Cobblestone Crossings Health Campus

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

so they decided to part ways. When she spoke with CNA 4 on the telephone she was not willing to acknowledge the requests to leave the room, and truly could not understand any errors in her behavior. The Administrator did feel CNA 4 would be safe to work with a dependent resident given more training and she did not feel she needed reported to the Board of Nursing for investigation.During a phone interview on 10/23/25 at 1:04 p.m., Resident B's husband indicated the incident happened on a Friday and he was not informed until he received a phone call on Sunday at noon. The DON called and said there had been an incident on Friday. It was a little situation that escalated to a point they felt they needed to suspend the staff member. That was all he had been told. She indicated they had looked Resident B over and they had not observed any bruising or redness. He was told they were going to investigate the incident and would inform him of the details when completed. She told him that under no circumstances would they allow a resident to be treated like that and it should not have happened. The employees know it was not allowed at this facility.

He felt she was trying to figure out if he was going to make a thing out of it. He remains in the dark about

the specifics of what occurred. It had been a couple weeks now and he still had no specific information.During a telephone interview on 10/23/25 at 1:37 p.m., the DON indicated she had spoken to Resident B's spouse on the phone in the middle of the investigation and had told him the details of the occurrence. She indicated during her investigation she had spoken to residents and other staff members.

She did not feel CNA 4 had intent to harm the resident. She did not feel it was an abuse situation due to the lack of intent. She felt CNA 4 was focused on getting her task completed of getting the resident to bed, so even though she was asked to leave by other employees, she returned to complete her task. She could not speak to what CNA 4 was thinking by returning after being asked to leave.An in-service document used for staff education, titled, Preventing, Recognizing, and Reporting Abuse & Neglect, provided by the Administrator on 10/22/25 at 12:01 p.m., included the following: Physical Abuse Definition includes hitting, slapping, pinching, spitting, holding or handling roughly, etc. It also includes controlling behavior through corporal punishment.Examples.Staff to resident abuse with or without injury; Staff member pulls a resident

in order to make them move more quickly.This citation relates to Intake 2641594.3.1-27(a)(1)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cobblestone Crossings Health Campus

1850 E Howard Wayne Dr Terre Haute, IN 47802

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on record review and interview, the facility failed to report an incident of potential resident abuse by a staff member in a timely manner to the Administrator for 1 of 3 residents reviewed for abuse. (Resident B)Findings include:An Indiana report form, dated 10/10/25 at 6:01 p.m., indicated CNA (Certified Nursing Aide) 2 had reported CNA 4 had rushed Resident B during care. CNA 4 was suspended, and an investigation was initiated. Residents with a BIMS (Brief Interview for Mental Status) of 8 or above were interviewed and skin checks completed on residents with a BIMS below 8 were completed. In-service trainings were started with staff. Resident B was to be monitored for psychosocial well-being.A clinical

record review for Resident B was completed on 10/22/25 at 11:30 a.m. Diagnoses included Alzheimer's disease, depression, and total urinary and bowel incontinence.An admission Minimum Data Set (MDS) assessment, dated 10/1/25, indicated the resident had severe cognitive impairment. She had difficulty communicating some words or finishing thoughts but was able, if prompted or given time, and could usually understand although missed some part/intent of a message but comprehends most conversation. She had no behaviors, no delusions or hallucinations, and no rejection of care. The resident used a wheelchair for mobility and was dependent on staff for all activities of daily living. She was totally incontinent of bowel and bladder and had a fall in the last month before admission.A health care plan, dated 9/19/25, indicated resident was at risk for skin breakdown related to mobility, weakness, Alzheimer's disease, and received hospice services. The goal was for resident's skin to remain intact. Interventions included to avoid shearing skin during positioning, turning, and transferring.A health care plan, dated 9/19/25, indicated Resident B required staff assistance to complete self-care and mobility functional tasks completely and safely. The goal was the resident would have functional needs met safely by staff. Interventions included to allow resident sufficient time to complete all or parts of tasks and to not rush the resident.A health care plan, dated 9/30/25, indicated resident's profile care guide included maximum assistance of two staff members for transfers.An Investigation Summary, dated 10/12/25 at 6:00 p.m., provided by the Administrator on 10/22/25 at 12:01 p.m., indicated a staff member had reported a concern about an interaction with CNA 4

during care with Resident B. The staff member felt CNA 4 had rushed the resident during care.A nursing progress note, dated 10/10/25 at 4:40 p.m., (recorded as a late entry on 10/12/25 at 6:47 a.m.) indicated physical and psychological assessments were completed. The resident was smiling, responsive and without distress. No physical injuries were noted and no bruising was noted at this time. Will continue to observe and update as needed.During an interview on 12/22/25 at 1:58 p.m., the Corporate Nurse Consultant indicated she had received a phone call from the DON on 10/10/25 at 4:40 p.m., indicating on 10/9/25 at around 8:30 p.m., LPN 8 had observed an incident with Resident B and CNA 4, where CNA 4 had was pulling on Resident B's arm in an effort to transfer her from her chair to her bed. An investigation was started at that time. LPN 8 had indicated to her that she had performed a head-to-toe assessment of Resident B, but had failed to document the incident or the assessment in the clinical record. She had not taken vital signs or completed a pain assessment following the incident. The facility follows their policy regarding any needed assessments. A current facility policy, undated, titled, Abuse and Neglect Procedural Guidelines, provided by the Administrator on 10/22/25 at 12:01 p.m., included the following: .Identification.ii.

Any person with knowledge or suspicion of suspected violations shall report immediately, without fear of reprisal.iv. Immediately notify the Executive Director.This citation relates to Intake 2641594.3.1-28(c)

Event ID:

Facility ID:

If continuation sheet