Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Trailpoint Village during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities experienced significant ongoing weight loss despite existing nutritional interventions such as a regular diet with high-calorie shakes and ice cream. Assessments documented severe cognitive impairment, low meal intake, refusal of extra nutritional items, and progressive weight decline well below the resident’s usual body weight range. An IDT note identified the resident as a picky eater and recommended re-evaluating food choices and updating the care plan, but the care plan was not revised to incorporate food preferences, contrary to facility policy requiring periodic IDT review and revision of care plans.
Failure to start a recommended restorative ambulation program after skilled PT ended. A cognitively intact resident with chronic pain, constipation, conversion disorder with seizures/convulsions, and COPD had progressed in PT to walking 50 to 60 feet with a 4-wheeled walker and CGA, and the PT discharge note said she was to continue with restorative services to maintain function. The resident later reported she could only walk a few steps to the toilet, and the DON of Therapy stated restorative therapy had not started because the restorative aide was unavailable due to a staff hospitalization.
Medication Administration Error Rate Exceeded 5%: Surveyors observed 4 medication errors during 31 administered meds, resulting in a 7.75% error rate. An RN omitted an ordered probiotic for one resident and omitted ordered venlafaxine, isosorbide mononitrate, and buprenorphine-naloxone for another resident during med pass. The ED stated one med had been moved to noon, one order had been entered incorrectly to the pharmacy, and one med was on hold due to non-delivery, but the orders and hold status were not documented as such.
A resident with multiple chronic conditions was verbally abused by a departing LPN, who used a disparaging term while exiting the facility after resigning. The incident was witnessed by others, though the exact words were not clearly heard, and was reported by the resident. Facility policy prohibits such abuse, but the event occurred as the LPN left her position.
A CNA failed to follow the care plan and facility policy requiring two staff for Hoyer lift transfers, resulting in a resident with significant medical needs falling from the lift and sustaining multiple fractures. The CNA performed the transfer alone despite prior training and available assistance, and the incident led to hospitalization for the resident.
A resident with multiple chronic conditions did not receive prescribed Oxycodone doses, and five tablets were found missing during a narcotic audit. An LPN with access to the medication could not account for the missing narcotics, refused a drug test, and left the facility abruptly after being questioned. The incident was identified through staff statements and medication count discrepancies.
A resident with complex medical needs was moved by a CNA and the Respiratory Manager after a fall during a Hoyer lift transfer, without first notifying or obtaining assessment from a nurse as required by facility policy. The resident sustained a hematoma above the eyebrow, and the nurse was only informed after the resident had been returned to bed.
The facility failed to properly label and store medications on three of four medication carts. Issues included undated and unlabeled bottles, improper storage of eye drops with oral medications, and incomplete instructions on medication labels. Staff acknowledged the deficiencies and referenced facility policies requiring proper labeling and storage.
A facility failed to coordinate advanced directives with hospice services for a resident receiving end-of-life care. The resident, initially documented as a full code, had a change to Do Not Resuscitate (DNR) status in the hospice's plan of care, which was not communicated to the facility until later. The facility's policy lacked guidelines for ensuring timely updates of new orders from hospice providers.
Failure to Revise Nutritional Care Plan for Ongoing Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to update and revise a comprehensive, person-centered care plan to address a resident’s ongoing nutritional needs and continued weight loss. The resident had diagnoses including dementia, COPD, depression, anxiety, and osteoporosis, and a quarterly MDS showed severe cognitive impairment, need for set-up assistance with eating, and weight loss of 5% or more in the past month and 10% or more in the past 6 months. The resident’s weight declined from 130 pounds to 120 pounds in a little over a month, representing more than a 7.5% loss, and a care plan initiated earlier identified the resident as being at nutritional risk with a goal to maintain a usual body weight range of 135–140 pounds. Interventions such as high-calorie milkshakes at lunch and ice cream at dinner were in place, but the resident continued to lose weight, and the daughter expressed concern about the ongoing weight loss. A follow-up nutrition review by the Corporate Dietary Manager documented that the resident’s weight had decreased further to 118 pounds, confirming significant weight loss over the last month and six months, and noted that while the resident was on a regular diet with high-calorie supplements, average meal intake remained low and extra nutritional items were refused. An IDT progress note recorded an even lower weight of 116 pounds and identified the root cause of the nutrition concern as the resident being a picky eater. The IDT recommended re-evaluating food choices and preferences and updating the care plan accordingly. However, despite this recommendation and the facility’s policy requiring periodic review and revision of care plan problems, goals, and interventions by the IDT, the care plan was not updated to address the resident’s food choices and preferences in response to the continued weight loss.
Failure to Start Recommended Restorative Ambulation Program
Penalty
Summary
The facility failed to initiate a recommended restorative program after skilled therapy ended for one resident reviewed for rehabilitation. The resident was cognitively intact, had diagnoses including chronic pain, constipation, conversion disorder with seizures or convulsions, and COPD, and the annual MDS dated 3/23/2026 indicated she required partial/moderate assistance for walking 10 feet, while walking 50 feet was not attempted due to her medical condition and/or safety. During interview, the resident stated she had been able to walk prior to surgery, had received rehabilitation, and that her insurance had cut her therapy; she reported she could now only walk a few steps to get to the toilet and that therapy had been planning to start a restorative ambulation program. Record review showed physical therapy was ordered from 1/10/2026 through 2/19/2026 for therapeutic activity, therapeutic exercises, gait training, moist heat, Bio freeze as needed, and group therapy as indicated. The PT discharge note dated 2/19/2026 documented excellent progress, with the resident able to walk 50 to 60 feet four times using a four-wheeled walker with contact guard assistance, and stated she was to continue with restorative services to maintain her current level of functioning. The Director of Therapy stated on interview that the resident should have received restorative therapy, but the restorative aide position had been down due to a staff member’s hospitalization, and the resident was at the top of the list to receive restorative services within the next week. The facility policy stated restorative nursing programs may be initiated following cessation of skilled therapy.
Medication Administration Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5% after surveyors observed 4 medication errors during administration of 31 medications, resulting in an error rate of 7.75% for Residents 39 and 112. During a medication pass observation, RN 3 prepared medications for Resident 39, including bupropion hydrochloride, calcium-vitamin D3, ferrous fumarate, fluoxetine, magnesium oxide, omeprazole, multivitamin, liquid protein, and pregabalin, but did not administer the ordered lactobacillus acidophilus 10 billion cell tablet. Record review showed the resident had an order for lactobacillus acidophilus, and RN 3 stated she gave all scheduled medications during the observation period. During another medication administration observation, RN 3 prepared medications for Resident 112, but did not administer ordered venlafaxine 37.5 mg two tablets, isosorbide mononitrate 60 mg one tablet, or buprenorphine-naloxone 8-2 mg buccal strip two strips. The Executive Director stated that lactobacillus acidophilus had been moved to noon because it contributed to nausea, that buprenorphine-naloxone had been ordered incorrectly to the pharmacy as one strip instead of two, and that isosorbide mononitrate had been placed on hold because the pharmacy had not delivered it; however, the lactobacillus order remained written for a morning dose and had not been rewritten, the buprenorphine-naloxone packaging indicated two strips, and there was no hold order or notification for the isosorbide mononitrate. The facility also stated it did not have a medication administration policy and instead used a skills check-off.
Resident Subjected to Verbal Abuse by Departing LPN
Penalty
Summary
A resident with diagnoses including osteomyelitis, type 2 diabetes with diabetic polyneuropathy, and spinal stenosis was subjected to verbal abuse by a former staff member. The resident's care plan noted a tendency for verbal aggression when frustrated. On the day of the incident, the former Unit Manager, an LPN who had resigned, approached the resident at the nurse's station and used a disparaging term, calling the resident a 'piece of shit.' This interaction was witnessed by others, though they could not discern the exact words. The incident was reported by the resident, who also described previous dissatisfaction with the LPN's performance regarding pain medication and transportation arrangements. The facility's policy prohibits all forms of abuse, including verbal abuse, and requires an environment free from such behavior. The administrator confirmed that the LPN spoke inappropriately to the resident as she was leaving the facility after resigning. The event was reported to the state agency, and the facility's abuse prohibition policy was reviewed as part of the investigation. The deficiency centers on the failure to protect the resident from verbal abuse by a staff member.
Failure to Follow Hoyer Lift Protocol Results in Resident Fall and Multiple Fractures
Penalty
Summary
A Certified Nurse Assistant (CNA) failed to follow a resident's comprehensive care plan and the facility's Mechanical Lift/Hoyer Lift Safety procedure during a transfer from a wheelchair to a bed. The care plan specified that the resident, who had diagnoses including chronic respiratory failure with ventilator dependence, cerebral palsy, paraplegia, and an anxiety disorder, required a two-person assist for transfers using a Hoyer lift. Despite being trained and having signed an attestation acknowledging the two-person requirement, the CNA attempted the transfer alone. During the transfer, the resident slipped out of the Hoyer sling and fell to the floor. The CNA reported using her body to guide the resident's fall, but the resident's head struck the floor, resulting in a hematoma above the left eyebrow. The incident was witnessed after the fact by the Respiratory Manager, who assisted in repositioning the resident onto the Hoyer sling and transferring the resident back to bed. The resident later exhibited neurological changes and was transported to the hospital, where multiple fractures were confirmed. Documentation and interviews revealed that staff, including an RN and another CNA, had offered assistance to the CNA prior to the transfer, but the CNA did not request help. The facility's policies and the resident's care plan were not followed, as the transfer was performed by a single staff member. The incident was reported to the state health department after the extent of the resident's injuries was confirmed.
Failure to Prevent Misappropriation of Resident Narcotics
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication for a resident with multiple complex medical conditions, including respiratory failure with hypoxia, diabetic neuropathy, dysphagia, diabetes, and chronic kidney disease. The resident had a care plan for pain management that included administration of Oxycodone 10 mg every 8 hours. According to the Medication Administration Record, the last dose of Oxycodone was administered at 2:00 P.M. on 5/14/25, and no further doses were given for the remainder of the month. During a routine narcotic audit, it was discovered that five Oxycodone tablets were missing from the resident's medication card, with the count showing 70 tablets instead of the expected 75. The missing medication was identified after a nurse noticed the narcotic cards had been repositioned and questioned the LPN who had access to the medication. The LPN did not provide an explanation and subsequently refused a drug test, left the facility abruptly, and could not be contacted afterward. Statements from staff confirmed that the narcotic count was correct prior to the LPN's shift, and the discrepancy was discovered during the LPN's shift. The incident was reported to the Director of Nursing, and the facility's policy defined such misappropriation as the wrongful use of a resident's property or medication without consent.
Failure to Follow Post-Fall Assessment Protocol Before Moving Resident
Penalty
Summary
The facility failed to ensure that staff members acted competently and followed established protocol regarding the notification and assessment by a licensed nurse after a resident experienced a fall. Specifically, a certified nurse aide (CNA) and the Respiratory Manager moved a resident who had fallen during a transfer using a Hoyer lift, without first notifying or obtaining an assessment from a nurse as required by facility policy. The CNA reported that the resident fell out of the Hoyer pad during a transfer, and the Respiratory Manager assisted in repositioning the resident and transferring him back to bed before a nurse was notified. When the nurse was eventually informed, the resident had already been moved and was back in bed. The resident involved had significant medical conditions, including chronic respiratory failure with ventilator dependence, a G-tube, cerebral palsy, paraplegia, and an anxiety disorder. After the fall, a hematoma was observed above the resident's left eyebrow. Facility policy required that any resident experiencing a fall be immediately assessed by the charge nurse for possible injuries before being moved, but this protocol was not followed in this incident.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure medications were labeled and stored according to professional principles on three of four medication carts observed. On the Memory Care cart, an opened, undated, and unlabeled bottle of calcium magnesium with zinc capsules was found, along with a bottle of One a Day Men 50+ vitamin supplement that only had a resident's first name written on the lid. RN 2 indicated that a family member had brought these items in and acknowledged that the bottles should have had labels and an opened date. On the 100 Hall cart, three bottles of prescription eye drops were stored in the same drawer as oral medications, and one of the bottles lacked complete instructions regarding which eyes were to receive the drops. RN 3 was unaware that eye drops could not be stored next to oral medications and noted that the incomplete instructions should have specified the drops were for the resident's right eye. On the 400 Hall cart, an opened and undated bottle of nasal spray and eye drops were found. The Unit Manager confirmed that these bottles should have had an opened date. The facility's policies on medication storage and labeling were provided, indicating that internal and external medications should be stored separately and that opened dates should be recorded on medication containers.
Failure to Coordinate Advanced Directives with Hospice Services
Penalty
Summary
The facility failed to ensure that advanced directives were properly coordinated with hospice services for a resident receiving end-of-life care. Resident 28, who had multiple diagnoses including occlusion and stenosis of the right posterior cerebral artery, metabolic encephalopathy, dementia, schizoaffective disorder, borderline personality disorder, bipolar disorder, and aortic stenosis, was initially documented as a full code according to a physician's order dated November 25, 2024. However, a subsequent physician's order on February 11, 2025, indicated that the resident was to receive hospice care, and the hospice's initial plan of care dated February 10, 2025, indicated a Do Not Resuscitate (DNR) status. Despite this change, the facility was not informed of the updated DNR status until February 28, 2025. During an interview, the facility's administrator acknowledged that the hospice provider was responsible for communicating any changes in orders, including code status. However, the hospice provider failed to notify the facility of the change in Resident 28's code status to DNR. The administrator confirmed the existence of a Physician Orders for Scope of Treatment (POST) form, signed on February 10, 2025, indicating the DNR status, which the facility was unaware of until the administrator contacted the hospice on February 28, 2025. The facility's policy on advanced directives did not include guidelines for communication between hospice providers and the facility to ensure timely updates of new orders.
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.
Illustrative
What surveyors actually found near you
We read the 472 citations issued within 25 miles in the last 12 months — including the 5 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 South Bend
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Twelfth Street Care Center | 2.5 mi | ★★★★★ | 29 | 0 |
| Cardinal Nursing And Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Southfield Village | 2.7 mi | ★★★★★ | 23 | 0 |
| Milton Home, The | 3.1 mi | ★★★★★ | 6 | 0 |
| Holy Cross Village At Notre Dame Inc | 3.6 mi | ★★★★★ | 20 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Trailpoint Village.
100% money-back within 48 hours.
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.