Average — CMS composite of the measures below.
A standard survey is most likely before 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 Cobblestone Crossings Health Campus during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was physically and mentally abused when a CNA rushed and roughly handled her during a transfer, despite care plans requiring two-person assistance and unhurried care. The CNA pulled and yanked the resident's arm, failed to communicate the procedure, and ignored requests from other staff to stop, resulting in the resident's distress.
A resident with severe cognitive impairment and total incontinence, who required maximum assistance for transfers, was reportedly rushed during care by a CNA. An LPN observed the incident but did not document it or complete required assessments, and the event was not reported to the Administrator in a timely manner, contrary to facility policy.
Food safety and sanitation lapses were observed in the kitchen when expired French toast mix was found, cold items on the salad bar were held above the required temp, an employee’s beard cover did not fully contain facial hair, and an unopened energy drink was kept in a food prep area. The issues occurred during meal service and food prep, and facility policy required cold foods at 41 degrees F or below, proper dating of leftovers, full facial hair restraint, and employee drinks only in designated areas.
Failure to Provide and Document ADL Assistance: Multiple residents who needed help with bathing and grooming were observed with untrimmed nails, heavy beard growth, or poor hygiene, while records showed missed showers and no documentation of refusals. Care plans called for scheduled showers and shaving, but staff interviews and chart review showed inconsistent completion and incomplete documentation of ADL care and resident refusals.
A resident with dementia, respiratory failure with hypoxia, and mood disorder repeatedly refused ordered meds, including Eliquis, Lasix, Tramadol, and Ciloxan eye ointment, and some eye drop doses were unavailable from the pharmacy. The EMAR lacked documentation that the MD or resident representative were notified of the refusals or the unavailable medication, despite staff stating the facility policy was to notify the MD and family when meds were refused.
Resident information was left exposed on unattended med cart computers during med passes. An open screen showed a resident’s name, DOB, age, allergies, and code status while staff walked away from the cart, entered a room, or left the area, with other residents and visitors nearby. Another resident’s screen was also visible on a different cart while no staff were present. The RNC provided a policy stating residents have a right to have records containing personal and financial information kept confidential.
A resident with hypokalemia and severe cognitive impairment had a critically low potassium lab result, but ordered potassium doses were not given because the medication was unavailable, and the MAR lacked documentation that the MD was notified. The resident’s potassium was also not re-checked as ordered, with the repeat lab delayed until later and again showing a critically low level.
A resident with flaccid neuropathic bladder, moderate cognitive deficit, and an indwelling urinary catheter was observed multiple times with the catheter bag contacting the floor or another surface, including the base of an overbed table. The resident’s record showed an active UTI and a healthcare acquired UTI, and the chart lacked a specific catheter care plan. Facility policy stated urinary drainage bags and tubing should be kept from touching the floor.
A resident with alcoholic cirrhosis of the liver and unspecified psychosis had a pharmacy recommendation for CMP, CBC, B-12, TSH, and FT3 testing, and the MD accepted the recommendation. The record lacked documentation that the ordered labs were completed, and the RN consultant could not locate the results or any progress notes explaining why the tests were not done.
Surveyors found expired and improperly stored meds on a medication cart, including an opened insulin pen labeled for a resident with DM and an opened Aplisol vial that was supposed to be refrigerated. The CRMA stated the insulin pen was past the 28-day open period and should have been discarded, and said the Aplisol had been left unrefrigerated for an unknown amount of time and would have to be discarded.
A resident with multiple complex conditions, including liver disease, dementia, and severe malnutrition, experienced significant weight gain and worsening edema during her stay. Despite repeated concerns from family about swelling and abdominal distension, staff attributed changes to improved nutrition and inconsistently documented edema. Compression stockings caused further harm, and the resident was ultimately transferred to the hospital, where large volumes of fluid were drained. The facility failed to thoroughly assess and address the resident's symptoms, resulting in a deficiency in quality of care.
A resident with significant edema and cognitive impairment sustained a superficial laceration to her lower extremity when an LPN used bandage scissors to remove a tight dressing, resulting in a cut that later became infected and required antibiotic treatment. The incident occurred after a family member requested the dressing be removed due to tightness, and the LPN acknowledged that unwrapping the dressing would have been safer given the resident's condition.
The facility failed to properly label and store medications on two medication carts. An opened Lantus insulin pen was undated, and several unopened medications, including insulin pens and eye drops, were not refrigerated as required. The RN attributed the oversight to a new night shift nurse unaware of proper procedures. Residents involved had conditions like type 2 diabetes and glaucoma, necessitating these medications.
A resident with respiratory issues was found with medications at her bedside without a completed self-administration assessment or authorization. Despite having physician's orders for medication administration, there was no order for self-administration. Facility staff confirmed that no residents were authorized to self-administer medications, and the medications matched those from the facility's cart, not brought from home. The facility's policy requiring an assessment and order for self-administration was not followed.
The facility failed to accurately document the code status for two residents, leading to discrepancies in their medical records. One resident's records showed conflicting DNR and full code statuses, while another resident's records had both DNR and CPR consent forms signed on the same date. These inconsistencies created confusion regarding the residents' advanced directives, highlighting a failure to adhere to the facility's policy on documenting end-of-life care wishes.
A facility failed to conduct quarterly care plan meetings for a resident with a bimalleolar fracture and type 2 diabetes. The resident could not recall recent meetings, and records showed no meetings since November 2023. Interviews confirmed the facility was behind on care plan meetings, lacking documentation for the resident's meetings.
A resident with a history of osteoporosis, DVT, and chronic kidney disease was observed with edema in her left foot and ankle, but the facility failed to notify a physician or maintain a care plan for this condition. Despite previous observations of swelling, there was no recent assessment or monitoring of the edema or DVT, as confirmed by staff interviews. The facility's policy to identify and monitor clinically at-risk residents was not followed in this case.
A resident's urinary catheter and biliary drain bags were repeatedly found on the floor without coverings, contrary to facility policy. The resident, with a complex medical history, required specific care interventions that were not followed, as confirmed by staff interviews. The facility's guidelines mandate that drainage bags be covered and not touch the floor, which was not adhered to in this case.
A facility failed to properly clean and store respiratory equipment for a resident, including nasal cannula and CPAP mask and tubing. Observations showed undated oxygen tubing and lack of a dated storage bag. Staff interviews confirmed non-compliance with facility policy, which required proper storage and dating of equipment. The resident had a history of respiratory issues, necessitating continuous oxygen therapy and CPAP use, but the facility did not follow the prescribed protocols.
The facility failed to maintain food safety and sanitation standards during a kitchen observation. Raw hamburger meat was improperly stored on a cart with prepared salads outside of the cooler, and an employee was observed without a beard covering in the kitchen. The Director of Food Services admitted to removing the meat from the cooler and placing it on the cart, but could not recall how long it had been out. Facility policies require proper storage of potentially hazardous foods and beard coverings in food production areas.
A facility failed to properly handle and sanitize a glucometer during medication administration for two residents with type 2 diabetes. A nurse used the glucometer without placing a barrier under it and did not sanitize it between uses, contrary to facility policy. This was confirmed by an LPN, who noted the glucometer was used for multiple residents and should be cleaned between uses.
A resident with chronic kidney disease and obstructive uropathy missed a urology appointment due to the facility's failure to arrange transportation. Despite a physician's order, the transport was not scheduled, partly due to a time-consuming process and lack of a specific policy. The Life Enrichment Director and nursing staff were involved, but the resident was not on the transport schedule.
A CRCA left a resident with dementia unattended during personal care due to frustration with the resident's combative behavior. The resident, who had a history of aggressive behavior, was later attended to by an RN and another CRCA. The facility's policy on resident rights, which emphasizes dignity and respect, was not followed.
Failure to Prevent Physical and Mental Abuse During Resident Transfer
Penalty
Summary
A deficiency occurred when a certified nursing aide (CNA) physically and mentally abused a resident with severe cognitive impairment during a transfer. The resident, who had Alzheimer's disease, depression, and was dependent on staff for all activities of daily living, was observed being rushed and handled roughly by the CNA. The CNA was seen pulling and yanking the resident's arm while attempting to transfer her from a chair to bed, without first explaining the procedure or ensuring the resident was ready. The resident became visibly upset, resisted the transfer, and displayed signs of distress, such as laughing angrily and gritting her teeth. Multiple staff members witnessed the incident. One CNA entered the room and observed the resident being pulled and yanked by the arm, and heard the CNA repeatedly and loudly urging the resident to get up. Despite being asked to leave the room by another CNA and an LPN, the CNA continued to attempt the transfer and only left after repeated requests. The resident was calmed by another CNA after the incident, and no physical injuries were noted, but the resident was clearly distressed by the interaction. The facility's care plans for the resident specified that she required maximum assistance from two staff members for transfers and that staff should allow her sufficient time to complete tasks without rushing. The CNA failed to follow these care plan interventions, instead rushing the resident and using rough handling during the transfer. The incident was reported by staff, and interviews confirmed that the CNA's approach was inappropriate and did not align with the resident's care needs or the facility's abuse prevention policies.
Failure to Timely Report Suspected Abuse Incident
Penalty
Summary
The facility failed to report an incident of potential resident abuse by a staff member in a timely manner to the Administrator. A Certified Nursing Aide (CNA) was reported by another CNA for rushing a resident during care. The incident involved a resident with severe cognitive impairment, Alzheimer's disease, depression, and total urinary and bowel incontinence, who was dependent on staff for all activities of daily living. The resident required maximum assistance for transfers and was at risk for skin breakdown. The care plan specifically indicated that staff should not rush the resident and should allow sufficient time for tasks. The incident was observed by an LPN, who saw the CNA pulling on the resident's arm during a transfer. Although a head-to-toe assessment was reportedly performed, the LPN failed to document the incident or the assessment in the clinical record, and did not take vital signs or complete a pain assessment following the event. The facility's policy required immediate reporting of suspected abuse to the Executive Director, but this was not done in a timely manner. The deficiency was identified through record review and staff interviews.
Food Safety and Sanitation Lapses in Kitchen Operations
Penalty
Summary
The facility failed to ensure foods were disposed of after the use-by date, cold foods were maintained at a safe temperature on the salad bar, beard restraints were effectively worn, and employee drinks were not kept in food prep areas during kitchen observations. During an initial kitchen tour, a container of French toast mix was labeled with a use-by date of 8/19/25, and the Food Services Director stated that date was the last date the food could be used and disposed of the mix. During a lunch observation, cottage cheese and hard boiled eggs were placed on the salad bar and served to three residents; at 12:06 p.m., the Food Services Director stated the cottage cheese was 53 degrees F and the hard boiled eggs were 55 degrees F, and removed the food from the salad bar. During a later kitchen observation, an employee placing food onto a plate was wearing a beard cover pulled down below his mouth, exposing his mustache. In another kitchen observation, an unopened energy drink was observed in the food preparation area while condiments were being portioned, and the Food Services Director stated employee drinks should not have been in food prep areas and discarded the drink. The Food Services Director later stated all facial hair was required to be contained in the beard cover. The facility policy indicated cold food should be held at 41 degrees F or below, leftovers must be dated and labeled, facial hair restraints are required in food production areas, and employees may drink only in designated areas or from closed containers handled to prevent contamination of exposed food.
Failure to Provide and Document ADL Assistance
Penalty
Summary
The facility failed to provide assistance with ADLs, including bathing, grooming, and nail care, for multiple residents who were unable to complete these tasks independently. Surveyors identified that Resident 34 was observed with long, untrimmed fingernails with dark debris underneath both hands on two separate observations. The resident’s record showed a diagnosis of unspecified dementia with agitation and major depressive disorder, and a quarterly MDS indicated moderate cognitive impairment and a need for substantial/maximal assistance with personal hygiene. The care plan scheduled showers twice weekly, but the bathing record for July and August documented only four showers in July and one in August, with no documentation that the resident refused care. Progress notes also lacked documentation of refusals for bathing or nail care. Resident 3 was observed with a full beard and mustache and stated he had not been shaved since admission despite asking staff multiple times. He reported that staff told him he needed to be on a list to be shaved and that he did not want to have a beard. His record showed end stage renal disease and dependence on renal dialysis, and an admission MDS indicated moderate cognitive impairment with substantial/maximal assistance needed for showers and bathing. The care plan directed staff to offer facial shaving on shower days, as needed, or as requested, and the bathing record showed only one shower in August with no documentation of refusals. Progress notes did not document refusals for showers or shaving. Resident 11 stated she had not received a shower since admission and that there was not enough staff to provide her care needs. She later again reported that she still had not received a shower and wanted her hair washed, with staff noting her hair was oily and unkept. Her record showed hemiplegia following cerebral infarction, type 1 diabetes, and end stage renal disease, and the admission MDS indicated assistance was needed with bathing and transfers with moderately impaired cognition. The care plan called for assistance with daily care needs and showers on Tuesday and Friday evenings, but the record lacked documentation of showers since admission and lacked documentation of refusals. Resident 36 was observed with heavy beard growth and stated he preferred to be shaved and that staff usually shaved him or assisted him to shave, but he could not remember the last time he had been shaved. His record showed paroxysmal atrial fibrillation and CHF, and the quarterly MDS indicated he required assistance with daily care needs and was cognitively intact. The care plan directed showers on Monday and Thursday evenings and facial shaving on shower days, as needed, or as requested. Review of the record showed no shower from 5/26/25 to 8/7/25, then only two showers from 8/7/25 to 8/25/25, while the record listed 'other' 24 times. Staff interviews showed uncertainty about the meaning of 'other' and uncertainty about shaving expectations, and the facility’s bathing preference guideline stated bathing should occur at least twice a week unless resident preference stated otherwise.
Failure to Notify Physician and Representative of Medication Refusals and Unavailable Medication
Penalty
Summary
The facility failed to notify the physician and the resident representative of medication refusals and medication unavailability for one resident reviewed for unnecessary medications. The resident was admitted with respiratory failure with hypoxia, unspecified dementia, and an unspecified mood affective disorder. The care plan directed staff to administer medications per orders, and the physician orders included Colace, a multivitamin, Eliquis, Lasix, Sertraline, Tramadol, and Ciloxan eye ointment. Review of the EMAR showed repeated refusals of Eliquis, Lasix, Tramadol, and Ciloxan, along with doses of Ciloxan that were unavailable from the pharmacy. The record lacked documentation that the physician or resident representative were notified of the medication refusals or the unavailable medication for July 2025 or August 2025. The resident's quarterly MDS indicated cognitive impairment. During interview, the RNC stated the resident had refused antibiotic eye drops several times and staff had difficulty administering them, and an LPN stated the facility policy was to notify the physician and family if a resident refused medications.
Resident Information Left Visible on Unattended Medication Carts
Penalty
Summary
The facility failed to keep residents’ personal and medical records private and confidential when medication cart computers were left open and unattended on the 200 hall and back 200 hall. During observation, Resident 18’s medication screen was exposed while the cart was unattended, with another resident standing next to the cart and two visitors speaking with a resident nearby. Certified Resident Medication Aide (CRMA) 5 later returned to the cart, walked away again to get ice without closing the computer, and then assisted another resident before closing the lid only after the screen went to sleep mode. Resident 18’s record showed diagnoses including chronic respiratory failure with hypoxia and atrial fibrillation, and the quarterly MDS indicated no cognitive deficit. The Regional Nurse Consult stated the resident’s private information should not have been exposed and the computer should be closed when staff are not at the medication cart; Resident 18 stated privacy was very important and she did not want her personal information exposed for anyone to see. During another medication pass, CRMA 5 walked away from the cart and entered a resident’s room while the computer screen remained open and Resident 3’s medication screen was visible, including her name, date of birth, age, allergies, and code status, with two residents sitting near the cart and other residents walking in the hallway. CRMA 5 did not return for several minutes. Later, the back 200 hall medication cart was observed unattended with Resident 43’s medication screen exposed, including her name, date of birth, age, allergies, and code status, while two residents were in the sitting area nearby. Resident 3’s record showed diagnoses including metabolic encephalopathy, meningitis, and non-Hodgkin lymphoma, and the admission MDS indicated moderate cognitive impairment. Resident 43’s record showed diagnoses including chronic respiratory failure with hypoxia and COPD, and the quarterly MDS indicated she was cognitively intact. An LPN stated that when walking away from the medication cart, she would minimize the computer screen or hit the walk-away button so residents’ private information would not be exposed. The facility policy provided by the Regional Nurse Consultant stated residents have a right to have records containing personal and financial information kept confidential.
Missed Potassium Doses and Delayed Lab Recheck After Critical Result
Penalty
Summary
The facility failed to ensure a resident with hypokalemia and unspecified atrial fibrillation received ordered potassium treatment after a critical lab result and failed to ensure the potassium level was re-checked as ordered. The resident’s record showed a potassium level of 3.4 mmol/L on 7/9/25 and a critically low potassium level of 2.6 mmol/L on 8/5/25. The resident’s quarterly MDS dated 7/14/25 indicated severe cognitive impairment. After the critical potassium result was reported to the facility at 5:42 p.m. on 8/5/25, the physician issued one-time orders for potassium chloride 40 mEq at 5:30 p.m. and again at 11:30 p.m. The MAR documented both doses were not administered because the medication was unavailable, and the MAR lacked documentation that the physician was notified of the missed administrations. A nursing progress note and an IDT progress note documented the critical lab notification and new orders, but neither documented that the physician was informed the ordered potassium was not given. A pharmacy recommendation on 8/12/25 noted the resident’s potassium was 2.6 mmol/L and recommended the lab be re-checked; the physician accepted the recommendation. The record showed a lab draw was attempted on 8/14/25 but was not completed because of a specimen problem, and the potassium was not re-drawn until 8/23/25, when it was again critically low at 2.7 mmol/L. During interviews, the Regional Nurse Consultant stated potassium should have been obtained from the EDK or a backup pharmacy, and if it was not administered, the physician should have been notified. She also stated the lab should have been re-drawn before 8/23/25, but it had been missed.
Indwelling catheter bag contacted floor and other surfaces
Penalty
Summary
The facility failed to ensure that Resident 33’s indwelling urinary catheter was maintained in a sanitary condition. During observations, the resident was seen in a wheelchair in the therapy room with the catheter bag in contact with the floor, later in the lounge area with the catheter bag again in contact with the floor, and while asleep in bed with the catheter bag hanging from the side of the bed and touching the base of the overbed table. A regional nurse consultant stated the expectation was that catheter bags or tubing should never be allowed to contact the floor or any other object. Resident 33’s record showed diagnoses including flaccid neuropathic bladder and moderate cognitive deficit, and the resident had an indwelling urinary catheter on the admission MDS. The care plan dated 8/20/25 identified an active UTI and included infection control precautions, but the record lacked documentation of a specific care plan related to the resident’s catheter. A McGeer’s criteria infection tracking report dated 8/19/25 indicated the resident had a healthcare acquired UTI. The facility policy titled, "Preserving Dignity with Indwelling Catheter," stated urinary drainage bags and catheter tubing should be kept from touching the floor surface.
Ordered Labs Not Completed for Resident With Liver Disease and Psychosis
Penalty
Summary
The facility failed to ensure that ordered lab tests were completed for one resident reviewed for unnecessary medications. The resident had diagnoses including alcoholic cirrhosis of the liver and unspecified psychosis, and a quarterly MDS indicated no cognitive deficit and no documented behaviors. The record also showed care plans noting a history of inappropriate behaviors and altered behaviors. A pharmacy recommendation dated 12/24/24 advised obtaining a CMP, CBC, B-12, TSH, and FT3, and the physician accepted the recommendation for the lab work to be completed. However, the record did not contain documentation that the ordered labs were completed. During interview, the Regional Nurse Consultant stated she could not locate any of the ordered labs, did not know why they were not completed, and could not find progress notes explaining the omission. The facility policy provided during interview stated that resident-ordered labs and/or other diagnostic tests should be completed in a timely manner.
Expired and Improperly Stored Medications Found on Medication Cart
Penalty
Summary
Medication storage was not maintained in accordance with accepted professional principles when surveyors found expired and improperly stored medications on the back 200 hall medication cart. At 8:45 a.m., an opened insulin pen labeled for Resident 16 was observed with an open date that had already passed the 28-day period described by the CRMA, who stated the pen should have been discarded because it was expired. Resident 16’s record showed diagnoses including type 2 diabetes mellitus with hyperglycemia and an order for insulin lispro 100 unit/ml, 5 units subcutaneously before meals three times a day. At 8:29 a.m., the same medication cart contained an opened multi-use vial of Aplisol with an open date that had already passed and a pharmacy label indicating it was to be refrigerated. During interview, the CRMA stated she did not know how long the vial had been in the cart and said it should have been refrigerated when not in use; she also stated it would have to be discarded because it had not been refrigerated and she did not know how long it had been unrefrigerated. The facility’s Medication Storage in the Facility policy stated opened medications should be dated, expired medications should not be administered, and all expired medication should be removed from active supply and destroyed; the Aplisol policy stated the product should be stored between 2 and 8 degrees Celsius and protected from light.
Failure to Assess and Address Edema and Weight Gain in Resident with Complex Medical Needs
Penalty
Summary
The facility failed to complete thorough assessments and provide appropriate care for a resident with significant medical conditions, including liver disease, dementia, acute kidney failure, ascites, localized edema, and severe protein-calorie malnutrition. The resident experienced a substantial weight gain over the course of her stay, with her weight increasing from 85.4 lbs at admission to 106 lbs at discharge. Despite this significant change, the facility attributed the weight gain to improved nutrition and did not adequately investigate or address the possibility of fluid retention, even though the resident had a history of ascites and generalized edema (anasarca). Family members repeatedly raised concerns to staff about the resident's increasing abdominal size and swelling in her lower legs, but these concerns were dismissed or minimized by both staff and the facility physician. Compression stockings were applied to the resident, resulting in hematomas and significant discomfort, leading the family to refuse further use. The facility's documentation of the resident's edema was inconsistent, with some assessments noting its presence and others, including one on the day of transfer to the emergency department, indicating its absence. However, emergency department records from the same day documented 2 to 3 plus pitting edema in the resident's lower extremities, as well as a blood blister and cold extremities. The resident's condition deteriorated to the point that her primary care physician arranged for her transfer to the emergency department, where she was found to have significant fluid accumulation and subsequently had three liters of fluid drained from her abdomen at an acute care hospital. Interviews with facility staff revealed a lack of awareness regarding the resident's abdominal swelling and weight gain, and the facility lacked a specific policy addressing the management of such changes in condition. The failure to conduct thorough assessments and respond appropriately to the resident's symptoms and family concerns led to a deficiency in the quality of care provided.
Resident Laceration During Dressing Removal
Penalty
Summary
A deficiency occurred when a resident sustained a laceration to her left lower extremity during a dressing removal performed by an LPN. The incident took place after the resident's family member requested the removal of a dressing on the resident's left knee, citing concerns that it was too tight. The LPN, who was in the middle of a medication pass, paused her duties to address the request. She used bandage scissors to cut through the gauze dressing, inserting the dull end under the dressing. During the process, the resident moaned, and upon removal of the gauze, a superficial cut approximately eight centimeters long was discovered on the resident's skin, with scant bleeding present. The resident had a medical history significant for liver disease, dementia, ascites, and edema, and was severely cognitively impaired and dependent on staff for most activities of daily living. The dressing that was removed had been in place for several days and was covering a pre-existing V-shaped skin tear. The LPN attributed the injury to the tightness of the dressing and the presence of edema, which made the skin puffy and more susceptible to injury. The LPN acknowledged that unwrapping the dressing, rather than cutting it, would have been a safer approach given the resident's condition. Following the incident, the laceration became infected, requiring treatment with an oral antibiotic and topical bacitracin. The facility's policy on wound and skin care emphasized the need for care when removing all dressings and tapes. The family member present at the time expressed concern about the nurse's competence and the additional harm caused to the resident, who had to recover from both the original wound and the new laceration.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications for two medication carts reviewed. On the 200 hall (front) medication cart, an undated and opened Lantus insulin pen was found, which was labeled for a resident with type 2 diabetes mellitus. The Registered Nurse (RN) acknowledged that insulin pens should have an open date when used. Additionally, the 200 hall (back) medication cart contained several unopened and non-refrigerated medications, including Basaglar and Lantus insulin pens, a vial of Humalog, and a bottle of Latanoprost eye drops, all of which were labeled for specific residents or facility stock. The RN indicated that these medications should have been refrigerated until used, and attributed the oversight to a new nurse on the night shift who was unaware of the proper storage procedures. The residents involved had various medical conditions, including type 2 diabetes, diabetic chronic kidney disease, and glaucoma, which required the administration of these medications. The facility's policies, as provided by the Regional Director of Clinical Services, indicated that insulin pens and certain other medications should be stored in the refrigerator until used, and that the date opened should be recorded on vials and ampules of injectable medications. The failure to adhere to these policies resulted in the improper storage and labeling of medications, as observed during the survey.
Failure to Assess and Authorize Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a medication self-administration assessment was completed for a resident with respiratory issues, identified as Resident 11. During an initial interview, it was observed that the resident had an inhaler, Trelegy Ellipta, on her bedside table, which she claimed was hers and used regularly. Additionally, during a random observation, two vials of nebulizer solution were found on the resident's bedside table. The resident mentioned that she usually set up the nebulizer herself but was currently unable to do so due to a wrist brace. Despite the presence of these medications, there was no documentation or assessment indicating that the resident was authorized to self-administer her medications. The resident's medical records revealed diagnoses including bipolar II, schizoaffective disorder, and chronic obstructive pulmonary disease (COPD). Physician's orders were in place for the administration of Trelegy Ellipta, ipratropium-albuterol solution, and albuterol sulfate inhaler, but there was no order for self-administration. The care plan noted the potential for complications related to respiratory disease, and a recent assessment indicated the resident was cognitively intact. However, interviews with facility staff, including an LPN and the Director of Health Services, confirmed that no residents, including Resident 11, had orders to self-administer medications. Further investigation revealed that the medications found at the resident's bedside matched those from the facility's medication cart, indicating they were not brought from home. The facility's policy required an assessment and physician's order for self-administration, which was not present in this case. The policy also stated that medications should not be left at the bedside unless specifically ordered by a prescriber, which was not adhered to, leading to the deficiency.
Discrepancies in Code Status Documentation for Two Residents
Penalty
Summary
The facility failed to accurately document the code status of two residents, leading to discrepancies in their medical records. For Resident 34, the face sheet and a physician's order indicated a Do Not Resuscitate (DNR) status, while the most recent Physician Order for Scope and Treatment (POST) form indicated a full code status, which meant resuscitation should be attempted. This inconsistency was noted during a review of the resident's record, and the Licensed Practical Nurse (LPN) confirmed the discrepancy upon checking the documents. The Regional Director of Clinical Services (RDCS) acknowledged the issue and mentioned contacting hospice and the resident's wife for verification. For Resident 196, the medical record indicated a DNR status, but a CPR consent form signed by the resident on the same date suggested CPR should be initiated. This conflicting information created confusion regarding the resident's advanced directives. The Director of Health Services (DHS) recognized the discrepancy and acknowledged the confusion it caused. The resident's medical record also lacked a care plan for advanced directives, further complicating the situation. The facility's policy on advanced directives, provided by the Regional Nurse Consultant, outlined procedures for obtaining and following residents' end-of-life care wishes. However, the discrepancies in the documentation of code status for both residents indicate a failure to adhere to these procedures, resulting in unclear and conflicting directives in the residents' medical records.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were held at least quarterly for a resident, identified as Resident 8, who was reviewed for care plan meetings. During an interview, the resident indicated that she could not recall having a care plan meeting for quite some time. A review of the resident's records showed that she had been admitted to the facility with diagnoses including a displaced bimalleolar fracture of the right lower leg and type 2 diabetes. The quarterly Minimum Data Set (MDS) assessment indicated that the resident had no cognitive deficit. However, the review of the Resident First Meeting Minutes lacked documentation of a care plan meeting since November 1, 2023. Interviews with the Resident Services Manager and the Regional Director of Clinical Services confirmed that the facility was behind in completing care plan meetings, and they were unable to locate any documentation indicating that a care plan meeting had been held for the resident since November 2023. The facility's policy, provided by the Regional Director of Clinical Services, stated that meetings for non-Medicare residents should be conducted at a minimum of quarterly and with significant change, while meetings for Medicare residents should be conducted minimally quarterly and prior to discontinuing Medicare services or being discharged from the facility.
Failure to Monitor and Notify Physician of Resident's Edema
Penalty
Summary
The facility failed to assess and ensure that a physician was notified of a resident's change in condition related to edema. Resident 7, who has a history of age-related osteoporosis, a previous DVT in the left leg, and chronic kidney disease stage 3b, was observed multiple times with edema in her left foot and ankle. Despite these observations, the resident's record lacked a care plan specifically addressing the edema, and there were no recent progress notes related to the condition. The resident had been prescribed Xarelto following a previous DVT diagnosis, but there was no evidence of continued monitoring of the edema or DVT by the staff. Interviews with facility staff revealed that the edema had been noticed previously, but there was no recent assessment or notification to the physician regarding the current state of the edema. The Regional Director of Clinical Services acknowledged that the edema should have been addressed with the physician and that a clinical assessment record should have been completed to ensure proper monitoring. The facility's policy indicated that residents clinically at risk should be identified and monitored, but this was not adhered to in the case of Resident 7.
Improper Catheter and Drainage Bag Care
Penalty
Summary
The facility failed to ensure proper care for a resident's indwelling urinary catheter and biliary drain, as observed during multiple routine checks. On several occasions, the urinary drainage bag and the biliary drainage bag were found lying on the floor without any covering, contrary to the facility's policy. The bags were observed touching the floor while the resident was in bed and attached to the wheelchair without any covering, which is against the guidelines that require drainage bags to be covered and not touch the floor. The resident involved had a complex medical history, including acute respiratory failure, cellulitis, chronic atrial fibrillation, chronic obstructive pulmonary disease, obstructive sleep apnea, dyspnea, and type 2 diabetes mellitus with diabetic chronic kidney disease. The care plan for the resident included maintaining a closed system with the urinary bag below the bladder and covered, but there were no specific interventions for the biliary drain. Interviews with staff confirmed the expectation that drainage bags should be covered and not touch the floor, yet these practices were not followed, leading to the deficiency.
Improper Cleaning and Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper cleaning and storage of respiratory equipment for a resident, specifically the nasal cannula and CPAP mask and tubing. Observations over several days revealed that the oxygen tubing used for a resident was not dated, and there was no dated storage bag present in the resident's room. Interviews with staff, including an LPN and the Director of Health Services, confirmed that the oxygen tubing was not dated, and the storage bag was only changed monthly. The facility's policy required oxygen cannula and tubing to be stored in a plastic bag when not in use and marked with the date and resident's name. The resident involved had a complex medical history, including acute respiratory failure, chronic obstructive pulmonary disease, obstructive sleep apnea, and other conditions requiring continuous oxygen therapy and CPAP use. Physician orders specified the need for regular cleaning and storage of the CPAP mask and tubing, as well as monthly changes of the oxygen tubing. Despite these orders, the facility did not adhere to the required protocols, leading to the deficiency noted in the report.
Food Safety and Sanitation Deficiency
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for food safety during a kitchen observation. Raw hamburger meat was observed on a tray on the bottom of a rolling cart outside of the cooler, alongside prepared salads. The Area Director of Food Services acknowledged that the meat should not have been on the cart and should have been stored in the cooler. The Director of Food Services admitted to removing the hamburger meat from the cooler and placing it on the cart with the salads, but could not recall how long the meat had been out of the cooler. Additionally, during the same observation, an employee was noted to be without a beard covering in the kitchen food product area. The Director of Food Services indicated that the employee had removed the beard covering. The facility's policy, as provided by the Regional Nurse Consultant, requires beard and mustache hair to be covered while in kitchen food product areas, with facial hair restraints required in any production area. The policy also states that potentially hazardous foods that have stood for more than four hours at room temperature are not considered safe and must be discarded.
Improper Glucometer Handling and Sanitation
Penalty
Summary
The facility failed to ensure proper handling and sanitation of a glucometer during medication administration for two residents. During an observation, a registered nurse was seen using a glucometer without placing a barrier under it when placing it on various surfaces, including the medication cart and a resident's side table. The nurse did not sanitize the glucometer between uses for different residents, which is against the facility's policy that requires cleaning and disinfecting the device after each use. Resident 8 and Resident 19, both diagnosed with type 2 diabetes mellitus, were involved in this deficiency. Resident 8 had a physician order to obtain blood glucose readings before meals and at bedtime, while Resident 19 had an order for insulin administration before meals. The lack of proper sanitation and handling of the glucometer was confirmed by a Licensed Practical Nurse, who stated that the glucometer was used for multiple residents and should be cleaned between uses. The facility's policy, provided by the Regional Director of Clinical Services, clearly indicated the requirement for cleaning and disinfecting glucometers when used for multiple residents.
Failure to Arrange Transportation for Medical Appointment
Penalty
Summary
The facility failed to ensure transportation arrangements were made for Resident B, resulting in her missing a medical appointment with her urologist. Resident B, who has chronic kidney disease, hypertensive chronic kidney disease, and obstructive uropathy, was scheduled for a treatment appointment with a urology nurse practitioner. Despite a physician's order to set up transport for the appointment, the necessary arrangements were not made, and the resident missed her appointment. Interviews revealed that the Life Enrichment Director, responsible for resident transport, did not have Resident B on her schedule, and the nursing staff, who were responsible for scheduling transport, found the process time-consuming due to the requirement to use a government website. Additionally, the facility lacked a specific policy on setting up transportation for resident appointments, although the expectation was that staff would arrange transportation for any resident needing it. The Executive Director confirmed that the facility's policy was to provide transportation for all residents requiring it.
Failure to Ensure Dignified Treatment During Personal Care
Penalty
Summary
The facility failed to ensure a resident was treated in a dignified manner during personal care. Certified Resident Care Associate (CRCA) 4 was involved in an incident where she became frustrated with a resident who was combative during personal care. In her frustration, CRCA 4 left the resident's room unattended without informing any other staff members on the unit. She intended to leave the facility but was calmed down by the Employee Experience Manager (EEM) and returned to her unit to complete her shift. The Director of Health Services (DHS) confirmed that CRCA 4 had been disciplined for her actions. The resident involved, identified as Resident B, had a diagnosis of unspecified dementia with behavioral disturbances, including aggression. The resident's care plan included interventions for aggressive behavior during hands-on care. On the day of the incident, Registered Nurse (RN) 5 and CRCA 6 discovered the resident unattended and completed the personal care. The facility's policy on resident rights emphasizes treating residents with dignity and respect, which was not upheld in this situation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 184 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Terre Haute
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springhill Village | 2.3 mi | ★★★★★ | 5 | 0 |
| Westminster Village Health & Rehab | 3.2 mi | ★★★★★ | 1 | 0 |
| Southwood Healthcare Center | 3.6 mi | ★★★★★ | 24 | 2 |
| Westridge Health Care Center | 4 mi | ★★★★★ | 10 | 0 |
| Majestic Care Of Deming Park | 5.7 mi | ★★★★★ | 4 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.