Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to monitor resident personal refrigerators and food dates: the facility had a policy for resident refrigerators, but observations found multiple resident fridges without a thermometer, temperature log, or documented checks for spoiled food. One resident had vegetables with a noticeable odor and no date, another said staff did not check the fridge, and a third had packaged sandwiches stored in a bag with a handwritten date. Staff stated nursing was not responsible for checking the refrigerators, despite the policy requiring a thermometer and weekly cleaning.
Failure to notify the physician of a resident’s significant weight loss. A resident lost 9.73% of body weight from admission, dropping from 182 pounds to 164.3 pounds, but the medical provider was not notified until later. Staff reported ongoing nutritional changes were made, yet the EHR showed no physician notification or involvement until the notification date, despite facility guidance that the MD should be informed of significant weight change.
Incorrect PASARR Coding on MDS Assessments: Two residents had MDS assessments that incorrectly coded Section A for PASARR status. One resident with Major Depressive Disorder and Schizoaffective Disorder, and another resident with Bipolar Disorder, Schizophrenia, and PTSD, both had Level I and Level II PASARRs completed with recommended services, yet the MDSs documented that they were not considered by the state Level II PASARR process to have SMI, ID, or a related condition.
A resident with a history of Bipolar II disorder, fetal alcohol syndrome, and PTSD experienced a significant mental status change with auditory hallucinations and fear of acting on them, leading to EMS transport to the ED for psych evaluation. The facility did not promptly obtain a new PASARR Level I screen after the change and hospital return, and staff stated a new PASARR review should have been requested with a new psych dx or psych clearance.
Two residents’ care plans did not reflect their POLST code status. One resident’s POLST indicated No CPR and the other indicated DNR, but both care plans documented Full code and included related interventions that did not match the POLST orders. Staff stated care plans were updated weekly, but could not explain why the code status was not reflected.
A resident with multiple chronic conditions, including insulin dependent DM, AF on anticoagulation, CHF, COPD on O2, and a left leg hematoma, did not have a documented MD visit within the required initial 30-day period after admission. Staff reported the resident was seen by a PA and referenced provider scheduling slippage and a pending physician license, but no physician note was found in the record.
Medication administration errors caused the facility’s observed error rate to exceed the 5% threshold. An LPN prepared a late pantoprazole dose for one resident and initially omitted one of two ordered Senna Plus tablets before correcting it after questioning. For another resident, an LPN identified that the MAR dose for magnesium oxide did not match the bottle label, noting the incorrect dose had been given for a while before administering the medication.
The facility failed to ensure its designated infection preventionist had completed specialized infection prevention training. Staff identified the infection preventionist as having only partially completed CDC training and not having certification, while the facility policy assigned that role oversight of the infection prevention and control program, including isolation precautions, exposures, surveillance, and epidemiological investigations.
Staff failed to ensure call lights were accessible for four residents, resulting in situations where individuals could not call for help when needed, including after a fall and during a respiratory complaint. Additionally, a resident with dementia and a history of wandering was not adequately supervised, leading to multiple incidents of elopement, including exiting through a window. Documentation of required safety checks was incomplete, and staff were unaware of who restricted access to call lights or why supervision protocols were not followed.
Staff did not consistently follow or understand Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device, as evidenced by staff entering and assisting the resident without required PPE and expressing confusion about EBP protocols, despite facility policies and signage indicating the need for gowns and gloves during high-contact care activities.
Multiple residents experienced unaddressed wall and baseboard damage in their rooms, with concerns about delayed repairs due to inconsistent maintenance request procedures. Additionally, a resident's room remained unclean for several days, with visible soiling on bathroom fixtures and surfaces, despite facility policies requiring daily cleaning and disinfection. Staff interviews revealed lapses in both maintenance and housekeeping routines.
A resident with a height of 6 feet 8 inches and weighing 337 pounds was admitted without the facility having the proper bed or equipment to accommodate his size. Staff improvised by attaching a piano bench to the end of a standard bed and using pillows to fill gaps, as the correct extension piece was not available until the next day. Staff later acknowledged that the admission process would have differed if they had known about the resident's height.
A staff member removed a resident's oxygen during the admission process to obtain a weight, leading to signs of hypoxia. The resident required seven liters of oxygen, which was not available in a portable form. Staff interviews indicated the removal was not willful abuse but due to inadequate preparation and resources, highlighting a lapse in protocol adherence.
A resident experienced symptoms of hypoxia after their oxygen was removed during the admission process, leading to nausea and vomiting. The incident was not reported to the State Survey Agency within the required timeframe, and staff interviews revealed confusion about reporting procedures. The facility's policy on neglect was not followed.
A resident with COPD was admitted to a facility without necessary physician orders and equipment for respiratory care. During the admission process, staff removed the resident's oxygen, leading to signs of hypoxia. The staff was unprepared and unfamiliar with the resident's needs, and the facility was not equipped with the necessary supplies, contributing to the resident's distress.
A facility failed to provide appropriate respiratory care for a newly admitted resident on high oxygen, leading to hypoxia signs after oxygen removal. Staff interviews revealed procedural misunderstandings and equipment shortages. Additionally, the facility did not follow physician orders for other residents' oxygen levels, indicating systemic issues in respiratory care and documentation.
A resident with cognitive impairments was unable to consent to sexual contact and was inappropriately touched by another resident with a history of hypersexual behavior. Despite previous incidents and measures such as medication and increased supervision, the resident was able to enter the other's room and engage in inappropriate contact. The facility's policies define such actions as sexual abuse, highlighting a deficiency in protecting vulnerable residents.
A facility failed to update a resident's care plan to protect her from unwanted sexual advances by another resident. Despite two incidents of inappropriate behavior, no interventions were added to her care plan to ensure her safety, although changes were made to the male resident's care plan. The revised care plan lacked instructions for staff on monitoring or removing her from the male resident's vicinity.
The facility failed to remove and dispose of expired medications and medical supplies in three medication rooms, three medication carts, and one wound supply cart. Additionally, wound vac supplies were improperly stored on the floor in one medication room. Staff interviews revealed that required night shift medication room and cart checks were not conducted due to a changeover in management.
The facility failed to administer respiratory treatments according to professional standards for four residents. Staff used soiled equipment, allowed residents to self-administer without orders, and did not document vital signs as required.
The facility failed to assess and document residents' ability to self-administer medications, allowing a resident to self-administer a nebulizer treatment without proper orders or assessments. Record reviews and staff interviews confirmed the lack of necessary evaluations and adherence to facility policies.
The facility failed to update the catheter care plan for a resident at risk of infection. The resident's room had a strong urine smell, and the catheter tubing was cloudy with white debris. Staff indicated that catheters are changed based on the physician's order, which was not reflected in the outdated care plan.
The facility failed to provide adequate incontinence care and repositioning for two dependent residents, leading to potential skin breakdown and discomfort. One resident was observed lying flat on her back multiple times without assistance in changing positions, while another resident was left in a wheelchair for extended periods with soaked pants and matted eyes, indicating a lack of incontinence care.
The facility failed to change a resident's catheter as ordered, leading to potential infection risk. The resident's room smelled strongly of urine, and the catheter tubing was cloudy with white debris. Staff indicated that catheters are changed based on physician orders, but records showed the catheter had not been changed in the past three months.
The facility failed to ensure staff used appropriate hand hygiene during catheter and wound care for two residents. Staff did not wash hands between glove changes and handled medical supplies with bare hands, contrary to facility policy.
Failure to Monitor Resident Personal Refrigerators and Food Dates
Penalty
Summary
The facility had a policy regarding the use and storage of foods brought to residents by family and other visitors, but it failed to implement a process to ensure food safety for resident personal refrigerators. During an observation on 4/20/26, resident #4’s personal refrigerator did not have a temperature gauge inside or a temperature log, and it contained a cup of cauliflower and carrots wrapped in a bag in the back of the refrigerator with a noticeable odor when the door was opened. The vegetables had no date on them, and there was also no date on the [NAME] syrup. In a follow-up interview, resident #4 stated she checked her own refrigerator for spoiled food and said staff did check the temperature, but would not use a thermometer. During an observation and interview on 4/20/26, resident #14 stated no staff members checked her refrigerator for temperature or spoiled food, and there was no temperature log in her room. During another observation on 4/20/26, resident #51’s personal refrigerator had no temperature log or temperature gauge, and inside were three individually packaged Crustable sandwiches placed in a Ziploc bag with the date of 3-4 written on the bag. Staff member M stated nursing staff was not responsible for checking residents’ personal refrigerators, and staff member C stated the facility was noncompliant with personal refrigerator temperatures and had started a Performance Improvement Plan. Review of the facility policy, titled Resident Refrigerators, dated 4/11/25, showed that a thermometer shall remain in the refrigerator and staff shall clean the refrigerator weekly and discard any foods that are out of compliance.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician about resident #3’s severe weight loss, which prevented physician assessment and involvement and did not allow the physician the opportunity to recommend or implement interventions. Review of the resident’s weight record showed a 9.73% weight loss from admission on 3/10/26 to 4/21/26, with weight declining from 182 pounds to 164.3 pounds. During an interview on 4/21/26, staff member G stated she had been following the resident closely since admission and had been making ongoing changes to accommodate the resident’s nutritional needs, but had not notified the medical provider of the weight loss until that day. During a later interview, staff member B stated the dietician was responsible for reporting weight loss to the medical provider and that resident #3’s weight loss was not reported until 4/21/26. The resident’s EHR contained no documentation that the physician was notified or involved in the weight loss until 4/21/26, and the facility’s Weight Monitoring document stated that the physician should be informed of a significant change in weight.
Incorrect PASARR Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately complete MDS assessments for two residents’ PASARR information in Section A. For resident #7, staff completed an Annual MDS with an ARD of 12/10/25 and documented that the resident was not considered by the state Level Two PASARR process to have serious mental illness, intellectual disability, or a related condition by answering “no,” even though the resident had a Level One PASARR completed on 1/15/24 and a Level Two PASARR completed on 1/22/24 with recommended services. Staff member F stated that when completing Section A, she did not think to review the resident’s PASARR information because the system pre-populated the demographic information. The same error occurred for resident #11 on a Significant Change in Status MDS assessment with an ARD of 3/8/26. The resident had diagnoses of Bipolar Disorder, Schizophrenia, and Post Traumatic Stress Disorder, and the record showed a Level One PASARR completed on 3/11/24 followed by a Level Two PASARR completed on 4/2/24 with recommended services. Despite this, Section A of the MDS again documented “no” to whether the resident was considered by the state Level Two PASARR process to have serious mental illness, intellectual disability, or a related condition. Staff member F stated the same issue occurred with this assessment and that she would need to start double-checking Section A of the MDS.
Delayed PASARR Level I Review After Significant Mental Status Change
Penalty
Summary
The facility failed to promptly obtain a new PASARR Level I screen for a resident with a significant change in mental status after re-admission from the hospital. Resident #68 had a prior PASARR Level I review request in the record, and the resident’s diagnoses included altered mental status, unspecified, with a diagnosis date of 3/20/26. The resident also had a history of Bipolar II disorder, fetal alcohol syndrome, and PTSD. On 4/8/26, the resident reported hearing voices that were repeating “Knife, knife, and kill, kill, kill,” and stated she was frightened and afraid she might act on the hallucinations. The resident was transported by EMS to the Emergency Department for evaluation, where psychiatry documented severe depressed bipolar II disorder with psychotic features. A new PASARR Level I review request was not documented until 4/22/26. During interview, staff stated a new PASARR Level I review should have been requested when there was a new psychiatric or mental health diagnosis or when the resident was sent out for psych clearance.
Care plans did not match POLST code status
Penalty
Summary
The facility failed to revise resident care plans to reflect POLST code status for 2 residents. During interview, staff member J stated care plans were updated weekly by the interdisciplinary team and that a nurse could update a care plan if an immediate update was needed, but she was not sure why the two residents’ care plans did not reflect their code status. Resident #50’s POLST showed No CPR, yet the care plan documented the resident as Full code, stated the resident’s wishes would be honored, and included an intervention to review the POLST every 3 months and upon the resident’s request. Resident #74’s POLST showed Do not Attempt Resuscitation (DNR), yet the care plan documented Advance Directive as Full code, listed the goal that wishes would be honored through the next review date, and included Full Code as an intervention. The facility policy stated that care plans would be updated with new or modified interventions when a resident experienced a status change.
Missed Initial Physician Visit
Penalty
Summary
The facility failed to ensure that resident #3 had a physician personally conduct an initial comprehensive visit within the first 30 days after admission. During interviews, staff member A stated the resident was seen by a physician assistant on 4/21/26 and said there was a 10-day slippage for provider visits, adding that the 4/21/26 visit would meet the 30-day physician visit deadline. Staff member A also stated the facility had contracted with a new physician, but the physician’s state license was still pending. Staff member B later stated she thought resident #3 had been seen by the provider during the week of 4/8/26 and said she would look for the physician’s note. Review of the resident’s hospital discharge note dated 3/10/26 showed multiple chronic medical conditions requiring monitoring and medical management, including insulin dependent diabetes, atrial fibrillation on anticoagulation therapy, congestive heart failure, COPD on nasal oxygen, and a left leg hematoma with progressive skin changes. Review of progress notes from 3/10/26 through 4/23/26 showed no physician visit note documenting that a medical doctor saw the resident at the facility, and no physician visit note was provided by the end of the survey. The facility policy stated that the physician should see the resident within 30 days of initial admission.
Medication Error Rate Exceeded Threshold
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with surveyors identifying an observed error rate of 10.34% for 2 of 34 sampled and supplemental residents. During an observation and interview, staff member K prepared medications for resident #38, including amlodipine, clopidogrel, aspirin, multivitamin, Norco, Senna Plus, and pantoprazole. The pantoprazole was shown on the MAR as due at 7:00 a.m. and was late, and staff member K stated it should be given before breakfast for best efficacy but was often administered later at the same time as other morning medications when running late. During the same medication pass, staff member K initially placed only one Senna Plus tablet in the medication cup for resident #38, then added a second tablet after the surveyor questioned why the ordered dose of two tablets was not being prepared. For resident #13, staff member L prepared medications including magnesium oxide and noted the MAR did not match the medication bottle. The MAR showed an order for 420 mg magnesium oxide, while the medication label showed 400 mg. When asked how long the incorrect dose had been given, staff member L stated it had been given "for a while," and then administered the magnesium oxide to the resident.
Infection Preventionist Lacked Required Specialized Training
Penalty
Summary
The facility failed to ensure that the designated infection preventionist had completed specialized training in infection prevention. During interview, staff member C identified staff member D as the facility’s infection preventionist and stated she had completed infection preventionist coursework in 2021 but could not retrieve a certificate of completion from the CDC website. Staff member D stated she had worked in infection control since approximately 2019 and had completed only the first 12 of 23 modules in the CDC infection preventionist training between 2020 and 2021, but did not complete the training and did not have infection preventionist certification. The facility policy stated the infection preventionist is responsible for oversight of the infection prevention and control program, including infectious diseases, resident room placement, isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations. The CDC training page reviewed by surveyors stated nursing homes are required to have a designated infection preventionist who has received specialized training in infection prevention and control.
Failure to Ensure Call Light Accessibility and Prevent Elopement
Penalty
Summary
Facility staff failed to ensure that call lights were accessible to four residents, resulting in situations where residents could not summon assistance when needed. One resident with left-sided weakness from a stroke was unable to reach his call light, which was tied to the bed and out of reach, leading him to call for help by yelling. Another resident, who reported difficulty breathing, did not have a call light within reach and required the surveyor to activate the call button for staff assistance. A third resident reported falling because she could not call for help before getting up, despite signage reminding her to do so, as her call light was not accessible. A fourth resident, who was unable to verbalize his needs, had his call light taped to the wall and was not able to use it, with staff unaware of who had done this. Staff interviews revealed there was no facility policy related to call lights. The facility also failed to prevent elopement for one resident with a diagnosis of unspecified mild dementia with agitation, who was known to wander and had impaired safety awareness and judgment. This resident was observed wandering the hallways, attempting to exit the building, and entering other residents' rooms without supervision. The resident had previously eloped by removing a window and screen from his room and exiting the facility, and on another occasion was found outside near the parking area. Staff interviews confirmed that the resident was on 15-minute checks, but there were missing visual check records for several days and incomplete documentation on other days. Staff also stated that the resident's door should have been open for supervision, but it was found closed multiple times without explanation. Review of the resident's care plan indicated interventions such as frequent checks and 1:1 supervision for safety and elopement risk, but these were not consistently implemented or documented. The facility's elopement policy did not specify procedures to follow after an incident report was filed. These deficiencies in supervision and environmental safety placed residents at risk of falls, injuries, elopement, or negative outcomes if a medical crisis occurred and assistance could not be summoned.
Failure to Ensure Staff Knowledge and Adherence to Enhanced Barrier Precautions
Penalty
Summary
Staff failed to adhere to and demonstrate knowledge of Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. Multiple staff members, including one in orientation and others working independently, were observed either not knowing what EBP stood for or not following the required use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. Staff interviews revealed confusion about when and how to use PPE, with some staff incorrectly associating EBP only with certain infections and expressing uncertainty about the full scope of required precautions. Observations included staff exiting a resident's room on EBP without PPE, and two staff assisting a resident under EBP without wearing gowns or gloves, despite signage and PPE being available. The resident's care plan specified the need for gown and glove use during high-contact activities, and facility policy outlined specific situations requiring PPE. However, staff training and understanding of these requirements were inconsistent, leading to non-compliance with established infection prevention protocols.
Failure to Maintain Safe, Clean, and Repaired Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for several residents, as evidenced by multiple areas of the building in need of repair and unaddressed housekeeping issues. Observations revealed that one resident's room had numerous holes in the wall near a grab bar, another had long vertical gouges above the bed, and a third had significant wall and baseboard damage. Residents expressed concern about the lack of timely repairs, and interviews with staff indicated that maintenance requests were not consistently entered into the facility's electronic system, resulting in delays. Staff members admitted to either forgetting to log repairs or preferring to verbally request them, leading to a lack of documentation and follow-through. Additionally, the facility failed to maintain cleanliness in at least one resident's room, where a thick brown substance was observed smeared on the commode seat, handrail, and toilet paper, along with a sticky substance on the floor and a full urinal left on the bedside table. Despite daily cleaning routines outlined in facility policy, these unsanitary conditions persisted over multiple days, and the resident confirmed that the bathroom had not been cleaned. Housekeeping staff acknowledged inconsistencies in cleaning due to staffing issues and unfamiliarity with the specific hall. Facility documents confirmed that daily cleaning and disinfection of toilets and handrails were required but not consistently performed.
Failure to Provide Appropriate Bed for Resident with Uncommon Height
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for a resident whose physical size required special accommodation. Upon admission, the resident's height (6 feet 8 inches) and weight (337 pounds) were documented in both the hospital history and the nurse handoff report. Despite this information, the facility did not have the appropriate bed or equipment available to accommodate the resident's height at the time of admission. Instead, staff improvised by removing the footboard from a standard bed, strapping a piano bench to the foot of the bed, and using a chair to secure the bench in place. The mattress was shifted down, and pillows were used to fill the gap at the head of the bed. The resident reported being told to sleep in a recliner, which he declined, leading staff to modify the bed as described. Staff interviews confirmed that while a wide bed extension was available, there was no extension piece to add length for the resident's height upon arrival. The necessary equipment to properly accommodate the resident was not provided until the following day. Staff also indicated that the admission process would have been different had they been aware of the resident's uncommon height in advance.
Oxygen Removal Leads to Resident Hypoxia
Penalty
Summary
A staff member at the facility removed a resident's oxygen during the admission process to obtain the resident's weight, despite knowing the oxygen was necessary to maintain the resident's oxygen levels. This action led to the resident showing signs of hypoxia, including nausea and vomiting, before the oxygen was replaced. The incident involved a resident who was admitted to the facility and required seven liters of oxygen, which was not available in a portable form at the time of the incident. Interviews with staff members revealed that the removal of the oxygen was not a willful act of abuse, but rather a result of inadequate preparation and resources. Staff member E, who was responsible for obtaining the resident's weight, reported that the room was not set up with the necessary supplies, such as a portable oxygen cylinder, and that the available portable cylinders could not meet the resident's seven-liter requirement. Staff members expressed that it was common knowledge not to remove a resident's oxygen during care, indicating a lapse in adherence to this protocol. The facility's policy defines neglect as the failure to provide necessary goods and services to avoid physical harm, which aligns with the events described in the report.
Failure to Report Neglect Incident
Penalty
Summary
The facility failed to report an incident of neglect involving a resident whose oxygen was removed during the admission process, leading to symptoms of hypoxia. The resident, who was admitted to the facility, had their oxygen removed while being wheeled down the hallway to obtain an admission weight, resulting in nausea and vomiting. This incident was not reported to the State Survey Agency within the required 24-hour timeframe, nor was a follow-up investigation reported within 5 working days. Interviews with staff members revealed a lack of clarity and communication regarding the reporting of neglect. Staff member E reported the incident to staff member G, who then informed staff member H. However, staff members A and B did not believe the event needed to be reported to the State Survey Agency, as they did not consider it a willful act of abuse. The facility's policy on abuse and neglect defines neglect as the failure to provide necessary goods and services to avoid harm, which was not adhered to in this case.
Failure to Provide Adequate Respiratory Services on Admission
Penalty
Summary
The facility failed to ensure that a resident received appropriate respiratory services upon admission, which resulted in neglect of care. The resident, who had a primary diagnosis of COPD, was admitted without the necessary physician orders and equipment for their respiratory needs. During the admission process, a staff member removed the resident's oxygen while obtaining an admission weight, leading to the resident showing signs of hypoxia, including nausea and vomiting. Staff members involved in the incident were not adequately informed or prepared for the resident's specific respiratory care needs. One staff member, who was unfamiliar with the resident, attempted to obtain a weight and vitals but encountered issues with the resident's oxygen saturation. The staff member noted that the room was not set up with the necessary supplies, such as a portable oxygen cylinder, and was unable to find a cylinder that could meet the resident's seven-liter oxygen requirement. This lack of preparation and communication contributed to the resident's distress. The chaotic environment on the day of admission further exacerbated the situation. Staff members were overwhelmed with multiple admissions and medication passes, leading to a lack of proper communication and documentation. The facility's policy required that the attending physician provide necessary information for immediate care, but this was not adequately followed, resulting in the resident's compromised condition during the admission process.
Failure to Provide Appropriate Respiratory Care and Follow Physician Orders
Penalty
Summary
The facility failed to provide appropriate respiratory care for a newly admitted resident who was on a high rate of oxygen. During the admission process, a staff member removed the resident's oxygen while transporting them to obtain an admission weight, resulting in the resident showing signs of hypoxia, including nausea and vomiting. The resident's electronic health record (EHR) lacked documentation of oxygen saturation readings and an admission nursing note, indicating a failure in proper record-keeping and monitoring. Interviews with staff members revealed a lack of understanding and communication regarding the proper procedures for handling residents requiring high levels of oxygen. Staff members admitted to removing the resident's oxygen and acknowledged the absence of necessary equipment, such as a portable oxygen cylinder, which contributed to the incident. The staff also reported that the day was chaotic, and there was a lack of information about the resident's medical needs due to insufficient communication from the hospital. Further observations showed that the facility did not follow physician orders for other residents receiving oxygen, with discrepancies in the oxygen concentrator settings compared to the prescribed levels. The facility's policies on oxygen administration and admission criteria were not adhered to, leading to potential neglect and adverse effects on residents receiving oxygen services. The report highlights a systemic issue in the facility's handling of respiratory care and documentation during the admission process.
Failure to Protect Resident from Non-Consensual Sexual Contact
Penalty
Summary
The facility failed to protect a resident who could not consent to sexual contact from another resident. On November 3, 2024, a staff member observed a resident in another resident's room with his hands under her covers, touching her. The resident being touched was not capable of consenting to sexual contact due to cognitive impairments, including dementia, impaired orientation, forgetfulness, confusion, poor recall, and impaired decision-making. The resident who initiated the contact was aware of his actions but had impulse control issues and a history of hypersexual behavior. The incident on November 3, 2024, was not the first occurrence between these two residents. An earlier incident on May 13, 2024, involved the same resident placing his hand on the other resident's breast in the hallway. Following the May incident, the facility had placed the resident on medication to decrease libido and increased staff supervision. However, the one-to-one observation was discontinued after the resident showed no further hypersexual behaviors. Despite these measures, the resident was able to enter the other resident's room and engage in inappropriate contact again. The facility's policies on abuse and neglect, as well as identifying types of abuse, clearly define sexual abuse as non-consensual sexual contact of any type with a resident. The facility's failure to maintain adequate supervision and protection for the resident who could not consent to sexual contact resulted in a deficiency. The facility's documentation and interviews with staff members revealed that the resident who initiated the contact had a history of inappropriate sexual behavior, yet the measures in place were insufficient to prevent the recurrence of such incidents.
Failure to Protect Resident from Unwanted Sexual Advances
Penalty
Summary
The facility failed to implement care plan interventions to protect a resident from unwanted sexual advances or abuse by another resident. This deficiency involved a resident who was subjected to inappropriate sexual behavior by a male resident on two occasions. The first incident occurred when the male resident touched the resident's breast, and the second incident involved the male resident being found in the resident's room with his hand under her bed covers, during which he touched her breasts and vagina. Despite these incidents, no changes were made to the affected resident's care plan to ensure her safety from the male resident, although changes were made to the male resident's care plan. The care plan for the affected resident, revised after the second incident, did not include interventions to protect her from the male resident or instructions for staff on monitoring or removing her from his vicinity.
Expired Medications and Improper Storage in Medication Rooms and Carts
Penalty
Summary
The facility failed to remove and dispose of expired medications and medical supplies in three medication rooms, three medication carts, and one wound supply cart. Additionally, the facility did not properly store medical supplies, as observed with wound vac supplies on the floor in one medication room. These deficiencies were identified during observations on 3/26/24, where numerous expired medications and medical supplies were found, including items such as Pen needles, Sharp debridement trays, various medications, and wound care supplies with expiration dates ranging from 2016 to early 2024. The presence of these expired items was confirmed in the 400-hall, 300-hall, and 200-hall medication rooms and carts, as well as the wound supply cart. Interviews with staff members revealed that the facility did not conduct the required night shift medication room and cart checks, as audit forms were not available. Staff member B indicated that these audits were likely not performed due to a changeover in management. The facility's policy on Medication Labeling and Storage, revised in February 2023, mandates contacting the dispensing pharmacy for instructions on returning or destroying discontinued, outdated, or deteriorated medications, which was not adhered to in this case.
Failure to Administer Respiratory Treatments According to Professional Standards
Penalty
Summary
The facility failed to administer respiratory treatments in accordance with professional standards of practice for four residents. During an observation, a staff member attempted to administer a nebulizer treatment to a resident using a soiled mask and a chamber containing an earlier dose of medication. The staff member did not clean the equipment properly before attempting to administer the treatment. Additionally, the resident did not have orders to self-administer medications, yet was allowed to start and stop the nebulizer treatment independently. Similar practices were observed for other residents, where staff set up nebulizer treatments and left the residents to complete them on their own without proper supervision or assessment. Interviews with staff revealed inconsistencies in the administration of nebulizer treatments, with some staff stating they stayed in the room while others left the residents unsupervised. Record reviews showed that there were no physician orders or assessments for self-administration for the involved residents, and there was no documentation of vital signs before and after treatments. The facility's policy required staff to remain with residents during treatments and monitor their vital signs, which was not followed in these cases.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were assessed and found safe to self-administer their own medications before doing so, and did not document these assessments in the electronic health records (EHRs) for four residents. During an observation, a staff member allowed a resident to self-administer a nebulizer treatment without having a physician's order or an assessment confirming the resident's capability to do so. Interviews with staff revealed that the resident did not have orders to self-administer medications and that the facility did not have the necessary assessments for other residents either. Record reviews showed that one resident had an evaluation indicating they were not capable of self-administration, while two other residents had no assessments documented in their EHRs. The facility's policy required staff to remain with residents during nebulizer treatments, which was not followed. The deficiency was confirmed through interviews, observations, and record reviews, highlighting a failure to comply with the facility's own policies and regulatory requirements for medication administration and resident safety assessments.
Failure to Update Catheter Care Plan
Penalty
Summary
The facility failed to review and revise the comprehensive care plan interventions for catheter care for a resident at risk of infection. During an observation, the resident's room had a strong urine smell, and the catheter tubing was cloudy with white debris. An interview with a staff member revealed that catheters are changed based on the physician's order in the Medication Administration Record. The physician's order indicated that the catheter should be changed for occlusion, leakage, dislodgement, or signs of infection. However, the resident's care plan, last revised over three years ago, stated that the catheter should be changed monthly and was not updated to reflect the physician's order.
Failure to Provide Adequate Repositioning and Incontinence Care
Penalty
Summary
The facility failed to provide adequate incontinence care and repositioning for two dependent residents, which had the potential to increase skin breakdown and cause discomfort. Resident #14 was observed multiple times lying flat on her back with minimal head elevation and reported that staff did not assist her in changing positions despite her care plan indicating the need for repositioning 3-4 times per shift. Staff confirmed that they did not turn her on her sides, only assisting with pulling her up in bed when she slipped down. This lack of repositioning was consistent throughout the observations made on different days and times. Resident #2 was observed sitting in her wheelchair for extended periods without being repositioned or provided with personal hygiene care. She was found with a strong odor of urine, matted eyes, and soaked pants, indicating a lack of incontinence care. Staff confirmed that she had not been repositioned or changed since the morning, despite her care plan requiring repositioning every two hours and monitoring for incontinence. The observations and interviews revealed that the staff did not follow the care plan interventions for repositioning and incontinence care, leading to potential discomfort and risk of skin breakdown for the residents.
Failure to Change Catheter as Ordered
Penalty
Summary
The facility failed to change a resident's catheter, which had the potential to increase the risk of infection. During an observation and interview, the resident's room smelled strongly of urine, and the catheter tubing was cloudy with white debris. The resident could not recall if the catheter had ever been changed. Staff indicated that catheters are changed based on physician orders in the Medication Administration Record. A review of the resident's catheter order and care plan showed that the catheter should be changed monthly and as needed. However, the Treatment Administration Record for the past three months indicated that the catheter had not been changed during this period.
Inadequate Hand Hygiene During Catheter and Wound Care
Penalty
Summary
The facility failed to ensure staff used appropriate hand hygiene during catheter care and wound care for two residents. In the first instance, a staff member performed initial hand hygiene but failed to wash hands between glove changes while providing pericare and catheter care to a resident. The staff member used keys from her pocket to open a package of wipes and did not perform hand hygiene after handling the keys. She also did not wash her hands between changing gloves multiple times during the procedure, which was acknowledged by another staff member as a learning opportunity. In the second instance, two staff members were observed performing wound care on another resident. One staff member removed gloves and handled medical supplies with bare hands before donning new gloves without washing hands in between. This was done despite the facility's policy requiring hand hygiene before and after direct contact with residents, and after handling contaminated equipment. The staff member admitted to not washing hands between glove changes because she believed it was unnecessary since it was the same resident.
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What surveyors actually found near you
We read the 27 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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 Butte
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Continental Care And Rehabilitation | 0.1 mi | ★★★★★ | 1 | 0 |
| Crest Nursing Home | 0.3 mi | ★★★★★ | 9 | 0 |
| Southwest Montana Veterans Home | 3.3 mi | ★★★★★ | 0 | 0 |
| Community Nursing Home Of Anaconda | 23.9 mi | ★★★★★ | 17 | 0 |
| Ivy At Deer Lodge | 29.8 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.