Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
Incomplete AIMS Monitoring and Missing Weight Documentation: The facility failed to complete required AIMS assessments for a resident receiving olanzapine, with a lapse of more than 6 months between assessments despite policy calling for AIMS monitoring every 6 months. The facility also failed to obtain and document ordered weights for another resident, with missing or invalid monthly and weekly weights in the MAR/vitals tab, no documented reweight after a significant gain, no readmission weight, and no record of ordered weekly weights after significant weight changes.
Missing consent and safety assessments for bed rails: Two residents had bilateral grab bars/transfer bars in bed, but the record lacked required consent and safety assessment documentation. One resident had severe cognitive impairment, dementia, and cerebrovascular deficits, while the other had dementia, repeated falls, and Parkinson's disease with dyskinesia. Staff stated the facility did not have consents or assessments for the enabler bars, and that the beds arrived with the rails already attached.
A resident with Parkinson’s disease missed multiple scheduled doses of Rytary because the medication was unavailable, and the record showed the pharmacy was not notified until after several doses had already been missed. Nursing notes documented a STAT pharmacy call only after the missed doses accumulated, while the ADON and DON gave differing accounts about medication supply and delivery. The contracted pharmacist stated the original supply had been sent and that no refill requests were received from the facility beyond the initial order.
Medication Labeling and Storage Deficiencies: The facility failed to ensure meds were properly labeled, dated, and stored in 2 of 4 med carts reviewed. An LPN found an opened but undated Novolog insulin pen, an opened Tramadol bubble pack, and an Advair inhaler and Fluticasone nasal spray that were not labeled with a resident name or open date; the LPN also noted an insulin pen should have had an open date and that insulin pens are only good for 30 days.
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.
Incomplete AIMS Monitoring and Missing Weight Documentation
Penalty
Summary
The facility failed to complete required assessments according to policy for a resident receiving olanzapine. Resident 42 had diagnoses including major depressive disorder, anxiety disorder, and dementia, and a physician order dated 5/10/25 directed olanzapine 10 mg daily. The care plan called for routine AIMS observation, and an AIMS assessment was completed on 5/9/25, but the next AIMS assessment was not completed until 12/16/25, leaving a greater than 6-month lapse between assessments. The DON stated staff should complete AIMS assessments quarterly, while Clinical Support 1 stated they should be completed every 6 months. The facility policy stated AIMS monitoring would be done every 6 months after the initial AIMS assessment. The facility also failed to ensure weights were obtained and documented in the clinical record for Resident 6. The resident had diagnoses including Parkinson's disease, fracture of the right femur, and weakness. A physician order dated 5/1/25 directed monthly weights, and the record also included periods of weekly weight monitoring after changes in weight status. However, the record showed missing or invalid weights on multiple dates in the MAR and vitals tab, including monthly weights that were not documented or were marked invalid. There was no documentation in the MAR to show weekly weights were obtained from 7/1/25 to 7/16/25 as ordered. Additional record review showed a Registered Dietitian note on 6/4/25 requested a reweight due to a 35-pound weight gain in 27 days, but the reweight was not located in the electronic medical record. After the resident was discharged to the hospital on 6/23/25 and later readmitted, a readmission weight was also not located. A later RD note on 9/10/25 requested weekly weights for four weeks due to significant weight loss, and a progress note on 9/17/25 documented a 12-pound weight loss in 27 days with weekly weights as the intervention, but the physician order or documentation of the weekly weights for that four-week period was not found in the record. The facility policies stated that resident weights would be measured on admission and weekly for four weeks thereafter and recorded in the medical record.
Missing consent and safety assessments for bed rails
Penalty
Summary
The facility failed to ensure consents were obtained and that assessments for the safe use of enabler bars/transfer bars were completed for 2 of 7 residents reviewed for accident hazards. Resident 115 had bilateral grab bars observed in bed on multiple occasions. The record showed diagnoses including difficulty walking, memory deficit following cerebrovascular disease, mild dementia with mood disturbance, speech and language deficits following cerebrovascular disease, and Alzheimer's disease. A care plan dated 11/4/25 indicated transfer bars were used in bed to aid transfers and bed mobility, and a physician's order dated 12/8/25 indicated the resident used mobility devices. A speech language pathology report dated 12/9/25 described severe cognitive impairment. However, the care plan meeting summary dated 12/12/25 did not include discussion of the transfer assist rails with the resident's representative, and the bed rail assessment completed after the start of the survey did not document the type of rail used, risks and benefits, alternatives, consent, or a safety assessment of the resident's ability to use the assist rails. The record also did not include bed rail consent from the resident's representative or the required safety assessment, although a progress note later documented verbal consent from the resident and discussion of risks and benefits. Resident 11 was observed with bilateral grab bars attached to the bed frame that could not be lowered. The resident's diagnoses included dementia, repeated falls, and Parkinson's disease with dyskinesia. A care plan dated 3/25/25 stated the resident was unable to independently perform ADLs and included an intervention to use transfer bars while in bed to aid transfers and bed mobility. At the time of record review, the electronic health record did not include a bed rail assessment or consent for bed rail use. Staff stated the facility would not have consents or assessments for enabler bars or transfer bars, and later explained the beds were delivered with the rails already attached and consents and assessments were not done.
Medication Not Available for Ordered Parkinson’s Treatment
Penalty
Summary
The facility failed to ensure medication was available and administered as ordered for a resident with Parkinson's disease, difficulty walking, unsteadiness on feet, orthostatic hypotension, and memory deficit. The resident had a physician's order for Rytary 61.25-245 mg, two capsules three times daily, and the record showed the medication was not given because it was unavailable on multiple scheduled doses beginning with the morning, midday, and evening doses on 12/14/25 and continuing through the morning dose on 12/16/25. The resident's record also showed he was admitted for rehabilitation after a fall related to Parkinson's disease with dyskinesia and required assistance with activities of daily living, including bed mobility, transfers, toileting, and eating. The medical record did not show the pharmacy was notified of the need for the Rytary until after the sixth missed dose. Nursing documentation showed a call to the pharmacy for a STAT order late on 12/15/25, and later notes indicated the resident reported dizziness and did not feel well, with the ADON notified that the resident did not have his Rytary. During interviews, the ADON stated she was unaware the resident had missed several doses and found 26 tablets in a box labeled as delivered on 12/7/25, while the DON stated the pharmacy knew of the need for the medication but had refused weekend deliveries due to weather. The contracted pharmacist stated the pharmacy had sent a 15-day supply on 12/7/25, had made deliveries every day in December, and had not received any refill requests from the facility beyond the original order.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were labeled and dated and that insulin was removed and discarded after 28 days in 2 of 4 medication carts reviewed. In Heritage Cart 1, an observation with an LPN found one Novolog insulin pen that had been opened but not dated and still contained 200 of 250 units, one Basaglar insulin pen that had been opened and dated, and a bubble pack of Tramadol 50 mg with open packaging at the number two dose. During the interview, the LPN stated the Novolog insulin should have had an open date, the Basaglar insulin pen was only good for 30 days, and the Norco pill should have been removed and discarded. In Ambassador Cart 1, an observation with an LPN found an Advair inhaler stored in the drawer rather than in a box and not labeled with a resident's name or an open date; the metal canister inside the plastic was also not labeled with a resident's name or open date. A Fluticasone nasal spray bottle was also found open, outside of its box, and without an open date or resident's name on the bottle. During the interview, the LPN stated the medications should have had a resident's name and dates on them. The facility policy titled DRUG STORAGE stated that expired, damaged, and/or contaminated medications are removed from resident care areas and stored separately from medications available for administration, and that insulin injectable vials or pens must be discarded after 28 days.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Westfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Retreat At The Stratford, The | 1.8 mi | ★★★★★ | 6 | 0 |
| Majestic Care Of Carmel | 2.9 mi | ★★★★★ | 0 | 0 |
| Wellbrooke Of Carmel | 3.4 mi | ★★★★★ | 10 | 0 |
| Barrington Of Carmel, The | 4.1 mi | ★★★★★ | 0 | 0 |
| Restoracy Of Carmel | 4.6 mi | ★★★★★ | 8 | 0 |
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