Cobblestone Crossings: Abuse Report Delays Flagged - IN
The resident, identified in inspection records only as Resident B, was in the late stages of Alzheimer's disease. She had been admitted to Cobblestone Crossings Health Campus less than a month earlier. She was entirely dependent on staff for every activity of daily living, incontinent of bowel and bladder, and receiving hospice services. Her care plan, written before the incident occurred, contained a specific instruction: do not rush this resident.
LPN 8 witnessed the incident on the evening of October 9, 2025, at around 8:30 p.m. CNA 4 was attempting to transfer Resident B from her wheelchair to her bed and was pulling on the resident's arm to do it. LPN 8 told investigators she performed a head-to-toe assessment of Resident B after the incident. But she did not document the incident in the clinical record. She did not document the assessment. She did not take vital signs. She did not complete a pain assessment.
She also did not report it to the administrator that night.
The next afternoon, more than 16 hours later, the Director of Nursing called the facility's Corporate Nurse Consultant at 4:40 p.m. on October 10. That call set off the formal response: CNA 4 was suspended, an investigation was opened, staff were interviewed, and in-service training was started. A nursing progress note timestamped 4:40 p.m. on October 10, recorded as a late entry two days later, noted that Resident B was smiling, responsive, and without distress, with no physical injuries or bruising observed.
The facility's own abuse and neglect policy, provided to inspectors by the administrator, stated plainly that anyone with knowledge or suspicion of a violation must report it immediately, and must immediately notify the executive director.
Nobody had.
Federal inspectors from the Centers for Medicare and Medicaid Services cited the facility following a complaint inspection completed October 23, 2025. The citation covered the failure to report a potential abuse incident in a timely manner to the administrator. The level of harm was assessed as minimal harm or potential for actual harm.
What the inspection record makes clear is that the gap between what happened and what was reported was not a matter of minutes or even a few hours. LPN 8 observed the incident, assessed the resident, and then left no trail. The first documentation of any kind, a nursing progress note, was not entered until the following afternoon, and it was later recorded as a late entry, meaning it was not written contemporaneously with the events it described.
Resident B's vulnerability was extensive and well-documented before any of this happened. Her admission assessment, dated October 1, 2025, recorded severe cognitive impairment. She had difficulty communicating, sometimes unable to finish thoughts, though she could generally understand conversation if given time. She used a wheelchair and needed full staff assistance for transfers, with a care plan specifying that two staff members were required for that task. She was on hospice. She had already had a fall in the month before her admission to Cobblestone Crossings.
Her care plan, written September 19, included an explicit intervention: allow the resident sufficient time to complete all or parts of tasks and do not rush her. A separate intervention in the same plan addressed the physical risks of moving a resident whose skin was already flagged as vulnerable, noting that staff should avoid shearing during positioning, turning, and transferring.
CNA 4 was pulling her by the arm.
The Corporate Nurse Consultant, interviewed during the inspection, said LPN 8 had told her she completed the head-to-toe assessment after witnessing the incident. But LPN 8's failure to document it meant there was no contemporaneous record of what she found, no baseline for comparison if Resident B's condition had changed overnight, and no alert to other staff or supervisors that anything had occurred at all.
The investigation summary, dated October 12, two days after the Director of Nursing's call, was not provided to inspectors until October 22, when the administrator handed it over at 12:01 p.m. That summary described the incident as a staff member reporting a concern about an interaction with CNA 4, characterizing it as CNA 4 having rushed the resident during care.
The Corporate Nurse Consultant's account was more specific. CNA 4 had been pulling on Resident B's arm.
Whether that distinction, rushing versus physically pulling, affected how the investigation was framed or what consequences followed for CNA 4 is not addressed in the inspection record. What the record shows is that the facility's investigation summary used softer language than what the Corporate Nurse Consultant described receiving directly from the DON.
Residents with sufficient cognitive capacity to be interviewed were interviewed as part of the investigation. For residents like Resident B, whose severe cognitive impairment made interviewing impossible, the facility completed skin checks instead. The inspection record notes that Resident B was to be monitored for psychosocial well-being going forward.
The inspection covered three residents reviewed for abuse. The timely reporting failure was found for one of them.
Cobblestone Crossings is a health campus in Terre Haute. The inspection was conducted in response to a complaint. The citation issued falls under federal regulations governing the reporting of alleged violations involving mistreatment, neglect, or abuse.
What the record does not resolve is what Resident B experienced between 8:30 on the night of October 9 and the afternoon of October 10, when the first call was made and the first note was written. She had Alzheimer's disease. She could not reliably communicate distress. She could not finish thoughts. She had a care plan built around the recognition that she needed time, gentleness, and two people to move her safely.
She spent that night, and the hours that followed, without a documented assessment, without recorded vital signs, and without anyone having told the people responsible for running the facility that something had happened to her at all.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
COBBLESTONE CROSSINGS HEALTH CAMPUS in TERRE HAUTE, IN was cited for abuse-related violations during a health inspection on October 23, 2025.
The resident, identified in inspection records only as Resident B, was in the late stages of Alzheimer's disease.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.