Copper Trace Health & Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Westfield, Indiana.
- Location
- 1250 W 146th Street, Westfield, Indiana 46074
- CMS Provider Number
- 155841
- Inspections on file
- 34
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Copper Trace Health & Living Community during CMS and state inspections, most recent first.
A resident with a recent right hip hemiarthroplasty and pre‑existing right hemiplegia and foot drop experienced persistent severe right leg and hip pain, inability to bear weight, and visible shortening and abnormal rotation of the operative leg. Her hydrocodone‑acetaminophen was changed from PRN to scheduled dosing, and therapy notes documented a one‑inch leg length discrepancy, ongoing pain with movement, limited ROM, and complaints of numbness. Family members repeatedly reported that the resident cried out in pain with movement and that her right leg and knee appeared deformed, and video showed her unable to bear weight on the right leg while therapists physically advanced it during gait training. Despite these findings and the facility policy requiring physician notification for significant changes in condition or treatment, there was no documentation that the orthopedic surgeon was notified of the medication change, leg length discrepancy, numbness, or continued severe pain and abnormal limb positioning prior to the resident’s follow‑up orthopedic visit, where a dislocated hip was identified.
A resident with severe cognitive impairment, multiple medical conditions, and significant care needs was discharged home alone without verified support or caregiver involvement. The facility did not assess the resident's ability to manage her prescribed diet, medications, or activities of daily living, nor did it provide discharge education to a responsible caregiver. The facility relied on unverified statements about a support network and did not assist with Medicaid applications or power of attorney, resulting in the resident being discharged to an unsafe environment.
A resident with severe cognitive impairment and multiple health needs was discharged home without adequate discharge instructions or documentation provided to the home health agency. The resident received discharge education alone, despite being unable to manage medications or daily needs independently, and the home health provider was not given essential information or notified of the urgency. The resident was later found at home with poor hygiene, nutrition, and no support, highlighting a breakdown in discharge planning and communication.
A resident with difficulty in walking and unsteadiness on feet fell during a transfer from bed to wheelchair because CNA 2 did not use a gait belt, contrary to facility policy. The resident lost balance due to bilateral lower extremity weakness, resulting in a left femoral neck fracture. The Director of Nursing and CNA 2 acknowledged the failure to use the gait belt, which was required by the facility's procedures.
The facility failed to follow physician orders for three residents, resulting in medication administration errors. A resident received blood pressure medication despite low readings, another did not receive a prescribed antibiotic before a dental visit, and a third had issues with blood sugar management, including unadministered insulin and undocumented low blood sugar incidents.
The facility failed to accurately document catheter urine output and removal for two residents. One resident's outputs were inconsistently recorded as small, medium, or large instead of in milliliters. For another resident, there was unclear documentation regarding catheter removal and missing bladder scan records. The DON acknowledged the documentation issues and the lack of proper communication among staff.
A resident with multiple health conditions experienced a significant weight gain of 5.56% in one month, but the facility failed to re-weigh the resident or notify the physician and RD as required by their policy. Interviews indicated that the initial weight might have been incorrect, yet no timely actions were taken to address the discrepancy.
A resident with COPD, pneumonia, and heart failure was not receiving prescribed oxygen therapy due to an unturned oxygen concentrator and later a malfunctioning device. The resident's oxygen saturation was critically low at 82%. Facility staff failed to adhere to policies for following physician orders and maintaining oxygen equipment.
The facility failed to properly label and store medications, and secure medication carts. An insulin pen lacked an open date, a medication cart was left unlocked and unattended, and an antifungal solution was stored with eye drops. Staff confirmed these practices were against policy.
A resident with COPD, emphysema, and vascular dementia experienced a significant change in condition, including a bad cough and low oxygen saturation. Although the Nurse Practitioner was notified, the family was not informed immediately, contrary to facility policy. The resident was later transferred to the hospital, and the family was notified of the transfer.
A resident's medication, Trulicity, was misappropriated by an LPN who had previously provided care to the resident. The facility was unaware of the missing medication until informed by an investigator from the Office of the Attorney General. The resident had diagnoses of type 2 diabetes, dementia, and anxiety disorder. The LPN was terminated prior to the discovery for unrelated reasons.
Failure to Notify Orthopedic Surgeon of Persistent Post‑Operative Pain and Abnormal Limb Findings
Penalty
Summary
The deficiency involves the facility’s failure to notify an orthopedic surgeon when a post‑operative resident’s pain regimen was changed, when her condition did not improve, and when she had ongoing complaints of significant pain and abnormal right leg findings. The resident had a recent right hip hemiarthroplasty and a history of right hemiplegia and right foot drop. Upon admission for rehabilitation, she was ordered hydrocodone‑acetaminophen 10/325 mg every four hours as needed for severe pain, which was changed the next day to a scheduled every‑four‑hours dose. There is no documentation that the orthopedic surgeon was notified of this change from PRN to routine dosing. Early therapy notes documented high pain levels (8–9/10) in the right lower extremity, and the nurse practitioner present at one assessment planned to review the pain regimen. Family members reported that from admission onward the resident cried out in severe pain (“Ouch, Ouch, Ouch”) whenever she was moved, did not want her right leg touched, and that her right knee appeared deformed and the right leg shorter than the left. Throughout the resident’s stay, therapy documentation showed slow progress, persistent pain, and functional limitations. Multiple PT and OT notes described the need for maximum assistance with sit‑to‑stand, transfers, and gait training, with the resident often unable to ambulate or bear weight effectively on the right leg. On one date, therapy staff measured a one‑inch discrepancy between the resident’s leg lengths, but there is no documentation that the orthopedic surgeon was contacted about this finding. Subsequent notes recorded increased pain in the right lower extremity with standing, limited active range of motion, and the resident’s report that her right lower leg felt numb; the unit manager was informed of the numbness, but there is no documentation that the orthopedic surgeon was notified. An OT note later indicated the resident was in constant pain and discomfort in the right hip area, and nursing was made aware, yet there is still no record of communication with the orthopedic surgeon prior to the already scheduled follow‑up visit. Family members repeatedly voiced concerns to nursing and therapy staff about the resident’s severe pain, shortened right leg, and abnormal positioning of the right knee and foot. One family member, who worked in an orthopedic office, reported that the resident could not bear weight on the right leg and that therapists were attempting to have her walk despite her crying out in pain. Video recordings from a therapy session showed the resident not bearing weight on the right leg, standing only on the left leg with the right knee flexed and foot off the floor, and a therapist physically lifting and advancing the right leg while the resident vocalized pain. At the follow‑up orthopedic appointment, imaging demonstrated a dislocated right hip, and the orthopedic nurse practitioner later stated there should be no limb length discrepancy after hip surgery and that the observed shortened, rotated limb and family description of a “mangled” knee were hallmark signs of dislocation. The facility’s own policy required notifying the attending or on‑call physician when there was a significant change in condition or a need to significantly alter treatment, yet the record contains no evidence that the orthopedic surgeon was contacted about the change in pain medication frequency, the leg length discrepancy, the numbness, or the persistent severe pain and abnormal limb positioning before the scheduled follow‑up visit.
Failure to Ensure Safe and Supported Discharge for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident was discharged to a location that met her needs and provided the necessary support and resources. The resident had multiple diagnoses, including severe cognitive impairment, dementia with psychotic and mood disturbances, memory deficits, speech and language deficits, dysphagia, pain, anxiety disorder, and difficulty walking. Clinical documentation indicated that the resident required a mechanically ground diet, supervision and assistance with medication management, and was not considered safe to use the stove. She also needed assistance with activities of daily living such as bathing, dressing, and mobility, and was noted to have poor nutritional status and significant recent weight loss. Despite these needs, the resident was discharged to live alone with no verified support system or caregivers. The facility did not document any assessment of the resident's ability to prepare her prescribed diet or safely manage her medications and activities of daily living. Discharge education and instructions were provided only to the resident, who had severe cognitive impairment, and not to any family member or caregiver. The facility relied on statements from the resident and her brother regarding the existence of a support network, but did not verify the availability, capacity, or willingness of any caregivers. There was no documentation of offers to assist with Medicaid applications or to help the brother obtain power of attorney, despite financial concerns being a barrier to alternative discharge options. After discharge, the resident was found to be unable to manage her medications, nutrition, or hygiene, and lacked any support at home. Home health assessment documented that she required 24-hour supervision, which was not available, and she was not eating or taking her medications. The resident was subsequently admitted to the hospital with further weight loss, confusion, and a new injury. The facility's discharge planning process did not include adequate assessment or documentation of the resident's needs, the capabilities of any support persons, or the provision of necessary education to those responsible for her care after discharge.
Failure to Provide Adequate Discharge Instructions and Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide specific discharge instructions and necessary documentation regarding a resident's cognitive status, medication administration, and food preparation needs to the home health provider at the time of discharge. The resident in question had multiple diagnoses, including dementia with psychotic and mood disturbance, memory deficit, speech and language deficits, dysphagia, and severe cognitive impairment. Despite these conditions, the discharge process did not include comprehensive communication of the resident's needs to the home health agency, nor did it ensure that the resident had adequate support or supervision at home. The clinical record and interviews revealed that the resident was discharged home alone, with no verified support network or caregiver present. Discharge education and instructions were provided only to the resident, despite her severe cognitive impairment and inability to manage her medications independently. The home health agency did not receive a complete discharge summary, medication list, or therapy notes, and was not notified of the urgency of the resident's needs. The resident was not assessed for her ability to manage medications or recall instructions, and there was no verification of food availability or environmental safety in her home. Upon the home health agency's initial visit several days after discharge, the resident was found to be confused, isolated, and unable to care for herself, with poor hygiene, nutrition, and mobility. She was not taking her medications and had no support network available. The lack of communication and coordination between the facility and the home health provider, as well as the failure to ensure the resident's needs were met upon discharge, directly contributed to the deficiency cited in the report.
Failure to Use Gait Belt Results in Resident Fall
Penalty
Summary
The facility failed to ensure that a resident was transferred with a gait belt, as per the policy and procedure, which resulted in an accident. CNA 2 was assisting Resident B, who had diagnoses including pain, difficulty in walking, and unsteadiness on feet, to transfer from bed to a wheelchair. During the transfer, Resident B lost her balance due to bilateral lower extremity weakness and fell, resulting in a left femoral neck fracture. It was noted that CNA 2 did not use a gait belt during the transfer, which was against the facility's policy. The incident was documented in several nursing progress notes and a facility document titled 'The Fall Huddle.' The Director of Nursing and CNA 2 both acknowledged that a gait belt should have been used during the transfer. The root cause of the fall was identified as the resident's overall decline and loss of balance. The facility's policy on using a gait belt to assist with ambulation was not followed, leading to the resident's fall and subsequent injury.
Medication Administration and Treatment Deficiencies
Penalty
Summary
The facility failed to adhere to physician orders for three residents, leading to deficiencies in medication administration and treatment. Resident 256, diagnosed with conditions including hypertension and memory deficit, was prescribed lisinopril with instructions to hold the medication if systolic blood pressure was below 140. However, the medication was administered on multiple occasions despite blood pressure readings below the hold parameter, and there was no documentation of physician notification regarding these deviations. Resident 4, with a history of cardiovascular and anxiety disorders, was prescribed azithromycin to be administered before dental appointments. The medication was not signed off on the Medication Administration Record (MAR) for a dental visit, and there was no evidence to confirm that the antibiotic was given as ordered. Interviews with facility staff revealed a lack of documentation and verification of medication administration. Resident 52, who has diabetes and dementia, experienced issues with blood sugar management. A high blood sugar level was recorded, but the sliding scale insulin was not administered as ordered, and there was no documentation of additional physician orders for treatment. Additionally, a low blood sugar incident was not properly documented or reported to the physician, indicating a failure to follow the facility's protocol for managing abnormal blood sugar levels.
Inadequate Documentation of Catheter Care
Penalty
Summary
The facility failed to ensure accurate documentation of catheter urine output and the removal of urinary catheters for two residents. For Resident 258, the clinical record indicated a physician's order to empty the Foley catheter every shift and document the output. However, the documentation was inconsistent, with outputs recorded as small, medium, or large instead of exact measurements in milliliters. This inconsistency was acknowledged by RN 7 and the Director of Nursing (DON), who confirmed that the actual amounts should have been charted. For Resident 259, the facility did not accurately document the Foley catheter output or the removal of the catheter. The clinical record showed a physician's order to record the output every shift and to remove the catheter with subsequent bladder scans. However, there were missing records of catheter output and bladder scans, and the documentation regarding the catheter's removal was unclear and inconsistent. The DON noted the absence of a progress note for the catheter removal and the confusion in the records about the catheter's presence, indicating a lack of proper documentation and communication among staff.
Failure to Review Significant Weight Gain
Penalty
Summary
The facility failed to ensure a significant weight gain was reviewed for a resident who experienced a 5.56% weight increase in one month. The resident, who had a history of thyroid disorder, muscle weakness, anorexia, bipolar disorder, and paranoid schizophrenia, was on a regular diet with pureed consistency and received dietary supplements as per physician's orders. Despite the significant weight gain from 140.30 pounds to 148.10 pounds between September and October, the facility did not re-weigh the resident or notify the physician and Registered Dietician (RD) as required by their Weight Management Policy. Interviews revealed that the facility staff believed the initial weight in September might have been incorrect, but no re-weighing was conducted until October. The Clinical Support Nurse admitted that the RD was only reviewing the resident's information at the time of the survey. Additionally, the facility's policy required significant weight changes to be reviewed by the Interdisciplinary Team (IDT) by the 10th day of each month, with documentation of family, physician, and RD notifications in the medical record, which was not adhered to in this case.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for a resident, identified as Resident 66, who was observed sitting in a recliner with oxygen tubing but not receiving supplemental oxygen because the oxygen concentrator was not turned on. The resident, who has a medical history of chronic obstructive pulmonary disease (COPD), pneumonia, and heart failure, was experiencing difficulty breathing. When a Licensed Practical Nurse (LPN) entered the room and turned on the concentrator, the resident's oxygen saturation was measured at 82%, indicating a low level of oxygen in the blood. Later, the oxygen concentrator was found to be malfunctioning, emitting a high-pitched noise, and not providing the required oxygen flow. The Minimum Data Set (MDS) Coordinator assisted in replacing the faulty concentrator and adjusting the oxygen flow to the physician-ordered 3 liters per minute. The facility's policies on following physician orders and oxygen administration were not adhered to, as the resident was not receiving the prescribed continuous oxygen therapy, and the equipment was not properly monitored or maintained.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as securing medication carts, leading to several deficiencies. During an observation, a Lantus insulin pen for a resident was found without an open date, despite being previously used. This was confirmed by an RN who acknowledged the absence of the open date. Additionally, a medication cart on the Ambassador Square unit was found unlocked and unattended, with the nurse positioned at the opposite end of the unit, unable to observe the cart. This was confirmed by another RN who stated that the cart should have been locked before leaving it unattended. Furthermore, an antifungal nail solution was improperly stored with eye drops in a medication cart on the Heritage Court unit. A QMA confirmed that these items should not have been stored together. The facility's current medication labeling policy did not address the requirement for open dates on medications, and the drug storage policy indicated that medication carts should be locked or attended by authorized personnel. These observations and interviews highlight the facility's failure to adhere to proper medication management protocols.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to promptly notify the responsible party or Power of Attorney (POA) of a resident's change in condition. Resident B, who had diagnoses including chronic obstructive pulmonary disease (COPD), emphysema, and vascular dementia, experienced a significant change in condition. On the specified date, the resident exhibited a bad cough, difficulty clearing her throat, and an oxygen saturation level of 82 percent. Although the resident initially refused supplemental oxygen, she eventually accepted it. The resident required assistance with feeding and toileting and was not waking up. The Nurse Practitioner was informed of the change in condition, but there was no documentation indicating that the family was notified at that time. Later that day, a nursing progress note indicated that the family was informed of new orders, and another note documented that the resident was transferred to the hospital, with the family being notified of the transfer. During interviews, the Director of Nursing acknowledged that the family should have been contacted immediately regarding the change in condition. RN 3, who was involved in the situation, stated that the facility's policy was to notify both the physician/nurse practitioner and the responsible party/POA of any changes. The facility's policy, last revised in April 2007, mandates prompt notification of the resident, attending physician, and representative of changes in the resident's condition or status.
Misappropriation of Resident's Medication by LPN
Penalty
Summary
The facility failed to protect a resident from the misappropriation of medication, specifically Trulicity, which is used for diabetes management. This incident involved a Licensed Practical Nurse (LPN) who had previously provided care to the resident and was later found to have the resident's medication at her home. The facility was unaware of the missing medication until an investigator from the Office of the Attorney General informed them during an investigation prompted by a domestic dispute involving the LPN. The medication was identified as belonging to the resident through its prescription number. The resident involved, referred to as Resident C, had a clinical record indicating diagnoses of type 2 diabetes, dementia, and anxiety disorder. The facility's policy on abuse, neglect, and misappropriation was in place, but the incident still occurred. The LPN had been terminated from the facility prior to the discovery of the misappropriation for unrelated reasons, specifically for failing to report to a scheduled shift without notice.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
Trusted data from CMS and state health departments
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