Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, record, and policy review, the facility failed to follow physician's orders and complete monitoring
and adjustment of warfarin (also called Coumadin, a high-risk medication used to prevent blood clots by
thinning the blood and has a significant risk for bleeding complications), for one of four residents sampled
for warfarin use (Resident 1), when Licensed Nurse (LN) A incorrectly revised Resident 1's physician's
order for a lab test for a prothrombin time and International Normalized Ratio (PT/INR, the laboratory
testing parameter utilized to monitor warfarin therapy. The PT is the number of seconds required for the
blood to clot, and the INR is the standardized ratio of the PT), and caused the order not to populate on to
Resident 1's Electronic Health Record (EHR).
Residents Affected - Few
This lapse in clinical oversight eliminated opportunities for timely intervention, which could have mitigated
the risk of bleeding complications and prevented Resident 1 from enduring serious clinical harm which
necessitated emergency treatments and a prolonged 12-day hospitalization. This had the potential to affect
all residents who take warfarin.
Findings:
A review of the facility's policy titled, Anticoagulant [blood thinners] -Clinical Protocol revised November
2018, indicated, a. Assess for any signs or symptoms related to adverse drug reactions due to the
medication alone or in combination with other medications. b. Assess for evidence or effects related to the
subtherapeutic [less than expected result] or greater than therapeutic drug level related to that particular
drug (for example, a resident with an above therapeutic level of an anticoagulation medication should be
assessed for bleeding). In addition, the nurse shall assess and document/report the following: a. Current
anticoagulation therapy (blood thinning), including drug and current dosage. b. Recent labs, including
therapeutic dose monitoring .
A review of National Library of Medicine (NIH, a nationally recognized professional resource for healthcare
providers), at ncbi.nlm.nih.gov, dated January 2024, indicated; Severe adverse effects of warfarin include
bleeding and significant hemorrhage (severe blood loss). Significant hemorrhage, examples of which
include intracranial (brain) hemorrhage, gastrointestinal (stomach) bleeding, hematemesis (vomiting blood),
intraocular (eye) bleeding, and hemarthrosis (bleeding in a joint), can occur at virtually any body site
.Patients should undergo a risk assessment, with appropriate adjustments to their treatment plan made
accordingly. Other adverse effects include nausea, vomiting, abdominal pain, bloating, flatulence (gas), and
an altered sense of taste .Monitoring: Consistent monitoring of INR levels is essential for all patients
receiving warfarin sodium therapy .Patients receiving treatment with warfarin should be closely monitored to
ensure the safety and efficacy [desired result] of the medication. Periodic blood testing is recommended to
assess the PT and INR .Routine assessment of INR is essential for patients receiving warfarin therapy. The
INR of a healthy patient not on
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
555316
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555316
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Copper Ridge Care Center
201 Hartnell Avenue
Redding, CA 96002
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Actual harm
Residents Affected - Few
anticoagulation therapy is approximately 1.0. Therefore, a patient with an INR of 2.0 or 3.0 requires 2 or 3
times longer for their blood to clot .Most patients receiving warfarin have an INR goal of 2 to 3 .Close INR
monitoring is strongly recommended for patients initiating warfarin therapy. This parameter requires more
frequent monitoring after beginning a warfarin regimen .More frequent monitoring is necessary for patients
with supratherapeutic or subtherapeutic INR to evaluate the safety and efficacy of treatment. Also, the
patient's INR requires assessment when initiating, discontinuing, or changing doses .Patients also require
close monitoring for signs and symptoms of active bleeding throughout their treatment. Close monitoring for
signs and symptoms of bleeding, such as dark, tarry stools, nosebleeds, and hematomas (bruises), is
necessary. Toxicity [poisonous]: Warfarin toxicity may be assessed by observing the signs and symptoms of
bleeding, as well as the determination of a supratherapeutic INR level. The risk of bleeding is significantly
greater for patients with an elevated INR, especially above 5.0. Nurses must recognize the signs of warfarin
toxicity so they can alert the attending or prescribing clinician.
Review of the facility's policy titled, Medication and Treatment Orders dated July 2016 indicated, 14. Orders
for anti-coagulants will be prescribed only with appropriate clinical and laboratory monitoring.
Review of admission records for Resident 1 indicated Resident 1 was admitted to the facility on [DATE],
with diagnoses that included fracture of right femur (broken hip).
A review of a Brief Interview for Mental Status screening (BIMS - an assessment tool used to screen and
identify resident memory, orientation, and judgement problems), reflected that Resident 1 scored 12 out of
15, which indicated that she had good memory and ability to make decisions.
A review of Resident 1's Physician's Orders, dated for the month of September 2024, was conducted and
reflected the following:
On 9/5/24, Resident 1's Attending Physician (AP), ordered warfarin 3.5 milligrams (mg, a unit of measure)
to be given once a day and to check her PT/INR by lab testing, on 9/6/24.
On 9/7/24, AP increased Resident 1's warfarin to 5 mg once a day and ordered to recheck her PT/INR on
9/9/24.
On 9/9/24, AP increased Resident 1's warfarin to 7.5 mg once a day and ordered to recheck her PT/INR on
9/12/24.
On 9/13/24, AP increased Resident 1's warfarin to 9 mg once a day and to recheck her PT/INR on 9/16/24.
A review of Resident 1's PT/INR lab testing results for the months of September and October 2024, was
conducted and reflected the following:
On 9/6/24, the PT was 17 and the INR 1.4.
On 9/9/24, the PT was 17.4 and the INR 1.4
On 9/12/24, the PT was 18.9 and the INR 1.6
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555316
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555316
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Copper Ridge Care Center
201 Hartnell Avenue
Redding, CA 96002
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
There was no evidence that the PT/INR lab test was done on 9/16/24.
Level of Harm - Actual harm
On 9/30/24, a PT/INR was done and the results were too high for the laboratory equipment to analyze.
Residents Affected - Few
On 10/1/24, a PT/INR was done and Resident 1's PT was greater than 120 and her INR was greater than
16 (a critical lab result).
A review of Resident 1's Progress Notes for September and October 2024, was conducted and
documentation reflected the following;
On 9/28/24, Resident 1 had blood in her urine.
On 9/29/24, at 5:55 AM, Resident 1 complained of nausea and vomiting, she didn ' t feel like eating, had
not eaten much the night before, had mostly drank water that day and had only soup for dinner the night
before. At 10:25 AM, Resident 1 complained of left abdomen pain, she had the urge to urinate and could
not. Resident 1 had not eaten much and had only eaten one yogurt and half of a banana for breakfast. At
6:10 PM, Resident 1 had blood in her urine and was having difficulty urinating and pain in her left side. At
8:15 PM, a urine sample was collected from Resident 1 for a urinalysis (UA, a test done on urine to check
for signs of infection), and the urine was bloody.
A review was conducted of Resident 1's Lab Results Report for the UA dated 9/29/24 at 10:06 PM, and
indicated, Unable to perform chemical analysis due to color interference caused by the grossly [extremely
obvious just by looking at it] bloody specimen received.
A review of Resident 1's Progress Notes dated 9/30/24, nursing documentation showed that at 8:51 AM,
Resident 1 reported nausea and vomiting. At 9:01 AM, an order was obtained for a PT/INR to be done
which was done at 12:53 PM. At 2:55 PM, lab called stated the PT/INR level was so high it could not be
read. At 3:48 PM, the Physician's Assistant (PA) was notified and ordered Vitamin K (a medication that
reverses the effects of too much warfarin and helps the blood clot), 1 Gram, hold warfarin for 3 days, and do
a PT/INR daily for 3 days. At 5:09 PM, another UA was collected from Resident 1 and sent to the lab and
the urine was noted by the nurse to be tinted red.
A review of Resident 1's Lab Results Report dated 10/1/24, indicated a PT of greater than 120 seconds (PT
greater than 27 is a critical value and indicates an increased risk of bleeding), and an INR of greater than
16 (INR greater than 5 is a critical value and indicates an increased risk of bleeding).
A review of Resident 1's Progress Notes dated 10/1/24, reflected at 11:43 AM the nurse received a phone
call with critical labs of an INR greater than 16. At 12:31 PM, a new order was obtained from the PA for
Vitamin K 2.5 milligrams (mg, a unit of measure) by mouth one time. At 11:07 PM, Resident 1 stated she
was nauseated and the Zofran (a medication for nausea), was not helping her.
A review of Resident 1's Progress Notes dated 10/2/24 reflected at 1:02 PM, a nurse documented that the
facility received a phone call from the lab reporting Resident 1's PT/INR was still critical with a PT greater
than 120 and INR greater than 16. At 2:23 PM, nursing documentation reflected that Resident 1 requested
to be sent to the hospital and was transferred to the hospital by ambulance at 2:25 PM.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555316
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555316
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Copper Ridge Care Center
201 Hartnell Avenue
Redding, CA 96002
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Actual harm
Residents Affected - Few
A review of Resident 1's, SNF/NF to Hospital Transfer Form dated 10/2/24 at 1:45 PM reflected that
Resident 1 was on warfarin and her last INR was done on 10/2/24 and was critical at greater than 16.
Under the GU/Urine [the urinary and bladder system] Evaluation the box blood in urine was checked.
A review of Resident 1's hospital emergency room [ER] documentation, dated 10/2/24, reflected that the
physician's preliminary concerns were that Resident 1 had a spontaneous retroperitoneal hematoma
(internal bleeding around the kidneys), the high INR, acute kidney injury (a condition in which the kidneys
suddenly can't filter waste from the blood), and possible sepsis (a life-threatening blood infection) related to
a urinary tract infection (UTI, an infection of any part of the urinary system) and low urine output. A
Computed Tomography scan (a CT scan is a medical imaging procedure that uses x-rays to make detailed
images of the body), of Resident 1's abdomen and pelvis was done and indicated fluid that was suspicious
for internal bleeding.
A review of Resident 1's hospital History and Physical dated 10/2/24, reflected that Resident 1's lab testing
at the ER showed a PT greater than 120 and an INR of greater than 12 (both critical). The physician
documented that Resident 1 had, warfarin coagulopathy (a bleeding complication due to too much warfarin
in the blood stream), which caused blood in her urine and internal bleeding around her kidneys and upper
ureters (thin tubes that connect the kidneys to the bladder). Resident 1 was given Kcentra (a medication
given for urgent reversal of warfarin overdose), and Vitamin K.
A review of Resident 1's, Hospital Record Progress Notes dated 10/2/24, reflected diagnoses of internal
bleeding around the kidneys, high INR, Acute Kidney Injury (AKI), metabolic acidosis (the buildup of acid in
the body due to kidney disease or kidney failure), and diabetes insipidus (a condition that causes the body
to make large amounts of urine and excessive thirst and causes the fluids in the body to be out of balance).
During an interview on 11/26/24 at 2:50 PM, with the Medical Director (MD), the MD stated that when the
warfarin dosage is being adjusted there should be PT/INR monitoring in about 2 days.
During an interview on 11/26/24 at 3:09 PM, with PA, the PA indicated Resident 1's PT/INR lab test, that
was ordered for 9/16/24, may have been missed due to the order being put in the wrong place in Resident
1's EHR. The PA indicated that her understanding was that there were two places lab orders could be within
a resident's EHR. The PA indicated the Attending Physician (AP) hand writes the orders directly on the lab
results report and faxes it back to the nurses. The nurses would then enter any new orders into the
residents EHR.
During an interview on 11/26/24 at 3:15 PM, with the Director of Nursing (DON), the DON stated that she
was not sure what caused the PT/INR to not populate on Resident 1's EHR, after LN A revised the order.
The DON confirmed that the order was not in Resident 1's EHR and the PT/INR was not done. The DON
indicated she caught this 14 days later, after Resident 1 began having active bleeding, it was an oversight.
During an interview on 12/5/24 at 2:51 PM, with the PA, the PA confirmed she saw Resident 1 on 9/25/24,
and had not recognized that the PT/INR, that was to be done on 9/16/24, was missed.
A review of Resident 1's Progress Notes dated 9/25/24, reflected that PA saw Resident 1 on 9/25/24 and
made a note that Resident 1 was taking warfarin, but had not addressed that the PT/INR that was ordered
by AP to be done on 9/16/24, had not been done.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555316
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555316
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Copper Ridge Care Center
201 Hartnell Avenue
Redding, CA 96002
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0760
Level of Harm - Actual harm
Residents Affected - Few
During an interview on 12/5/24 at 3:29 PM, with the DON, the DON stated that nurses enter physician's
orders into the EHR LAB flow sheet, and from there every night a nurse runs a report for lab tests that are
to be done for that day. The nurse then filled out lab requisition (request) form which indicated what lab
tests were to be done each day. The DON stated that if the physician's orders do not make it on to the LAB
flow sheet, the labs may not show up on the report thererfore, will not likely get done.
During an interview on 12/6/24 at 11:36 AM, with the MD, the MD stated that acute retroperitoneal
hemorrhage is very common complication when too much warfarin is taken and PT/INRs are too high. The
MD stated that after a review the PT/INR lab results, a physician would be expected to give orders to the
nurses that would include; when to get the next PT/INR, change or hold the warfarin dose, either verbally
(in person or on the phone), or by handwritten orders directly on the lab result sheet and faxed to the nurse.
The nurses would then enter the physician's order into the resident's EHR.
During an interview on 12/11/24 at 9:05 AM, with Resident 1, Resident 1 indicated that the nurses had not
listened to her when she told them she had been sick for days, so she asked to be sent to the hospital.
Resident 1 stated, I was bleeding from my mouth, nose, and vagina, and it was very much a nightmare and
I felt like I was dying.
During an interview on 12/12/24 at 1:12 PM, with LN A, LN A indicated that Resident 1's PT/INR lab testing
order that was to be done on 9/16/24, was on the wrong MAR. LN A indicated that there were MARs for
medications and different MARs for Lab testing. LN A indicated that her intention was to move the PT/INR
lab test order from the medication MAR to the lab MAR, and had not recognized that the order never made
it to the lab MAR. LN A indicated that she does not know how that happened.
During an interview on 12/12/24 at 3:59 PM, with the Assistant Director of Nursing (ADON), the ADON
confirmed that nursing staff received training on the facility's EHR system upon hire and and when any
changes to the system occur.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555316
If continuation sheet
Page 5 of 5
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
FAQ · About this visit
Common questions about this visit
What happened during the December 13, 2024 survey of Copper Ridge Care Center?
This was a inspection survey of Copper Ridge Care Center on December 13, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Copper Ridge Care Center on December 13, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure that residents are free from significant medication errors."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.