A list of the most recent deficiencies for Peak Healthcare at Copper Ridge. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-23 | 2023-01-11 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-23 | 2023-01-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-11-23 | 2023-01-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-11-23 | 2023-01-11 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-11-23 | 2023-01-11 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-11-23 | 2023-01-11 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-11-23 | 2023-01-11 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-23 | 2023-01-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-23 | 2023-01-11 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-23 | 2023-01-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-23 | 2023-01-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-23 | 2023-01-11 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-11-23 | 2023-01-11 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-23 | 2023-01-11 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-11-23 | 2023-01-11 | Y |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2022-11-23 | 2023-01-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-23 | 2023-01-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-23 | 2023-01-11 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2021-09-17 | 2022-02-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-09-17 | 2022-02-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-09-17 | 2021-12-01 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-09-17 | 2021-12-01 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-09-17 | 2021-12-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-09-17 | 2021-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-17 | 2021-12-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-09-17 | 2021-12-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2021-09-17 | 2021-12-01 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-09-17 | 2021-12-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-17 | 2021-12-01 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-09-22 | 2021-11-21 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-09-22 | 2021-11-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-09-22 | 2021-11-21 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-09-22 | 2021-11-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-22 | 2021-11-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-09-22 | 2021-11-21 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-09-22 | 2021-11-21 | N |
| Post nurse staffing information every day. | Health | 2021-09-22 | 2021-11-21 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2021-09-22 | 2021-11-21 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-22 | 2021-11-21 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-22 | 2021-11-21 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-09-22 | 2021-11-21 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-09-22 | 2021-11-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-09-22 | 2021-11-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-22 | 2021-11-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-09-22 | 2021-11-21 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-09-22 | 2021-11-21 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-09-22 | 2021-11-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-22 | 2021-11-21 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-22 | 2021-11-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-22 | 2021-11-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-22 | 2021-11-21 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-09-22 | 2021-11-21 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-09-17 | 2018-11-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-09-17 | 2018-11-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-09-17 | 2018-11-09 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2018-09-17 | 2018-11-09 | N |
| Keep complete, dated laboratory records in the resident's record. | Health | 2018-09-17 | 2018-11-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-17 | 2018-11-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-17 | 2018-11-09 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-09-17 | 2018-11-09 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-09-27 | 2018-10-26 | N |
| Meet other general requirements. | Fire Safety | 2018-09-27 | 2018-10-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-09-27 | 2018-10-26 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-09-27 | 2018-10-26 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-09-27 | 2018-10-26 | N |
| Allow residents to easily view the results of the nursing home's most recent inspection. | Health | 2017-06-30 | 2017-08-15 | N |
| Provide housekeeping and maintenance services. | Health | 2017-06-30 | 2017-08-15 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-06-30 | 2017-08-15 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-06-30 | 2017-08-15 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-06-30 | 2017-08-15 | N |
| Post nurse staffing information/data on a daily basis. | Health | 2017-06-30 | 2017-08-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-06-30 | 2017-08-15 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-06-30 | 2017-08-15 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2017-06-30 | 2017-08-15 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-06-30 | 2017-08-15 | N |
| Meet other general requirements. | Fire Safety | 2017-07-06 | 2017-08-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-07-06 | 2017-08-07 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2017-07-06 | 2017-08-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2017-07-06 | 2017-08-07 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-07-06 | 2017-08-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2017-07-06 | 2017-08-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2017-07-06 | 2017-08-07 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-07-06 | 2017-08-07 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2017-07-06 | 2017-08-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-07-06 | 2017-08-07 | N |
