff revealed a lack of adherence to medication administration protocols, including verifying resident identity and notifying physicians of medication discrepancies. The facility's policies on medication administration and insulin administration were not followed, contributing to the errors. The Director of Nursing and other staff were aware of the errors, but no root cause analysis or investigation was conducted to address the deficiencies.
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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 Rogersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| James River Nursing And Rehabilitation | 5.3 mi | ★★★★★ | 2 | 0 |
| Glendale Gardens Nursing & Rehab | 5.9 mi | ★★★★★ | 15 | 0 |
| Ozark Care & Rehab Center | 7.2 mi | ★★★★★ | 5 | 0 |
| Sunterra Springs Springfield | 7.7 mi | ★★★★★ | 0 | 0 |
| Spring Valley Health & Rehabilitation Center | 7.8 mi | ★★★★★ | 5 | 0 |
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