The October 9 incident at Cobblestone Crossings Health Campus involved CNA 4 and Resident B, a woman with severe cognitive impairment from Alzheimer's disease who required maximum assistance from two staff members for transfers. LPN 8 witnessed the aide "pulling on Resident B's arm in an effort to transfer her from her chair to her bed" around 8:30 p.m., according to federal inspection records.
The licensed practical nurse performed a head-to-toe assessment of the resident but failed to document either the incident or the assessment in clinical records. She also didn't take vital signs or complete a pain assessment following what she observed.
The facility didn't report the incident until 4:40 p.m. the next day, when the Director of Nursing called the Corporate Nurse Consultant. An Indiana report form wasn't filed until 6:01 p.m. on October 10, nearly 22 hours after the incident occurred.
Federal regulations require nursing homes to report suspected abuse immediately. The facility's own policy states that "any person with knowledge or suspicion of suspected violations shall report immediately" and must "immediately notify the Executive Director."
Resident B's care plan specifically warned against rushing her during care. A health care plan dated September 30 noted she required "maximum assistance of two staff members for transfers." Another plan from September 19 instructed staff to "allow resident sufficient time to complete all or parts of tasks and to not rush the resident."
The resident was considered high-risk for injury. Her care plan warned staff to "avoid shearing skin during positioning, turning, and transferring" due to her mobility limitations, weakness, and Alzheimer's disease. She used a wheelchair for mobility and was completely dependent on staff for all daily activities.
When CNA 2 reported concerns about CNA 4's interaction with Resident B, the facility suspended the aide and began an investigation. Staff interviewed residents with cognitive scores of 8 or above and completed skin checks on residents with lower cognitive function scores.
The facility started in-service training sessions with staff following the incident. Managers also implemented monitoring of Resident B's psychosocial well-being.
A nursing progress note recorded on October 12 as a late entry described assessments completed on October 10. The resident was "smiling, responsive and without distress" with "no physical injuries" and "no bruising noted at this time."
The investigation summary, completed October 12 at 6:00 p.m., confirmed that a staff member had reported concerns about CNA 4's interaction with the resident. The reporting staff member "felt CNA 4 had rushed the resident during care."
Resident B's admission assessment from October 1 showed severe cognitive impairment that affected her communication abilities. She had "difficulty communicating some words or finishing thoughts" but could usually understand conversations, though she "missed some part/intent of a message but comprehends most conversation."
The assessment noted she had no behavioral issues, delusions, hallucinations, or rejection of care. She was totally incontinent of bowel and bladder and had experienced a fall in the month before admission.
Her diagnoses included Alzheimer's disease, depression, and total urinary and bowel incontinence. She received hospice services as part of her care plan.
The facility's abuse and neglect policy, provided to inspectors, required immediate reporting of any suspected violations "without fear of reprisal" and immediate notification of the Executive Director. The policy appeared to be undated when provided to federal inspectors.
During the investigation, inspectors reviewed clinical records for Resident B and interviewed facility staff about the incident and reporting procedures. The Corporate Nurse Consultant confirmed receiving the delayed report from the Director of Nursing about what LPN 8 had observed.
The delay in reporting violated federal requirements that nursing homes immediately report suspected abuse, neglect, or theft to proper authorities. The citation noted the facility "failed to report an incident of potential resident abuse by a staff member in a timely manner to the Administrator."
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The inspection was conducted in response to a complaint filed with state authorities.
The incident highlighted gaps between the facility's written policies and actual practice. While care plans explicitly warned against rushing Resident B and required two-person transfers, the witnessed incident involved a single aide pulling on the resident's arm during transfer.
The failure to immediately document the incident also violated standard nursing practices. LPN 8's decision not to record the incident or her subsequent assessment left no contemporaneous record of what occurred or the resident's condition immediately afterward.
Staff training initiated after the incident suggested the facility recognized deficiencies in how employees handled transfers and recognized potential abuse situations. The decision to interview cognitively intact residents and check others for injuries indicated broader concerns about unreported incidents.
Resident B's vulnerability made the delayed reporting particularly concerning. Her severe cognitive impairment, complete dependence on staff, and high fall risk created multiple opportunities for harm that might go undetected without proper oversight and immediate incident reporting.
The October inspection occurred just weeks after the resident's admission to the facility on October 1, suggesting the incident happened during her initial adjustment period when she was still adapting to new surroundings and staff routines.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cobblestone Crossings Health Campus from 2025-10-23 including all violations, facility responses, and corrective action plans.
Additional Resources
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