Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Cumberland Pointe Health Campus during CMS and state inspections, most recent first.
A resident with significant mobility limitations and a history of falls was not assessed for or provided with bed rails despite multiple requests from the resident and his POA. During incontinence care, the resident was rolled to the edge of an elevated bed and fell, resulting in a right femoral neck fracture, scalp laceration, and multiple bruises. Facility staff did not follow policies for bed rail assessment or fall prevention, and the resident's representative was not promptly notified of the incident.
Two residents with complex medical histories had deficiencies in the documentation and updating of their advanced directives and code status. In one case, a POST form indicating DNR was not signed by a physician, and the code status was not updated to reflect the resident's wishes. In another case, conflicting code status orders were present in the EHR without a POST form, leading to confusion among staff about which order to follow. These failures resulted in the facility not ensuring residents' end-of-life care preferences were properly documented and honored.
Two residents with complex medical conditions did not have required quarterly care plan meetings documented following their MDS assessments. The DON confirmed that these meetings, mandated by facility policy, were not completed as required.
A resident with multiple chronic conditions received furosemide for blood pressure management outside of physician-ordered parameters, as the medication was administered on several occasions when the resident's systolic blood pressure was below the threshold specified in the order. Nursing staff and the DON confirmed that the medication should have been held in these instances, but it was not.
A resident admitted with an indwelling urinary catheter did not have physician's orders for catheter care and monitoring entered until five days after admission, despite facility policy requiring immediate review and implementation of standing orders. This resulted in a lack of documented catheter care and assessments in the MAR.
A resident with a g-tube received nutrition and hydration through the tube without clear physician orders specifying the route or authorization for these interventions. Staff interviews and documentation revealed that only water flushes were ordered for the g-tube, but additional fluids and supplements were administered via the tube, contrary to facility policy and physician instructions.
A resident receiving IV antibiotic therapy did not have appropriate physician orders or documentation for IV site assessments, flushes, or infection prevention measures. Staff interviews confirmed that standard IV care orders were not initiated or obtained, and required documentation was missing until several days after therapy began.
A resident with acute and chronic respiratory conditions was observed using oxygen equipment without a current physician's order, and the nasal cannula was repeatedly found on the floor rather than stored properly. The clinical record lacked an active order for oxygen therapy during the period of use, and staff confirmed the oversight, contrary to facility policy requiring documented orders and proper equipment handling.
A resident with multiple chronic conditions did not receive several prescribed medications on multiple occasions because the medications were not available from the pharmacy. The resident reported missed and delayed doses, and the DON confirmed that the medications were not administered due to unavailability, contrary to facility policy requiring timely medication administration.
The facility failed to follow physician orders and care protocols for several residents. A resident with constipation did not receive bowel protocol interventions, and another resident was not wearing prescribed compression hose. A third resident received metoprolol despite orders to hold it under certain conditions, and a fourth resident was without a required pressure-reducing cushion. Staff were unaware of reasons for non-compliance, and the facility lacked policies to ensure adherence to physician orders.
A facility failed to document a PASARR level 2 on the MDS assessment for a resident with multiple diagnoses, including cerebral palsy and major depressive disorder. Although a PASARR level 2 was completed, the annual MDS assessment did not reflect this. The MDS Clinical Support nurse confirmed the oversight and stated that the facility followed the RAI manual as a policy.
A facility failed to conduct a PASARR for a resident after prescribing Seroquel, an antipsychotic medication. The resident, with diagnoses including bipolar disorder and depression, was initially prescribed 25 mg of Seroquel, later increased to 50 mg. Despite this change, no new PASARR assessment was completed. The facility's procedure requires a PASARR for changes in status, such as starting an antipsychotic.
A resident with chronic pain did not receive prescribed doses of hydrocodone-acetaminophen due to unavailability, despite the medication being in the Emergency Drug Kit. The facility failed to notify the physician about the missed doses, contrary to their policy on emergency medication access.
The facility failed to appoint a qualified Infection Preventionist (IP) who was professionally trained and could dedicate at least part-time to the role. The Executive Director, acting as the IP, lacked a nursing degree and could not allocate sufficient time due to other responsibilities. The Assistant Director of Nursing, also acting as the IP, was not certified, leading to a deficiency in the facility's infection prevention and control program.
A resident on a gluten-free diet did not receive a full meal as per her dietary menu slip. The meal served lacked gluten-free pasta and garlic bread, which were not prepared in advance. Staff failed to communicate with the kitchen to rectify the issue promptly, resulting in the missing items being delivered late. The facility's policy on altered diet verification was not adhered to, leading to this deficiency.
A resident with metabolic encephalopathy and constipation was not provided with a divided plate as required by their care plan and physician's order. Despite the dietary menu indicating the need for a divided plate, staff served meals on regular plates, and interviews revealed a lack of awareness about the resident's dietary needs.
The facility failed to ensure staff wore appropriate hair and facial coverings in the kitchen, as observed with three staff members. One staff member was without a hairnet, another without a facial covering over his mustache, and a third had his facial hair covering under his chin. The facility's policy requires hair restraints, but these were not adhered to during the observations.
Failure to Assess and Provide Bed Rails Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with significant mobility limitations and multiple comorbidities, including congestive heart failure, dementia, diabetes, and hypertension, was not adequately protected from accident hazards during care. The resident required substantial to maximal assistance for mobility and was identified as a fall risk upon admission. Despite repeated requests from both the resident and his daughter, who was his Power of Attorney, for bed rails to be installed, no bed rail assessment was documented, and bed rails were never provided. The facility's policies required assessment and informed consent for bed rail use, but these steps were not followed. The incident occurred when a CNA was providing incontinence care and rolled the resident onto his side on a bed that was elevated to waist level. The resident, who typically used a trapeze bar for self-adjustment but not for turning, was left at the edge of the bed and subsequently fell to the floor. The fall was unwitnessed by the resident's private aide, who was not permitted to assist with care. The resident sustained a right femoral neck fracture, a left scalp laceration, a hematoma of the frontal scalp, and multiple bruises and skin tears. The resident and his daughter both reported that requests for bed rails had been made multiple times, but these were not acted upon by facility staff. Interviews with facility staff revealed that the DON relied on nursing judgment rather than completing a documented bed rail assessment, and the care plan did not include specific interventions to address the resident's risk of falling from bed during care. The facility's fall management and bed rail policies were not followed, as risk factors were not fully evaluated, and care plan interventions were insufficient to prevent the accident. The resident's daughter was not promptly notified of the fall, learning about it from a private aide instead. The lack of appropriate assessment and implementation of assistive devices directly contributed to the resident's injuries.
Failure to Update and Document Advanced Directives and Code Status
Penalty
Summary
The facility failed to ensure that residents' code statuses were accurately updated and that required physician signatures were obtained on advanced directive forms. For one resident with multiple diagnoses including diabetes, cardiomegaly, and hypertension, the clinical record showed a full code status order, while a POST form completed by the resident's POA indicated a DNR status but lacked a physician's signature. The resident herself expressed a desire to be DNR, and facility leadership acknowledged that the form should have been completed by the physician and the code status updated accordingly. Facility policy required that advanced directives be reviewed at admission and quarterly, with nursing staff responsible for confirming code status and obtaining physician orders, but this process was not followed. For another resident with immunodeficiency and other conditions, conflicting code status orders were present in the EHR, with both full code and DNR orders documented within a short period. There was no POST form in the EHR for this resident. Staff interviews revealed confusion regarding which code status to follow when discrepancies existed, with the practice being to use the highest code status. The lack of consistent documentation and failure to obtain and maintain accurate, physician-signed advanced directive forms led to deficiencies in honoring residents' wishes regarding end-of-life care.
Failure to Complete and Document Required Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that care plan meetings were completed quarterly for two residents, as required by both facility policy and regulatory standards. For one resident with diagnoses including diabetes type 2, cardiomegaly, hypertension, obesity, and age-related physical debility, there was no documentation of care plan meetings following quarterly and annual Minimum Data Set (MDS) assessments. The Director of Nursing (DON) confirmed that these meetings should have occurred but were not documented in the clinical record. Similarly, another resident with gastrostomy status, type 2 diabetes mellitus with diabetic chronic kidney disease, and diverticulosis of the large intestine had an admission care plan conference documented, but no subsequent quarterly care plan meetings were recorded after later MDS assessments. The DON acknowledged that required quarterly care plan meetings had not been conducted for this resident. Facility policy specifies that care plan meetings should be held at least quarterly and with significant changes, but this was not followed for the residents reviewed.
Failure to Administer Blood Pressure Medication per Physician Orders
Penalty
Summary
A deficiency occurred when a resident with diagnoses including congestive heart failure, dementia, diabetes mellitus, and hypertension did not receive blood pressure medication according to the physician's orders. The care plan specified the need for medications as ordered and monitoring for cardiovascular distress. The physician's order required that furosemide 20 mg be administered daily but held if the resident's systolic blood pressure was less than 120. Despite this, the Medication Administration Record showed that the medication was given multiple times when the resident's systolic blood pressure was below the specified threshold. Interviews with nursing staff and the DON confirmed that the medication should have been withheld when the resident's blood pressure was outside the ordered parameters. Facility policy required that current orders, including standing orders, be maintained and followed as documented in the electronic clinical record. The failure to hold the medication as ordered resulted in the administration of furosemide outside of the physician's specified parameters.
Failure to Obtain Timely Physician Orders for Catheter Care Upon Admission
Penalty
Summary
A deficiency occurred when the facility failed to obtain physician's orders for the care and monitoring of an indwelling urinary catheter upon admission for a resident with multiple diagnoses, including chronic kidney disease, diabetes mellitus, urinary tract infection, myoglobinuria, and urogenital implants. The resident was admitted with an indwelling catheter, as documented in the admission observation and data collection form. The care plan noted the presence of the catheter and included approaches such as recording urinary output and providing care per physician's orders. However, physician's orders related to the catheter, its care, and monitoring were not entered until five days after admission. Interviews with the DON and an RN confirmed that standing orders for the catheter should have been initiated upon admission and that the lack of these orders resulted in the absence of catheter care and assessment documentation in the Medication Administration Record (MAR). Facility policies required the admitting nurse to review and implement standing orders with the physician at admission, and to assess the need for continued catheterization. These procedures were not followed, leading to the deficiency.
Failure to Follow Physician Orders for G-Tube Care and Administration
Penalty
Summary
Staff failed to follow physician's orders regarding the care and use of a gastrostomy tube (g-tube) for a resident with multiple diagnoses, including gastrostomy status, type 2 diabetes mellitus with chronic kidney disease, and diverticulosis. The physician's order specified that the g-tube should be flushed with 30 ml of water three times daily. However, documentation showed that a nurse administered 120 ml of Med Pass 2.0 nutrition and 240 ml of water through the g-tube, despite no physician's order specifying the administration of Med Pass or hydration via the g-tube. Additionally, the order for Med Pass did not indicate the route of administration, and there was no order for the 240 ml water flush through the g-tube. Interviews with staff confirmed that the only authorized use of the g-tube was for 30 ml water flushes per shift, as per the physician's order. Facility policy required that the route of administration for any medication or supplement via feeding tube be clearly specified in the physician's order and documented in the medication administration record. The lack of clear orders and documentation, as well as the administration of fluids and supplements through the g-tube without proper authorization, led to the deficiency.
Failure to Implement IV Care Orders and Documentation for Resident Receiving IV Therapy
Penalty
Summary
The facility failed to implement physician's orders and follow current professional standards of practice for the maintenance and infection prevention of an intravenous (IV) line for a resident receiving IV therapy. The resident, who had diagnoses including immunodeficiency, benign neoplasm of the meninges, and osteonecrosis, had a physician's order for IV ceftriaxone but no accompanying orders for the care and use of IV pumps, tubing, syringes, or flushes. The electronic health record lacked documentation of IV site assessments, normal saline flushes, heparin lock flushes, monitoring for side effects, or PICC dressing changes until several days after the IV therapy began. Interviews with facility staff revealed that standard orders for IV care, such as flushing and site assessment, were not initiated upon admission, and the nurse on duty did not obtain the necessary orders from the physician. The facility's policy required the admitting nurse to review and verify standing orders with the physician, but this process was not followed, resulting in the absence of essential IV care orders and documentation. This deficiency was identified for one resident reviewed for IV therapy.
Failure to Ensure Physician's Order and Proper Storage for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a physician's order for oxygen therapy was in place and that oxygen equipment was stored properly for a resident with multiple respiratory and cardiac diagnoses. Observations over several days showed that the resident's oxygen concentrator was set to deliver 3 liters per minute, but the resident was not always wearing the nasal cannula, which was found lying on the floor on multiple occasions. The clinical record review revealed that there was no active physician's order for oxygen therapy until several months after the resident returned from the hospital, despite the resident's ongoing use of oxygen equipment. Additionally, the nasal cannula was not stored in a manner that would prevent contamination when not in use. The care plan noted the resident's non-compliance with physician's orders, including refusal to wear oxygen as ordered. Interviews with facility staff confirmed the absence of a current physician's order for oxygen therapy during the period in question, and facility policies required verification and documentation of such orders, as well as proper storage and administration of oxygen equipment.
Failure to Provide Timely Pharmaceutical Services Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, resulting in multiple instances where prescribed medications were not administered as ordered. The resident, who was cognitively intact and had diagnoses including pneumonia, COPD, pulmonary fibrosis, congestive heart failure, and chronic atrial fibrillation, reported not receiving all her medications and noted that some were given very late. Staff informed her that the medications were not administered because they had not been received from the pharmacy. A review of the Medication Administration Record (MAR) revealed that several medications, including alprazolam, calcium citrate with vitamin D, Effexor XR, gabapentin, magnesium oxide, and venlafaxine, were documented as not available and therefore not given on multiple occasions. The DON confirmed awareness of these missed doses due to unavailability. The facility's policy required adherence to the five rights of medication administration, but these were not met in this case.
Non-Compliance with Physician Orders and Care Protocols
Penalty
Summary
The facility failed to adhere to the bowel protocol for Resident 43, who had a diagnosis of metabolic encephalopathy and constipation. The resident did not have a documented bowel movement for four days, from February 11 to February 14, 2024, and the bowel protocol was not initiated as per the physician's order. The order specified a sequence of interventions, including administering a natural laxative, Milk of Magnesia, and a Dulcolax suppository, which were not followed. Additionally, Resident 43 was observed multiple times without the prescribed compression hose, despite a physician's order to apply them daily. There was no documentation to support the facility's claim that the resident's daughter requested the hose not be used due to a wound. Resident 44, diagnosed with dementia and heart conditions, was also observed without TED hose, contrary to the physician's order and care plan. The staff was unaware of the reason for the non-compliance. Similarly, Resident 15, with heart failure and hypertension, received metoprolol despite physician orders to hold the medication if the systolic blood pressure was below 110 or the heart rate was under 65 beats per minute. The medication was administered on multiple occasions when these parameters were not met, and there was no documentation indicating the medication was held. Resident 25, who had an unstageable pressure ulcer and required a pressure-reducing cushion in her wheelchair, was observed without the cushion on several occasions. The cushion was not found in the resident's room, and staff were unsure of its whereabouts. The facility lacked a policy for ensuring compliance with physician orders, as indicated by interviews with the Clinical Support Nurse and the Administrator.
Failure to Document PASARR Level 2 on MDS Assessment
Penalty
Summary
The facility failed to ensure that a PASARR (Preadmission Screening and Resident Review) level 2 was accurately documented on the comprehensive/annual MDS (Minimum Data Set) assessment for a resident. The clinical record for the resident, who had diagnoses including cerebral palsy, major depressive disorder, bipolar disorder, anxiety disorder, and insomnia, was reviewed. A PASARR level 2 was completed for the resident on a previous date, but the annual MDS assessment did not indicate that the PASARR level 2 had been completed. During an interview, the MDS Clinical Support nurse acknowledged that the MDS assessment should have been marked to reflect the completion of the PASARR level 2 and confirmed that the facility followed the RAI manual as a policy.
Failure to Complete PASARR After Antipsychotic Prescription
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) for a resident after they were prescribed an antipsychotic medication. The resident, who had diagnoses including bipolar disorder, insomnia, and depression, was initially prescribed Seroquel 25 mg at bedtime, which was later increased to 50 mg. Despite this change in medication, no subsequent PASARR assessment was conducted. The resident's previous PASARR level 2 outcome, dated prior to the prescription of Seroquel, did not include this medication. During an interview, the Assessment Clinical Support nurse confirmed that a PASARR level 2 should have been completed following the initiation of the antipsychotic medication. The facility's standard operating procedure for PASRR, which was reviewed, indicated that a change in status, such as the introduction of an antipsychotic, necessitates a new PASARR assessment.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to administer pain medication as ordered by the physician for a resident with chronic pain, chronic respiratory failure, and type 2 diabetes mellitus. The resident reported experiencing pain due to not receiving her medications on time. The care plan indicated the resident was at risk for pain and required medications to be administered as ordered. However, the Medication Administration Record showed that the resident did not receive the prescribed doses of hydrocodone-acetaminophen on a specific date because the medication was not available, and staff were waiting for the pharmacy. The Clinical Support Nurse confirmed that the facility had the medication available in the Emergency Drug Kit, but staff did not utilize it. Additionally, there was no documentation in the electronic health record indicating that the physician was notified about the missed doses. The facility's policy on medication ordering and receiving from the pharmacy stated that emergency pharmacy services are available 24/7, and medications can be obtained from the emergency supply or by special order. However, the staff failed to follow this policy, resulting in the resident not receiving the necessary pain management.
Inadequate Qualification and Time Dedication of Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) was professionally trained in a relevant field such as nursing, medical technology, microbiology, or epidemiology. During an interview, the Executive Director, who was acting as the IP, indicated that she had taken continuing education unit (CEU) classes for the role. However, she did not possess a nursing degree and could not dedicate part-time to the IP role due to her responsibilities in overseeing the day-to-day operations of the facility. Additionally, the Assistant Director of Nursing (ADON), who was the acting IP, had not passed the necessary testing and was not certified. The State Operations Manual (SOM) specifies that the IP must be professionally trained and able to dedicate at least part-time to the role, based on the facility's assessment of its needs. The facility's failure to appoint a qualified IP who could fulfill these requirements led to the deficiency. The report highlights that the IP must have the necessary time to assess, develop, implement, monitor, and manage the Infection Prevention and Control Program (IPCP) effectively, which was not the case in this facility.
Failure to Provide Timely Gluten-Free Meal
Penalty
Summary
The facility failed to provide a full meal in a timely manner to a resident on a gluten-free diet. During a dining observation, Resident 43 was served a meal that did not include all the gluten-free items specified on her dietary menu slip. The resident's meal consisted of chicken, brussels sprouts, and a dessert, whereas the menu indicated she should have received caprese chicken with gluten-free pasta, roasted brussels sprouts, gluten-free garlic bread, and lemon mousse. The discrepancy was noted during an observation at 12:13 p.m., and by 12:44 p.m., the resident still had not received the gluten-free garlic bread or pasta. Interviews with staff revealed that the gluten-free items were not prepared in advance, and there was a failure to communicate with the kitchen to rectify the situation promptly. [NAME] 12 admitted to not calling the kitchen to prepare the missing items, and the Dietary Manager later confirmed that the missing items were only delivered around 1:00 p.m. The facility's policy on altered diet verification, which requires meals to be plated according to diet requirements listed on the tray card, was not followed, leading to the deficiency.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide adaptive dining equipment for a resident who required it, as observed during multiple dining sessions. On two separate occasions, the resident was served meals on regular plates instead of the prescribed divided plate. The resident's care plan, initiated in February, and a physician's order from May both indicated the need for a divided plate at meals. Despite these directives, the staff did not adhere to the dietary requirements, as evidenced by the observations and interviews conducted. The resident in question had diagnoses including metabolic encephalopathy and constipation, which necessitated the use of a divided plate to assist with feeding. Interviews with staff revealed a lack of awareness and communication regarding the resident's dietary needs. The Dietary Manager confirmed that the resident's menu ticket specified the use of a divided plate, and the facility's policy required staff to ensure the provision of appropriate assistive devices. However, this policy was not followed, leading to the deficiency noted in the report.
Non-compliance with Hair Restraint Policy in Kitchen
Penalty
Summary
The facility failed to ensure that staff members adhered to the policy of wearing appropriate hair and facial coverings while in the kitchen. During a random observation, three staff members were found not complying with the facility's hair restraint policy. Staff Member 52 was observed in the kitchen without a hairnet, and [NAME] 6 was seen without a facial covering over his mustache. Additionally, Kitchen Employee 13 was noted to have his facial hair covering under his chin, which he admitted was due to forgetting to put it back on. The facility's policy, last approved in January 2024, mandates that employees wear hair restraints such as hats, hair coverings or nets, and beard restraints while in the kitchen.
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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 West Lafayette
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Village - West Lafayette | 0.3 mi | ★★★★★ | 6 | 1 |
| Heritage Healthcare | 1.1 mi | ★★★★★ | 7 | 0 |
| University Place Health Center And Assisted Living | 1.3 mi | ★★★★★ | 5 | 0 |
| Indiana Veterans Home | 2.1 mi | ★★★★★ | 4 | 0 |
| Saint Anthony Rehab And Nursing Center | 2.9 mi | ★★★★★ | 5 | 0 |
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