Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Cloverleaf Of Knightsville during CMS and state inspections, most recent first.
Untrained RN and LPN staff administered a resident’s peritoneal dialysis despite an order for nightly treatment and a facility policy requiring the procedure to be performed only by nurses specifically trained in PD procedures, complications, and infection control. The contracted dialysis center stated staff had to be trained for each specific resident, but the facility could not provide documentation that the staff who charted the treatments had been trained for this resident.
Dementia Care Information Not Communicated to Direct Care Staff: The facility failed to ensure person-centered dementia care needs were communicated in writing to direct care staff for two residents. One resident had Alzheimer's disease with severe cognitive impairment, and another resident was severely cognitively impaired and dependent on staff for all daily care needs. Interviews showed CNAs and an RN did not know where to find the residents' person-centered information, and staff relied on word of mouth or report. The records contained activity evaluations and limited care plan information, but the specific dementia interventions and resident preferences were not consistently documented for staff use.
Clean mopheads and cleaning linens were observed stored in a soiled laundry room next to the washer and beside chemicals, with the IP nurse and DON acknowledging the placement. In addition, an RN administered insulin without gloves and did not perform hand hygiene during medication passes for two residents, despite staff and DON statements that gloves and hand hygiene were required.
The facility failed to address two residents with dignity during meal service. A CNA called a resident "Honey" despite her care plan indicating a preference for her first name. Another resident was assisted while the CNA stood, contrary to policy, and was addressed as "Honey" and "Sweet girl" without care plan indication. Both residents had severe cognitive impairments.
A facility failed to monitor a resident's weight as ordered, despite the resident having chronic kidney disease stage 3 and prediabetes. The resident's weight was not documented on specified dates, and there was no record of refusal. The initial weight was not recorded in the electronic health record at admission, and subsequent weights were inconsistently documented. The DON confirmed the lack of documentation, and the facility's policy on weight assessment was not followed.
A resident's indwelling urinary catheter, drainage bag, and tubing were not maintained properly, as they were observed in contact with the floor on multiple occasions. The resident, who had severe medical conditions and cognitive deficits, was receiving hospice services. The facility's policy required that catheter tubing and drainage bags be kept off the floor, but this was not followed.
A resident with end-stage renal disease reported that staff did not check her dialysis access site after treatments, leading to an incident where the site bled and soaked through the bandage. Observations confirmed the lack of monitoring, and the care plan did not include specific instructions for access site observation. Despite physician orders to check for bruit and thrill and assess vitals post-dialysis, these were not consistently followed, as confirmed by staff interviews.
A facility failed to properly monitor and document a resident's behaviors, despite physician's orders and care plans indicating the need for such monitoring due to multiple diagnoses, including anxiety and depression. The lack of documentation in the Treatment Administration Records (TAR) and progress notes over several months was attributed to issues with the documentation system and inadequate nurse education. The behavior committee's recommendations against medication dose reductions were based on verbal reports rather than documented evidence.
A facility failed to maintain a medication error rate below 5%, with errors observed in the administration of medications to three residents. RNs crushed medications that should not be crushed and failed to prime an insulin pen, violating facility guidelines. Additionally, privacy was not provided during insulin administration.
The facility failed to label insulin pens with the date they were opened for three residents, as observed during a survey. Staff interviews confirmed the requirement to date insulin pens upon opening, but this was not adhered to, resulting in a deficiency. The residents involved had Type 2 diabetes, and the facility's policy requires dating multidose containers, which was not followed.
A resident with end-stage renal disease and diabetes repeatedly requested not to be served vegetables, but the facility failed to document and honor this preference. Despite staff interviews indicating awareness of the resident's dislike for vegetables, the dietary tray slip did not reflect this, leading to continued service of unwanted food.
The facility failed to properly store and dispose of food, as observed during a kitchen inspection. Expired corn and wilted lettuce were found in the refrigerator, and cucumbers were not labeled with a date. A staff member confirmed that food should be labeled and discarded after three days if opened, but these items were not handled accordingly. Facility policies require food to be labeled, dated, and discarded if over 72 hours old or without identification.
A resident with a history of recurrent UTIs and VRE was on long-term antibiotic therapy without proper physician assessment or documentation of education to the responsible party. The facility did not conduct additional urinalysis or cultures after admission, and the antibiotic stewardship policy requiring treatment duration was not followed.
Untrained staff administered peritoneal dialysis
Penalty
Summary
Safe, appropriate peritoneal dialysis services were not provided for a resident with end stage renal disease and dependence on renal dialysis. The resident’s physician ordered peritoneal dialysis with two 6-liter bags over 12 hours per machine, starting at bedtime and removing it when completed daily. The care plan identified the resident as at risk for complications with dialysis treatment and included completing peritoneal dialysis daily, giving medications as ordered, observing for pain at the site, and weighing the resident as ordered. The resident was cognitively intact and was receiving dialysis during the review period. The MAR showed that RN 15, RN 16, and LPN 17 documented multiple administrations of peritoneal dialysis for the resident from admission through February 2026. However, the record lacked in-service documentation showing that these staff members had been trained by the contracted dialysis center to administer peritoneal dialysis for this specific resident. The contracted dialysis center administrator stated that only trained and qualified staff were to administer peritoneal dialysis in the facility and that staff had to be trained for each specific resident admitted on peritoneal dialysis. During interview, the DON stated the dialysis center usually provided annual training at the facility and that staff called the contracted dialysis center when a new resident on dialysis was admitted. She was unable to explain why RN 15, RN 16, and LPN 17 had not been trained and could not provide documentation that they had been trained to administer peritoneal dialysis for this resident. The facility’s policy stated that the procedure must be performed by a nurse specifically trained in peritoneal dialysis procedures, complications, and infection control for dialysis.
Dementia Care Information Not Communicated to Direct Care Staff
Penalty
Summary
The facility failed to ensure that person-centered, specific care needs for residents with dementia were communicated to staff for 2 of 5 residents reviewed. Resident 45 had diagnoses including Alzheimer's disease with late onset and dementia with mood disturbance, and a quarterly MDS dated 1/28/26 indicated severe cognitive deficit. The care plan, dated 5/31/25 and revised on 1/16/26, noted the resident liked to reminisce using photos of family and friends, but it lacked further documentation of person-centered interventions. An activity evaluation dated 5/19/25 contained personal information about the resident's past, favorite things, and preferences. During interviews, the DON stated the Activity Director had completed the personal information at admission and would update it periodically, and that a plan was being worked on to inform floor staff of person-centered information for each resident, but it had not yet been put in place. CNA 8 stated she did not know where to immediately access the person-centered information and would likely ask a nurse. CNA 9 stated he learned person-centered information from the resident or by word of mouth and did not know where to find it. RN 6 stated the information would be somewhere in the EMR but was unsure where. The DON later provided an assignment sheet for Resident 45 that included person-centered information and stated it had just been updated on 2/11/26 to include some residents' person-centered information. Resident 8's record showed diagnoses including Parkinson's disease, diabetes, Alzheimer's disease, and HTN, and a quarterly MDS indicated the resident was severely cognitively impaired and dependent on staff for all daily care needs. The record lacked evidence of a specific care plan for dementia care and interventions. An activity evaluation dated 11/10/25 listed likes, dislikes, personal preferences, and alternate activities to reduce anxiety, but the Activity Director stated this information was not written down for staff and was being added to the assignment sheet and care plans. CNA 4 stated staff received information in report and recorded it on CNA report sheets, but there was nothing written for them to review for interventions. The DON stated staff had been educated to review the Kardex for guidance on interventions for behaviors, and the facility's Dementia Clinical Protocol stated resident needs would be communicated to direct care staff through written documentation.
Infection Control Lapses in Laundry Storage and Medication Administration
Penalty
Summary
The facility failed to maintain separation between clean and soiled cleaning mops and cleaning linens in the laundry area. During observation with the Infection Prevention nurse and the DON, clean mopheads and cleaning linens were seen stored on a shelf in the soiled laundry room next to the washing machine, and additional cleaning linen items were stored on top of a plastic crate containing cans of chemicals beside the washer. The IP nurse stated she had not noticed the clean linens were within the soiled laundry area, and the DON stated the cleaning linens had always been stored there. The facility also failed to ensure proper infection control practices during medication administration for two residents. An RN administered insulin to one resident without wearing gloves, then handed the resident oral medications and a fortified nutrition shake without performing hand hygiene before or after leaving the room. The same RN later administered oral medications to another resident and did not perform hand hygiene before or after the medication pass. Staff interviews indicated gloves should be worn for insulin administration and hand hygiene should be performed between residents during medication administration, and the DON confirmed those expectations.
Failure to Address Residents with Dignity During Meal Service
Penalty
Summary
The facility failed to ensure residents were addressed in a dignified manner during meal service, as observed in two separate dining incidents involving two residents. During a lunch meal observation, a CNA addressed Resident 56 as "Honey" from across the table, despite the resident's care plan indicating a preference to be called by her first name. Resident 56, who has severe cognitive impairment and a history of dementia and cerebral infarction, was independent with eating according to her MDS assessment. The care plan did not include a preference for being called "Honey." In another incident, the same CNA assisted Resident 31 with her meal while standing, which is against the facility's policy that requires staff to sit while assisting residents. The CNA also addressed Resident 31 as "Honey" and "Sweet girl," without any indication in the care plan that the resident preferred these terms. Resident 31, who has severe cognitive impairment and requires maximum assistance with eating, was diagnosed with unspecified dementia and complex partial seizures. The Director of Nursing confirmed that staff should not stand while assisting residents and should address them by their preferred names.
Failure to Monitor Resident's Weight as Ordered
Penalty
Summary
The facility failed to monitor a resident's weight as ordered, which was identified during an interview and record review. Resident 59, who has chronic kidney disease stage 3, prediabetes, and a history of repeated falls, was supposed to have his weight monitored daily for three days and then weekly for four weeks as per a physician's order. However, the records showed that the resident's weight was not documented on the specified dates, and there was no record of the resident refusing to have his weight taken. The initial weight was not recorded in the electronic health record at the time of admission, and subsequent weights were inconsistently documented. The Director of Nursing confirmed the lack of documentation for the daily weights as per the physician's order. A paper report sheet indicated a weight of 198.7 pounds for the resident, which was not entered into the electronic health record until a later date. The facility's policy on weight assessment and intervention requires that weights be measured on admission and recorded in the medical record, with any resident refusals documented. This policy was not adhered to, leading to the deficiency in monitoring the resident's weight as ordered.
Failure to Maintain Catheter Hygiene
Penalty
Summary
The facility failed to maintain a resident's indwelling urinary catheter, drainage bag, and tubing in a manner that prevented contact with the floor. During multiple observations, the resident's catheter bag was seen in contact with the floor while the resident was in bed, which was in a low position. Additionally, the catheter's tubing was observed resting on the electrical cord of the resident's oxygen concentrator, which was also in contact with the floor. These observations occurred on different occasions, indicating a consistent issue with the catheter's maintenance. The resident involved had significant medical conditions, including stage 3 chronic kidney disease, a stage 4 pressure ulcer in the sacral region, and muscle wasting and atrophy. The resident also had a severe cognitive deficit and was receiving hospice services. The care plan for the resident included the use of a Foley catheter due to wounds, but it lacked documentation on monitoring the catheter bag or tubing to prevent floor contact. The facility's policy on catheter care, which was provided by the Administrator, clearly stated that catheter tubing and drainage bags should be kept off the floor, yet this was not adhered to in practice.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to properly assess a resident's condition for complications before and after hemodialysis treatments. Resident 49, who has end-stage renal disease and requires dialysis, reported that staff did not check her vascular access site after returning from dialysis sessions. On one occasion, the access site bled and soaked through the bandage, which the resident had to change herself using supplies in her room. Observations confirmed that the dressing on the resident's access site was not checked for bleeding after her return from dialysis. The medical record review revealed that the care plan for Resident 49 lacked specific instructions for monitoring the access site for bleeding, swelling, or abnormalities. Although there was a physician order to check the access site for bruit and thrill daily, and to assess vital signs after dialysis, these were not consistently followed. Interviews with staff, including an LPN and the DON, indicated a lack of adherence to the required checks and documentation. The facility's policy on dialysis care, which mandates monitoring the shunt site and notifying a physician of any issues, was not adequately implemented.
Failure in Behavior Monitoring and Documentation
Penalty
Summary
The facility failed to ensure proper behavior monitoring for a resident who was reviewed for unnecessary medications. The resident had multiple diagnoses, including alcoholic cirrhosis of the liver, visual hallucinations, anxiety disorder, and major depressive disorder. Despite having physician's orders to monitor behaviors such as depression, tearfulness, insomnia, and visual hallucinations every shift, the facility's records lacked documentation of any behavioral symptoms for several months. The resident's care plans indicated a risk for ineffective coping and emotional and physical distress, with interventions including medication administration and collaboration with medical and psychiatric service providers. However, pharmacy recommendations to evaluate and potentially reduce medication doses were not acted upon due to the behavior committee's assessment that the resident remained symptomatic. The physician agreed with the committee's recommendation not to reduce medication doses, but the lack of documented behavioral symptoms in the Treatment Administration Records (TAR) and progress notes suggests inadequate monitoring. Interviews with the Director of Nursing (DON) and the Social Services Director (SSD) revealed issues with the documentation process. The DON indicated that nurses needed more education on completing the TAR for resident behaviors. The SSD noted that a change in the documentation system prevented Certified Nursing Assistants (CNAs) from directly documenting behaviors, leading to a reliance on nurses who were lax in documentation. The facility's policy on behavioral assessment and monitoring was not effectively implemented, contributing to the deficiency.
Medication Administration Errors and Privacy Breach
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in an error rate of 21.43 percent for three residents. Registered Nurse (RN) 15 was observed preparing and administering medications incorrectly to two residents. For Resident 169, RN 15 crushed and administered enteric-coated ferrous sulfate and slow-release Klor-Con in applesauce, contrary to physician orders and facility guidelines that specified these medications should not be crushed. Similarly, for Resident 14, RN 15 crushed and administered enteric-coated ferrous sulfate and extended-release Myrbetriq, again violating the facility's 'do not crush' guidelines. Additionally, RN 17 was observed administering insulin to Resident 26 without priming the insulin pen, as required by the manufacturer's guidelines and the facility's standard operating procedure. The RN also failed to provide privacy during the administration by leaving the door open and not pulling the curtain. The RN admitted to not knowing the requirement to prime the insulin pen and acknowledged the oversight in providing privacy. These actions contributed to the facility's high medication error rate.
Improper Labeling of Insulin Pens
Penalty
Summary
The facility failed to ensure proper labeling of insulin pens for three residents, as observed during a survey. On the morning of December 17, 2024, three medication carts were inspected, revealing that insulin pens for three residents were not labeled with the date they were opened. Specifically, Tresiba insulin for one resident, Lantus insulin for another, and Basaglar insulin for a third resident were all missing the required opening date. Interviews with nursing staff confirmed that insulin pens should be dated when opened, and if no date is present, the pen should be discarded. The medical records of the affected residents were reviewed, revealing that each resident had a diagnosis of Type 2 diabetes, among other health conditions. The facility's policy, provided by the Director of Nursing, mandates that the expiration date be checked and the opening date be placed on multidose containers. However, this procedure was not followed, leading to the deficiency noted in the survey.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of a resident, identified as Resident 49, who had repeatedly requested not to be served vegetables. Despite these requests, vegetables continued to be included on her plate. An observation of the dietary tray slip for Resident 49 revealed that her dislike for vegetables was not documented. Interviews with facility staff indicated that the resident's preferences were supposed to be recorded and communicated to the dietary department, but this was not done effectively in this case. Resident 49 was admitted with diagnoses including end-stage renal disease, dependence on renal dialysis, and type 2 diabetes mellitus with diabetic chronic kidney disease. Her physician had ordered a controlled carbohydrate diet with specific restrictions. The resident was cognitively intact, as indicated by a quarterly Minimum Data Set assessment. The facility's policy required individual food preferences to be assessed upon admission and updated as needed, but this was not adhered to, resulting in the resident's preferences not being honored.
Improper Food Storage and Disposal Practices
Penalty
Summary
The facility failed to ensure proper food storage and disposal practices, as observed during a kitchen inspection. During the inspection, a walk-in refrigerator was found to contain a clear plastic container with corn that was dated beyond the acceptable timeframe for consumption. Additionally, a plastic bag of lettuce was found to be brown and wilted, with a delivery date from October, indicating it was expired. Three cucumbers were also found in an open and undated plastic bag, making it impossible to determine their freshness or safety for consumption. An interview with a staff member revealed that food should be labeled and disposed of after three days if opened and placed in a new container. The staff member acknowledged that the corn and lettuce should have been discarded and was unsure why they had not been. The cucumbers were also deemed necessary for disposal due to the lack of proper labeling. The facility's policy documents, provided by the Administrator, confirmed that food should be labeled and dated, and discarded if over 72 hours old or if there is no identification or date on the item.
Failure to Follow Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to adhere to its antibiotic stewardship protocol for a resident who was on long-term antibiotic therapy. The resident, who had a history of Parkinson's disease, COPD, urinary retention, and recurrent urinary tract infections, was admitted with an order for prophylactic Ampicillin 500 mg via G-tube. The medical record lacked evidence of a physician's assessment to justify the long-term use of antibiotics and did not document any education provided to the resident's responsible party regarding the implications of prolonged antibiotic use. Interviews with the Director of Nurses (DON) and the Medical Director revealed that the resident was on antibiotics due to a history of chronic urinary tract infections and a diagnosis of VRE. Despite the resident's admission with an antibiotic regimen from a previous facility, no additional urinalysis or cultures were conducted after admission to the current facility. The Medical Director acknowledged the potential resistance to penicillin and indicated plans to discontinue the antibiotic in favor of non-antibiotic measures. The facility's policy on antibiotic stewardship, which requires specific elements such as the duration of treatment, was not followed in this case.
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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 Knightsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hutsonwood At Brazil | 1.1 mi | ★★★★★ | 14 | 0 |
| Hickory Creek At Sunset | 14 mi | ★★★★★ | 7 | 0 |
| Asbury Towers Health Care Center | 14.3 mi | ★★★★★ | 10 | 0 |
| Waters Of Greencastle, The | 14.4 mi | ★★★★★ | 12 | 0 |
| Signature Healthcare Of Terre Haute | 15.1 mi | ★★★★★ | 19 | 0 |
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