Inspection Reports for Copper Ridge Health and Rehab
3251 Nettie St, Butte, MT 59701, United States, MT, 59701
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% worse than Montana average
Montana average: 5.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 10, 2025
Visit Reason
The inspection was conducted due to complaints regarding inadequate access to call lights for residents and failure to prevent elopements, specifically involving resident #54.
Complaint Details
The complaint investigation focused on resident #54's elopement incidents, including exiting the facility through a window and wandering unsupervised, as well as inadequate supervision and safety measures. The resident was on 15-minute checks but still managed to elope twice. The facility's policy on elopements was outdated and did not specify post-incident procedures.
Findings
The facility failed to ensure call lights were accessible to four residents and did not prevent elopements by resident #54, who was observed wandering unsupervised, exiting the facility through a window, and entering other residents' rooms. The facility lacked policies related to call lights and had incomplete visual checks for resident #54 despite known elopement risks.
Deficiencies (2)
Facility staff failed to ensure call lights were accessible to residents #16, 24, 49, and 54.
Facility failed to prevent elopements for resident #54, who exited the building through a window and wandered unsupervised.
Report Facts
Residents sampled: 22
Residents affected by call light deficiency: 4
Residents affected by elopement deficiency: 1
Missing visual checks duration: 3
Missing visual checks time: 90
Check frequency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member H assessed resident #24 after call light was pushed by surveyor | ||
| Staff member F stated resident #54's call light should be in reach and door partially open | ||
| Staff member A stated facility had no policy related to call lights | ||
| Staff member O redirected resident #54 from exit door | ||
| Staff member I stated CNAs should have ensured resident #54's door was open and noted two elopements | ||
| Staff member M stated resident #54 pulled window out and eloped; noted resident's background and 15-minute checks |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to facility maintenance, housekeeping, resident safety, infection control, and elopement risk at Copper Ridge Health and Rehabilitation Center.
Findings
The facility failed to maintain areas of the building in need of repair for 3 of 22 sampled residents and failed to maintain a clean environment for 1 resident. Additionally, the facility failed to ensure call lights were accessible for 4 residents and failed to prevent elopements for 1 resident. Staff were also not adequately educated on Enhanced Barrier Precautions, increasing infection risk.
Deficiencies (5)
Failure to maintain areas of the building in need of repair including wall damage in residents' rooms.
Failure to maintain a clean environment related to housekeeping services, including unclean bathrooms.
Failure to ensure call lights were accessible to residents, placing them at risk of falls and injuries.
Failure to prevent elopements for a resident at risk, including inadequate supervision and environmental controls.
Failure to provide adequate staff education and adherence to Enhanced Barrier Precautions, increasing infection risk.
Report Facts
Residents sampled: 22
Residents affected: 3
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents sampled for infection control: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member M | Named in relation to wall repairs and elopement incident | |
| Staff member F | Named in relation to call light accessibility and PPE use | |
| Staff member P | Named in relation to lack of knowledge about Enhanced Barrier Precautions | |
| Staff member Q | Named in relation to knowledge about Enhanced Barrier Precautions | |
| Staff member C | Named in relation to staff training on Enhanced Barrier Precautions | |
| Staff member A | Named in relation to call light policy and maintenance request system | |
| Staff member L | Named in relation to wall gouges and maintenance reporting | |
| Staff member K | Named in relation to maintenance request process | |
| Staff member J | Named in relation to maintenance request reporting | |
| Staff member I | Named in relation to elopement risk and supervision | |
| Staff member O | Named in relation to redirecting resident at elopement risk |
Inspection Report
Deficiencies: 1
Date: Mar 12, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding providing a safe, clean, comfortable, and homelike environment, specifically focusing on the facility's ability to accommodate a resident's physical size upon admission.
Findings
The facility failed to collect and act on admission information necessary to accommodate the physical size of a resident, resulting in inadequate bed/equipment for a resident who was 6 feet 8 inches tall and weighed 337 pounds. Staff had to modify the bed with a piano bench and other makeshift adjustments until proper equipment was obtained.
Deficiencies (1)
Facility failed to have the necessary bed/equipment on hand for the resident's admission to accommodate the resident's height.
Report Facts
Residents sampled: 6
Resident weight: 337
Resident height: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member H interviewed regarding bed extension availability and modifications | ||
| Staff member C interviewed regarding admission process and resident's height |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Feb 24, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding the removal of a resident's oxygen during admission, which resulted in the resident showing signs of hypoxia and vomiting.
Complaint Details
The complaint involved resident #5 whose oxygen was removed during admission, leading to nausea, vomiting, and hypoxia symptoms. The facility did not report the incident to the State Survey Agency as required and failed to conduct a timely follow-up investigation.
Findings
The facility failed to protect a resident from neglect when a staff member removed the resident's oxygen during admission, causing hypoxia symptoms. The facility also failed to timely report the incident to the State Survey Agency, lacked physician orders and necessary equipment for respiratory care, and staff were not adequately educated on the resident's respiratory needs.
Deficiencies (4)
A staff member removed a resident's oxygen during admission, causing signs of hypoxia and vomiting.
The facility failed to timely report the incident of neglect to the State Survey Agency within 24 hours and failed to report a follow-up investigation within 5 working days.
The facility failed to ensure physician orders and necessary equipment were available and staff were educated on the resident's respiratory care needs, resulting in neglect of care.
Physician orders for oxygen were not followed for three residents, with oxygen levels set higher than ordered.
Report Facts
Residents sampled: 5
Residents affected: 1
Oxygen liters required: 7
Oxygen liters maximum portable cylinder: 6
Oxygen liters observed: 3
Oxygen liters ordered: 1
Oxygen liters observed: 4
Oxygen liters ordered: 2
Oxygen liters observed: 5
Oxygen liters ordered: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member E | Reported oxygen removal incident and described lack of portable oxygen cylinders | |
| Staff member G | Provided personal statement about oxygen removal incident and response | |
| Staff member C | Stated they would never take a resident to get a weight without oxygen and described oxygen tank storage | |
| Staff member A | Acknowledged oxygen removal was wrong and provided statement about incident documentation | |
| Staff member F | Described reporting procedures for abuse or neglect | |
| Staff member D | Described admission process including obtaining weight and vitals | |
| NF1 | Family member of resident #5, described resident's condition and frustration with facility |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 4, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a failure to protect a resident (#3) from sexual abuse by another resident (#2) at Copper Ridge Health and Rehabilitation Center.
Complaint Details
The complaint investigation was substantiated based on video observation, interviews, and record reviews confirming sexual abuse incidents on 5/13/24 and 11/3/24 involving resident #2 and resident #3. Resident #2 was placed on one-to-one observation and medication to manage hypersexual behavior, but resident #3's care plan lacked protective interventions.
Findings
The facility failed to protect resident #3, who could not consent to sexual contact, from inappropriate sexual advances and abuse by resident #2. The investigation revealed two incidents of sexual contact, inadequate care planning to protect resident #3, and insufficient monitoring despite resident #2's known hypersexual behaviors and prior incidents.
Deficiencies (2)
Failed to protect resident #3 from sexual abuse by resident #2, including unwanted touching of breasts and vagina.
Failed to develop care plan interventions to keep resident #3 safe from unwanted sexual advances or abuse from resident #2.
Report Facts
Residents sampled for abuse: 7
Residents affected: 1
Dates of incidents: Incidents occurred on 5/13/24 and 11/3/24
One-to-one observation start date: One-to-one observation for resident #2 initiated on 11/3/24 and previously on 5/14/24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Interviewed regarding incidents and care planning failures | |
| Staff member J | Witnessed incident on 11/3/24 and provided interview | |
| Staff member E | Travel nurse who documented behaviors and communicated care plan changes | |
| NF1 | Interviewed expressing concern about resident #2's placement |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 27, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, catheter care, respiratory treatments, care planning, activities of daily living, medication storage, and infection control.
Findings
The facility failed to ensure residents were properly assessed and documented for self-administration of medications, failed to revise care plans according to physician orders, did not provide adequate incontinence care and repositioning, failed to change catheters as ordered, improperly administered respiratory treatments, stored expired medications and supplies, and did not consistently follow hand hygiene protocols during care.
Deficiencies (7)
Failed to ensure residents were assessed and found safe to self-administer medications and failed to document assessments for 4 of 6 sampled residents.
Failed to review and revise comprehensive care plan interventions for catheter care for 1 of 26 sampled residents.
Failed to provide incontinence care and repositioning for dependent residents, potentially increasing skin breakdown and discomfort for 2 of 26 sampled residents.
Failed to change a resident's catheter as ordered, increasing risk of infection for 1 of 26 sampled residents.
Failed to administer respiratory treatments in accordance with professional standards for 4 of 6 sampled residents.
Failed to remove and dispose of expired medications and medical supplies in multiple medication rooms and carts, and failed to properly store supplies.
Failed to ensure staff used appropriate hand hygiene during catheter care or wound care for 2 of 26 sampled residents.
Report Facts
Residents sampled: 26
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 4
Expired medication items: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NF1 | Interviewed regarding resident #49's medication self-administration orders and appropriateness | |
| Staff member K | Observed administering nebulizer treatments and interviewed about medication self-administration and respiratory treatment procedures | |
| Staff member A | Interviewed about lack of physician orders for self-administration and missing assessments | |
| Staff member L | Interviewed about respiratory treatment monitoring and repositioning care | |
| Staff member G | Interviewed about catheter care, respiratory treatment monitoring, and hand hygiene practices | |
| Staff member B | Observed and interviewed regarding expired medication audits and hand hygiene during catheter care | |
| Staff member I | Observed performing catheter care with inadequate hand hygiene | |
| Staff member C | Interviewed about respiratory treatment monitoring practices | |
| Staff member N | Assisted with repositioning resident #2 | |
| NF2 | Assisted with repositioning resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 20, 2023
Visit Reason
The inspection was conducted based on a complaint investigation regarding the facility's failure to properly revise a resident's care plan related to gravity enteral tube feeding complications and failure to properly administer enteral tube feedings, which resulted in a resident's decline and death.
Complaint Details
The complaint investigation was triggered by concerns about improper enteral tube feeding administration for resident #1, which led to aspiration, respiratory arrest, and death. The investigation included interviews, record reviews, and observation of staff practices.
Findings
The facility failed to revise a resident's care plan to reflect complications with gravity enteral tube feeding and failed to properly administer enteral tube feedings, leading to the resident receiving incorrect feeding amounts, aspiration, respiratory arrest, and subsequent death. Staff communication and training deficiencies were also noted.
Deficiencies (3)
Failed to revise a resident's care plan to reflect an intervention regarding gravity enteral tube feeding complications.
Failed to properly administer enteral tube feedings and failed to clarify enteral tube feeding orders, resulting in incorrect feeding amounts and resident decline.
Failed to ensure nurses and nurse aides had appropriate competencies for enteral tube feeding administration, resulting in resident decline and emergency room transfer.
Report Facts
Residents sampled: 7
Residents sampled: 2
Feeding frequency: 5
Oxygen saturation: 46
Feeding cartons administered: 4
Feeding carton volume: 250
Stomach capacity: 750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Interviewed regarding care plan revision, feeding complications, and resident transfer | |
| Staff member C | Administered enteral feeding incorrectly, lacked training, and provided incomplete handoff | |
| Staff member E | Interviewed about questioning feeding orders | |
| Staff member D | Interviewed about feeding administration and questioned feeding volume | |
| Staff member F | Reported feeding complications in handoff | |
| Staff member B | Authored IDT Event Review progress note | |
| Staff member NF2 | Authored progress note describing resident's decline |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Apr 13, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to timely report suspected abuse, failure to initiate a Significant Change MDS after a resident's fall with fracture, failure to prevent pressure ulcers, failure to provide appropriate respiratory care, failure to ensure pharmacist recommendations were rationalized by physicians, failure to follow infection prevention and control protocols, and failure to provide updated pneumococcal vaccinations.
Complaint Details
The complaint investigation revealed failure to report abuse allegations, failure to initiate significant change assessments, failure to prevent pressure ulcers, failure to provide appropriate respiratory care, failure to ensure physician rationale for pharmacist recommendations, failure to follow infection control protocols, and failure to provide updated vaccinations.
Findings
The facility failed to report allegations of abuse to the State Survey Agency, failed to initiate a Significant Change MDS for a resident with a femur fracture, failed to prevent development of pressure ulcers, failed to provide appropriate respiratory care including timely equipment changes, failed to ensure physician rationale for pharmacist recommendations, failed to follow infection control procedures including hand hygiene and sharps disposal, and failed to provide updated pneumococcal vaccines to several residents.
Deficiencies (7)
Failure to timely report suspected abuse to the State Survey Agency for 2 residents.
Failure to initiate a Significant Change MDS for a resident who had a fall with fracture and changed transfer status.
Failure to prevent development of three Stage II pressure ulcers after a resident's fall and increased dependency.
Failure to provide safe and appropriate respiratory care, including failure to change oxygen tubing and nebulizer supplies weekly.
Failure to ensure physician provided rationale for pharmacist recommendation responses for 2 residents.
Failure to follow infection prevention and control procedures including hand hygiene during wound care and safe glucose monitoring and insulin administration practices.
Failure to provide updated pneumococcal vaccines for 6 residents.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 3
Residents affected: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff member A | Did not report abuse allegations to State Survey Agency; provided documents related to abuse investigation; unaware of inappropriate sexual comments; stated resident had tendency to fabricate. | |
| Staff member C | Discussed chain of command for complaints; re-educated staff member E about communication style; stated responsibility for reporting abuse lies with staff member A; stated some pneumococcal immunizations were not completed. | |
| Staff member E | Accused by resident #27 of making inappropriate sexual comments; management re-educated her; no documentation of re-education found. | |
| Staff member H | Observed failing to clean glucose monitor and improper sharps disposal; stated frustration with sharps disposal process. | |
| Staff member B | Reached out to MD for pharmacist recommendation response; did not track provider rationale for disagreements with pharmacist recommendations. | |
| Resident #27 | Reported inappropriate sexual comments by staff member E. | |
| Resident #4 | Refused alcohol wipes for glucose monitoring; stated knowledge of infection control. |
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