Inspection Reports for Copper Trace Family-first Senior Living
1250 W 146th St, Westfield, IN 46074, United States, IN, 46074
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 96
Capacity: 165
Deficiencies: 0
Apr 29, 2025
Visit Reason
This visit was conducted to investigate Nursing Home Complaints IN00457603 and IN00458337, as well as Residential Complaint IN00457711.
Findings
No deficiencies related to the allegations in complaints IN00457603, IN00458337, and IN00457711 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaints IN00457603, IN00458337, and IN00457711 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF beds: 22
Census SNF/NF beds: 74
Census Residential beds: 69
Total licensed capacity: 165
Census Medicare residents: 10
Census Medicaid residents: 50
Census Other payor residents: 36
Total census: 96
Inspection Report
Complaint Investigation
Census: 101
Capacity: 167
Deficiencies: 0
Apr 11, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456409.
Findings
No deficiencies related to the allegations in Complaint IN00456409 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00456409 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census by bed type: 25
Census by bed type: 76
Census by bed type: 66
Total licensed capacity: 167
Census by payor type: 14
Census by payor type: 52
Census by payor type: 35
Total census: 101
Inspection Report
Complaint Investigation
Census: 101
Capacity: 166
Deficiencies: 0
Mar 26, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00455893.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00455893; no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type - SNF: 24
Census Bed Type - SNF/NF: 77
Census Bed Type - Residential: 65
Total Capacity: 166
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 54
Census Payor Type - Other: 37
Total Census: 101
Inspection Report
Re-Inspection
Census: 97
Capacity: 104
Deficiencies: 0
Mar 12, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/03/25 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this PSR survey, Copper Trace Health & Living Community was found in compliance with Requirements for Participation Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety From Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is a one-story, fully sprinklered Type V (111) construction with a fire alarm system and smoke detection throughout.
Report Facts
Facility capacity: 104
Census: 97
Inspection Report
Complaint Investigation
Census: 98
Capacity: 159
Deficiencies: 0
Mar 4, 2025
Visit Reason
This visit was for the investigation of complaints IN00453179 and IN00453699.
Findings
No deficiencies related to the allegations were cited for either complaint. The facility was found to be in compliance with applicable regulations regarding the investigation of these complaints.
Complaint Details
Investigation of Complaints IN00453179 and IN00453699 found no deficiencies related to the allegations.
Report Facts
Census: 98
Total Capacity: 159
Census Bed Type - SNF: 26
Census Bed Type - SNF/NF: 72
Census Bed Type - Residential: 61
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 51
Census Payor Type - Other: 37
Inspection Report
Complaint Investigation
Census: 111
Capacity: 173
Deficiencies: 1
Feb 10, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450891 regarding allegations of inadequate supervision and accident prevention.
Findings
The facility failed to ensure a resident (Resident B) was transferred with a gait belt to prevent a fall, resulting in a left femoral neck fracture. The deficient practice was corrected prior to the survey with additional staff education and daily audits.
Complaint Details
Complaint IN00450891 was substantiated with federal/state deficiencies cited related to the allegations. The deficient practice involved failure to use a gait belt during transfer of Resident B, leading to a fall and fracture.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident was transferred with a gait belt to prevent a fall according to policy and procedure. | SS=D |
Report Facts
Census total residents: 111
Total licensed capacity: 173
Number of residents reviewed for accidents: 3
Date of fall incident: Jan 7, 2025
Date deficient practice corrected: Jan 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Named in fall incident and deficient practice for not using gait belt during transfer |
| RN 3 | Registered Nurse | Responded to fall incident and communicated with family |
| Director of Nursing | Director of Nursing | Provided interviews and oversaw corrective actions and audits |
Inspection Report
Life Safety
Census: 97
Capacity: 104
Deficiencies: 2
Feb 3, 2025
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with fire safety and life safety code requirements.
Findings
The facility was found not in compliance with life safety requirements due to deficiencies including failure to provide an approved method for returning kitchen cooking appliances to their approved location, and failure to maintain clear access and working space in electrical enclosures. Corrective actions and monitoring plans were outlined in the plan of correction.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide an approved method for returning cooking appliances to their approved location after maintenance or cleaning, violating NFPA 96 standards. | SS=E |
| Failed to ensure access and working space was maintained in enclosures housing electrical apparatus, with items blocking electrical panels. | SS=E |
Report Facts
Certified beds: 104
Census: 97
Residents potentially affected: 32
Staff potentially affected: 6
Visitors potentially affected: 2
Residents potentially affected: 18
Staff potentially affected: 4
Visitors potentially affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Pollick | Administrator | Signed plan of correction and referenced in correspondence |
| Brenda Buroker | Director, Long-Term Care Division, Indiana State Department of Health | Recipient of plan of correction letter |
| Maintenance Director | Interviewed regarding deficiencies related to kitchen appliance placement and electrical panel access |
Inspection Report
Annual Inspection
Census: 164
Deficiencies: 8
Jan 8, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey and the Investigation of Complaint IN00449971.
Findings
The facility was found deficient in multiple areas including medication administration errors, inaccurate catheter output documentation, oxygen equipment not turned on as ordered, medication cart security and labeling issues, incomplete dementia training for staff, missing resident service plan signatures, incomplete annual health statements, and untimely tuberculosis testing.
Complaint Details
Complaint IN00449971 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 5
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure blood pressure medication was held according to physician's order, antibiotic was signed off on eMAR, and elevated blood sugar was treated per sliding scale for 3 residents. | SS=D |
| Failed to ensure catheter urine output was accurately recorded and to document removal of urinary catheter with post-removal bladder scan measurements for 2 residents. | SS=D |
| Failed to ensure oxygen equipment was turned on and physician's orders were followed for 1 resident. | SS=D |
| Failed to ensure insulin was labeled with open date, medication carts were locked when unattended, and medications with different routes were stored separately for 2 medication carts. | SS=D |
| Failed to ensure staff completed required annual dementia training for 3 staff members. | SS=D |
| Failed to ensure service plans were signed and dated by residents or representatives for 5 of 7 residents reviewed. | — |
| Failed to ensure annual health statements were completed and signed by physician for 2 of 7 residents reviewed. | — |
| Failed to ensure two-step Mantoux tuberculosis test was completed timely for 1 of 7 residents reviewed. | — |
Report Facts
Survey dates: January 2, 3, 6, 7 and 8, 2025
Resident census: 164
Medication administration errors: 3
Residents reviewed for catheter output: 2
Residents reviewed for oxygen care: 3
Medication carts audited: 2
Staff reviewed for dementia training: 10
Residents reviewed for service plan signatures: 7
Residents reviewed for annual health statements: 7
Residents reviewed for tuberculosis testing: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 7 | Registered Nurse | Interviewed regarding medication administration and catheter output documentation |
| Director of Nursing | Director of Nursing | Interviewed regarding medication errors, catheter documentation, oxygen equipment, and service plan signatures |
| LPN 3 | Licensed Practical Nurse | Observed and interviewed regarding oxygen concentrator use |
| RN 9 | Registered Nurse | Interviewed regarding insulin pen labeling |
| RN 10 | Registered Nurse | Interviewed regarding medication cart locking |
| QMA 2 | Qualified Medication Aide | Interviewed regarding medication storage |
| Administrator | Facility Administrator | Interviewed regarding dementia training compliance |
Inspection Report
Renewal
Deficiencies: 0
Jan 8, 2025
Visit Reason
Paper compliance review to the Recertification and State Licensure survey completed on January 8, 2025.
Findings
Copper Trace Health & Living Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 2
Dec 6, 2024
Visit Reason
This visit was conducted for the investigation of three complaints (IN00443879, IN00444037, and IN00447334) and included a COVID-19 Focused Infection Control Survey.
Findings
The facility was found deficient in timely notification of a resident's responsible party/POA regarding a change in condition for one resident, and failed to protect a resident from misappropriation of medication for another resident. One complaint had no deficiencies cited. The misappropriation issue was corrected prior to the survey.
Complaint Details
Complaint IN00443879 had no deficiencies related to the allegation. Complaint IN00444037 had federal deficiencies related to timely notification of changes in condition. Complaint IN00447334 had federal deficiencies related to misappropriation of medication. The misappropriation deficiency was corrected on 11/22/24 prior to the survey.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure staff notified the responsible party/Power of Attorney of a resident's change in condition timely for 1 of 1 resident reviewed. | SS=D |
| Failed to protect a resident from misappropriation of medication for 1 of 3 residents reviewed. | SS=D |
Report Facts
Census: 56
SNF/NF beds: 42
SNF beds: 14
Medicare residents: 6
Medicaid residents: 32
Other payor residents: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Pollock | Administrator | Signed as Laboratory Director's or Provider/Supplier Representative |
| RN 3 | Interviewed regarding notification of family about resident's change in condition | |
| Director of Nursing | Director of Nursing | Interviewed regarding notification policies and misappropriation investigation |
| LPN 7 | Licensed Practical Nurse | Terminated nurse involved in misappropriation of medication |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 6, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00444037.
Findings
Copper Trace Health & Living Community was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00444037 completed on December 6, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 135
Deficiencies: 0
Jul 9, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00435883 and IN00436360 and included a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies related to the allegations in complaints IN00435883 and IN00436360 were cited. The facility was found to be in compliance with relevant regulations including 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00435883 and Complaint IN00436360 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type - SNF: 26
Census Bed Type - SNF/NF: 73
Census Bed Type - Residential: 36
Census Total: 135
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 31
Census Payor Type - Total: 99
Inspection Report
Original Licensing
Census: 98
Capacity: 104
Deficiencies: 0
Apr 1, 2024
Visit Reason
A Pre-Occupancy Survey was conducted by the Indiana Department of Health to assess compliance with Medicare/Medicaid participation requirements and Life Safety Code standards for a new addition and remodeling at Copper Trace Health & Living Community.
Findings
The facility was found in compliance with all applicable requirements including fire safety, sprinkler systems, and smoke detection. The one-story addition and remodeled areas met the 2012 NFPA 101 Life Safety Code and state regulations.
Report Facts
Facility capacity: 104
Census: 98
Addition size: 1553
Inspection Report
Complaint Investigation
Census: 97
Capacity: 134
Deficiencies: 0
Mar 15, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00424793, IN00428674, and IN00430436.
Findings
No deficiencies related to the allegations in complaints IN00424793, IN00428674, and IN00430436 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00424793, IN00428674, and IN00430436 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 26
Census Bed Type - SNF/NF: 71
Census Bed Type - Residential: 37
Total Capacity: 134
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 52
Census Payor Type - Other: 38
Total Census: 97
Inspection Report
Follow-Up
Census: 100
Capacity: 104
Deficiencies: 0
Jan 2, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/16/23 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Copper Trace Health & Living Community was found in compliance with Requirements for Participation Medicare/Medicaid, 42 CFR Subpart 483.90(a), Life Safety From Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinklered except for one detached storage building.
Report Facts
Facility capacity: 104
Census: 100
Inspection Report
Complaint Investigation
Census: 104
Capacity: 141
Deficiencies: 0
Dec 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00423585.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Investigation of Complaint IN00423585 found no deficiencies related to the allegations; the complaint was not substantiated.
Report Facts
Census Bed Type - SNF: 26
Census Bed Type - SNF/NF: 78
Census Bed Type - Residential: 37
Total Capacity: 141
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 58
Census Payor Type - Other: 35
Total Census: 104
Inspection Report
Complaint Investigation
Census: 100
Capacity: 137
Deficiencies: 0
Dec 4, 2023
Visit Reason
The visit was conducted to investigate Nursing Home Complaints IN00421860 and IN00421926, as well as Residential Complaint IN00422239.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaints IN00421860, IN00421926, and IN00422239 were investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 77
Census Bed Type - SNF: 23
Census Bed Type - Residential: 37
Total Capacity: 137
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 35
Total Census: 100
Inspection Report
Life Safety
Census: 104
Capacity: 104
Deficiencies: 1
Nov 16, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements. However, the facility was found not in compliance with Life Safety Code requirements due to failure to enforce the non-smoking policy, evidenced by cigarette butts near facility exits affecting staff safety.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to enforce non-smoking policies; smoking was evident near facility exits with cigarette butts found around door #10 and door #7. | SS=E |
Report Facts
Certified beds: 104
Census: 104
Cigarette butts: 30
Cigarette butts: 50
Staff potentially affected: 6
Monitoring duration: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Named in observation and exit conference acknowledging the smoking policy deficiency | |
| Executive Director | Named in observation and exit conference acknowledging the smoking policy deficiency |
Inspection Report
Recertification
Census: 100
Capacity: 136
Deficiencies: 3
Nov 3, 2023
Visit Reason
This visit was for a Recertification, State Licensure Survey and included the Investigation of Complaints IN00419473, IN00419599, IN00420240, and IN00420683.
Findings
The facility was found to have deficiencies related to infection control practices for catheter care, medication administration errors, and food storage labeling. Some complaints were substantiated with deficiencies cited, while others had no deficiencies related to allegations.
Complaint Details
Complaint IN00419599 and IN00420240 had no deficiencies related to the allegations. Complaint IN00420683 had deficiencies related to the allegations cited at F760.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure infection control practices were followed for catheter care for 2 of 3 residents reviewed. | SS=D |
| Failure to ensure medications were given as ordered for 1 of 3 residents reviewed, resulting in a medication error. | SS=D |
| Failure to properly label stored food under sanitary conditions related to unlabeled food. | SS=E |
Report Facts
Census Bed Type: 136
Census Payor Type: 100
Residents affected by catheter care deficiency: 2
Residents reviewed for medication errors: 3
Residents receiving food prepared in kitchen: 93
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Pollock | Administrator | Signed the report. |
| LPN 1 | Licensed Practical Nurse | Named in medication error finding. |
| QMA 4 | Qualified Medication Aide | Named in medication error finding. |
| LPN 4 | Licensed Practical Nurse | Provided information regarding catheter care education. |
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 3, 2023
Visit Reason
Paper compliance review of the Recertification and State Licensure Survey and Investigation of Complaint IN00420683.
Findings
Copper Trace Health & Living Community was found to be in compliance with 42CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the Recertification and State Licensure survey and Investigation of Complaint IN00420683.
Complaint Details
Investigation of Complaint IN00420683 was included in the review.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 16, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00412733 completed on July 24, 2023.
Findings
Copper Trace Health & Living Community was found to be in compliance with 42CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint.
Complaint Details
Investigation of Complaint IN00412733; paper compliance review found the facility in compliance.
Inspection Report
Complaint Investigation
Census: 104
Capacity: 139
Deficiencies: 1
Jul 21, 2023
Visit Reason
This visit was for the investigation of Complaint IN00412733 regarding allegations related to resident care and caregiver preferences at Copper Trace Health & Living Community.
Findings
The facility failed to ensure that a resident's and her representative's choice of caregiver was consistent with her plan of care, specifically regarding the preference for female caregivers. Resident B was discharged following concerns about a male caregiver providing care contrary to her care plan.
Complaint Details
Complaint IN00412733 was substantiated with federal/state deficiencies cited related to the allegations. Resident B's daughter reported concerns about a male caregiver providing care despite a preference for female caregivers. The resident was transferred to an alternate facility due to these concerns.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a resident and her representative's choice of caregiver was consistent with her plan of care for 1 of 3 residents reviewed for choices (Resident B). | SS=D |
Report Facts
Census: 104
Total Capacity: 139
Residents discharged: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Pollock | Administrator | Signed the report |
| Assistant Director of Nursing | Mentioned in relation to caregiver preference and interventions | |
| Director of Nursing/Designee | Responsible for auditing consistency of honoring caregiver preferences | |
| Unit Manager | Provided interview about caregiver restrictions for Resident B | |
| CNA 2 | Interviewed regarding care provided to Resident B | |
| LPN 1 | Interviewed regarding care provided to Resident B |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Jun 30, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00410514.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00410514 - No deficiencies related to the allegations are cited.
Inspection Report
Complaint Investigation
Census: 99
Capacity: 131
Deficiencies: 0
Apr 4, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00404293 and IN00404707.
Findings
No deficiencies related to the allegations in complaints IN00404293 and IN00404707 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00404293 and Complaint IN00404707 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type - SNF: 22
Census Bed Type - SNF/NF: 77
Census Bed Type - Residential: 32
Total Capacity: 131
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 59
Census Payor Type - Other: 32
Total Census: 99
Inspection Report
Complaint Investigation
Census: 100
Capacity: 135
Deficiencies: 0
Mar 6, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00402791.
Findings
No deficiencies related to the allegations of Complaint IN00402791 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00402791 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 24
Census Bed Type - SNF/NF: 76
Census Bed Type - Residential: 35
Total Capacity: 135
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 50
Census Payor Type - Other: 37
Current Census: 100
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 0
Feb 9, 2023
Visit Reason
This visit was conducted to investigate Complaints IN00393521 and IN00401248.
Findings
Both complaints were found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00393521 - Unsubstantiated due to lack of evidence. Complaint IN00401248 - Unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type - SNF/NF: 75
Census Bed Type - SNF: 23
Total Census: 98
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 57
Census Payor Type - Other: 31
Inspection Report
Deficiencies: 0
Nov 29, 2022
Visit Reason
The document reports on paper compliance for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey conducted on 10/24/22 and completed on 11/29/22 at Copper Trace Health & Living Community.
Findings
Copper Trace Health & Living Community was found in compliance with the Medicare/Medicaid Emergency Preparedness Requirements and Life Safety Code requirements, including 42 CFR Subpart 483.73 and 483.90(a), and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
Oct 26, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00392940 and IN00390281.
Findings
Both complaints were substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00392940 - Substantiated with no deficiencies cited. Complaint IN00390281 - Substantiated with no deficiencies cited.
Report Facts
Census Bed Type - SNF/NF: 74
Census Bed Type - SNF: 26
Census Total: 100
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 57
Census Payor Type - Other: 31
Inspection Report
Life Safety
Census: 98
Capacity: 104
Deficiencies: 3
Oct 24, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. Deficiencies included failure to document required four-hour supplemental load testing of the emergency generator within the last 36 months, failure to conduct quarterly fire drills at unexpected times on the second shift for 3 of 4 quarters, and failure to ensure annual inspection and testing of all fire door assemblies were completed and documented.
Severity Breakdown
SS=F: 2
SS=C: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to implement emergency power system inspection, testing, and maintenance requirements; specifically, missing documentation of four-hour supplemental load testing of the diesel fired emergency generator within the most recent 36 months. | SS=F |
| Failed to conduct quarterly fire drills at unexpected times under varying conditions on the second shift for 3 of 4 quarters. | SS=C |
| Failed to ensure annual inspection and testing of all fire door assemblies were completed and documented in accordance with NFPA 80. | SS=F |
Report Facts
Certified beds: 104
Census: 98
Deficiency count: 3
Emergency generator rating: 250
Fire drills missing at unexpected times: 3
Fire door locations inspected: 18
Fire door locations missing: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Pollock | Administrator | Named in relation to review of findings during exit conference |
| Maintenance Director | Named in relation to findings about emergency generator testing, fire drills, and fire door inspections | |
| Administrator in Training (AIT) | Participated in facility tour during observations of emergency generator and fire door locations |
Inspection Report
Annual Inspection
Census: 36
Capacity: 134
Deficiencies: 9
Sep 14, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, including a State Residential Licensure Survey conducted over September 7, 8, 9, 12, 13, and 14, 2022.
Findings
The facility was found deficient in multiple areas including accuracy of Minimum Data Set assessments, development of person-centered care plans, pressure ulcer prevention and treatment, fall prevention supervision, medication labeling and storage, semi-annual and self-administration medication evaluations, PRN medication administration authorization, and tuberculosis skin testing protocols.
Severity Breakdown
SS=D: 5
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure Minimum Data Set (MDS) assessment was coded correctly for resident discharge status. | SS=D |
| Failed to develop person-centered care plans for residents, with incomplete care plan documentation. | SS=D |
| Failed to monitor and prevent development of Stage III pressure ulcer for a resident. | SS=D |
| Failed to ensure adequate supervision to prevent falls for a resident with a history of falls. | SS=D |
| Failed to label medications with open dates and discard expired medications timely in medication refrigerators and carts. | SS=D |
| Failed to obtain semi-annual evaluations and self-administration medication evaluations for some residents. | — |
| Failed to ensure PRN medication administration by QMA was authorized by a licensed nurse prior to administration. | — |
| Failed to administer two-step Tuberculin skin tests upon admission for some residents. | — |
| Failed to administer annual Tuberculin skin test for a resident. | — |
Report Facts
Survey dates: 6
Census Bed Type - SNF/NF: 77
Census Bed Type - SNF: 21
Census Bed Type - Residential: 36
Total Capacity: 134
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 60
Census Payor Type - Other: 22
Total Census Payor: 98
Deficiencies cited: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding MDS assessment coding error, care plan development, pressure ulcer prevention, fall supervision, PRN medication authorization, and TB testing. |
| LPN 10 | Licensed Practical Nurse | Interviewed regarding medication labeling deficiencies in medication refrigerator. |
| LPN 11 | Licensed Practical Nurse | Interviewed regarding medication labeling deficiencies in medication cart. |
| Unit Manager | Unit Manager | Interviewed regarding medication labeling deficiencies in medication refrigerator. |
| Corporate Support Nurse | Corporate Support Nurse | Interviewed regarding medication labeling, PRN medication authorization, TB testing policies, and facility compliance. |
| Executive Director | Executive Director | Provided facility policies on care plans, wound management, drug storage, and TB testing. |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 14, 2022
Visit Reason
Paper compliance review of the Recertification and State Licensure Survey completed on September 14, 2022.
Findings
Copper Trace Health and Living Community was found to be in compliance with 42CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the Recertification and State Licensure survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 1, 2022
Visit Reason
The visit was a paper compliance review related to the Investigation of Complaint IN00386581 completed on August 9, 2022.
Findings
Copper Trace Health & Living Community was found to be in compliance with 42CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00386581 was completed with findings of compliance.
Inspection Report
Complaint Investigation
Census: 98
Capacity: 98
Deficiencies: 1
Aug 8, 2022
Visit Reason
This visit was for the investigation of Complaint IN00386581, which was substantiated with federal/state deficiencies cited.
Findings
The facility failed to obtain a treatment order, document in the medical record, and notify the physician of a non-pressure wound for 1 of 3 residents reviewed for quality of care (Resident B). The wound dressing was observed without a treatment order or documentation, and the physician was not initially notified.
Complaint Details
Complaint IN00386581 was substantiated. The deficiency relates to failure in quality of care regarding wound management for Resident B.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain a treatment order, document in the medical record, and notify the physician of a non-pressure wound for Resident B. | SS=D |
Report Facts
Census: 98
Total Capacity: 98
Medicare Census: 15
Medicaid Census: 60
Other Payor Census: 23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Interviewed regarding wound dressing and treatment order for Resident B |
| Director of Nursing | Director of Nursing | Provided interviews and information regarding wound management and facility policies |
| Nurse Practitioner 3 | Nurse Practitioner | Provided email correspondence regarding nursing wound care policy |
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