Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crossroads Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with cognitive impairment and multiple health conditions experienced an unwitnessed fall resulting in an abrasion. Although documentation indicated the responsible party was notified, interviews and progress notes revealed that staff were unable to reach her and did not ensure follow-up, resulting in the responsible party learning of the incident several days later.
A resident with a history of falls, cognitive impairment, and multiple medical conditions experienced several falls, including an unwitnessed incident resulting in injury. The care plan was not updated to address the actual falls, their causes, or to add new interventions after each event, despite facility policy and staff acknowledgment that updates were required.
A resident with a history of falls, cognitive impairment, and mobility limitations experienced multiple falls, including an unwitnessed incident resulting in injury. Despite these events, the care plan was not updated to address the actual falls or implement individualized interventions, and staff confirmed that required reassessments and care plan modifications were not completed as per facility policy.
A resident with severe cognitive impairment exhibited behavioral issues that were not addressed in her care plan, leading to a deficiency. Despite incidents where she slapped another resident, the care plan was not updated until after a surveyor's inquiry. This oversight placed residents at risk of unmet needs and potential injury. Staff interviews revealed miscommunication about responsibilities for updating care plans.
A facility failed to maintain the dignity of a resident by not covering her urinary catheter bag, despite her care plan specifying the need for a privacy cover. Additionally, another resident experienced delays in meal service, waiting significantly longer than her tablemates on two occasions. Staff interviews revealed that these issues were due to oversight and communication lapses, contrary to facility policies.
A resident with a Stage 4 pressure ulcer did not receive the prescribed wound vacuum treatment due to a nurse's inability to follow orders. The nurse applied a wet to dry dressing without notifying the physician or documenting the change, potentially delaying wound healing. The resident expressed concern over the improper care, and the facility acknowledged the failure to adhere to physician orders and documentation requirements.
A resident with a Stage 4 pressure ulcer did not receive the prescribed wound vacuum treatment due to a nurse applying a wet to dry dressing instead. The nurse failed to document the change or notify the physician, potentially delaying the healing process. The resident expressed concern about the deviation from the care plan, and staff confirmed that supplies were available and the prescribed treatment should have been followed.
A facility failed to maintain an effective infection control program during wound care for a resident with a Stage 4 pressure ulcer. RN A contaminated supplies and used unclean scissors on the wound, despite the facility's policy requiring clean and dirty areas during procedures. The resident, with moderate cognitive impairment, was at risk of infection due to these breaches.
The facility failed to maintain respiratory equipment for two residents, leading to deficiencies in care. A resident with dementia and dysphagia did not have her oxygen tubing and humidifier bottle replaced weekly, and her air concentrator filter was dusty. Another resident with cerebral palsy and cystic fibrosis had outdated nebulizer equipment. Staff interviews confirmed that equipment should be changed weekly, but this was not done, risking respiratory infections.
The facility failed to provide necessary wound care treatments for three residents with pressure ulcers, as per physician's orders. The residents, who had various medical conditions and cognitive impairments, did not receive consistent care, with multiple missed treatments documented in April and May. Interviews with staff suggested possible documentation errors, but the incomplete records made it difficult to confirm whether the care was actually provided.
A resident's privacy was compromised during wound care when the DON, an RN, and a CNA failed to draw the privacy curtain, exposing the resident's chest area. Despite closing the room door, the oversight left the resident visible to anyone entering. Staff interviews confirmed the lapse, and records showed no recent training on privacy protocols.
Failure to Notify Responsible Party After Resident Fall
Penalty
Summary
The facility failed to immediately notify a resident's responsible party following an unwitnessed fall that resulted in an abrasion. The resident, who had a history of left femur fracture, diabetes mellitus type II, osteoarthritis, moderate cognitive impairment, and functional limitations, experienced a fall in her room early in the morning. Documentation indicated that the responsible party was notified shortly after the incident; however, nursing progress notes later revealed that attempts to contact the responsible party were unsuccessful due to a reported busy signal. The responsible party later stated she was not contacted and only learned of the fall several days later when the resident complained of pain. Interviews with facility staff confirmed that the night nurse was unable to reach the responsible party and passed the information to the ADON, who also failed to make successful contact and did not ensure follow-up. The responsible party clarified that she only uses a cell phone, which does not produce a busy signal, suggesting the wrong number may have been used. Facility policy requires notification of significant changes in resident status to the responsible party, but this was not achieved in this instance.
Failure to Update Care Plan After Multiple Resident Falls
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan with measurable objectives and timetables to address the needs of a resident who had a history of multiple falls. The resident, who had a left hip fracture, unsteadiness on her feet, diabetes mellitus type II, osteoarthritis, and moderate cognitive impairment, experienced several falls during her stay. Despite these incidents, the care plan was not updated to reflect the actual falls, their causes, or to include new interventions after each event, particularly following an unwitnessed fall that resulted in an abrasion and bruising. Review of the resident's care plan showed that while some interventions were listed, such as fall risk signage, ensuring call lights were within reach, and providing non-skid footwear, the plan did not address the specific circumstances or root causes of the repeated falls. The care plan also lacked updates after significant events, including the most recent unwitnessed fall. Interviews with the resident revealed she was aware of her frequent falls and sometimes attempted to transfer herself if assistance was delayed, despite needing supervision or assistance with transfers. Staff interviews confirmed that the care plan should have been reviewed and updated after each fall to identify root causes and implement appropriate interventions. However, the care plan remained unchanged after the most recent incident, and the facility's policy requiring comprehensive, person-centered care planning with measurable objectives and timeframes was not followed. This failure resulted in the resident's individualized needs not being addressed in a timely manner.
Failure to Update Care Plan and Provide Adequate Supervision After Multiple Falls
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and individualized interventions to prevent accidents, specifically falls. The resident, who had a history of left femur fracture, unsteadiness, diabetes mellitus type II, and osteoarthritis, was assessed as having moderate cognitive impairment and functional limitations in both upper and lower extremities. Despite being identified as a fall risk and experiencing multiple falls over several months, the resident's care plan was not updated to address actual falls, including an unwitnessed fall that resulted in abrasions and bruising. The care plan contained general fall prevention interventions but was not revised after each incident to reflect new or individualized strategies based on the circumstances of the falls. Interviews with facility staff confirmed that the care plan should have been reviewed and updated after each fall, particularly following the most recent unwitnessed fall. The facility's policy required reassessment and immediate updating of the interdisciplinary plan of care after each fall, but this was not done. The lack of timely review and modification of the care plan after repeated falls constituted a failure to provide adequate supervision and assistance devices, as required to prevent further accidents.
Failure to Update Care Plan After Behavioral Incidents
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with severe cognitive impairment, resulting in a deficiency. The resident, who had been admitted with diagnoses including dementia and diabetes, exhibited behavioral issues that were not reflected in her care plan. Despite incidents on two separate occasions where the resident slapped another resident, the care plan was not updated to address these behaviors until after the surveyor's inquiry. The first incident occurred when the resident slapped another resident's arm while he was asleep, and the second incident involved the resident repeatedly putting her hands in another resident's face, leading to a physical altercation that resulted in injuries to the resident's face. Despite these events, the care plan did not include any problems related to behaviors until it was updated on the day of the surveyor's visit. The lack of timely updates to the care plan placed residents at risk of not having their individualized needs met and could result in injury and a decline in physical well-being. Interviews with facility staff revealed that the care plan updates were overlooked due to miscommunication and assumptions about responsibilities. The Director of Nursing (DON) and the Assistant Director (AD) acknowledged the oversight and the importance of updating care plans promptly to ensure appropriate care. The facility's policy on comprehensive care planning emphasizes the need for ongoing discussions and timely updates to reflect changes in residents' goals, preferences, and needs, which was not adhered to in this case.
Failure to Maintain Resident Dignity and Timely Meal Service
Penalty
Summary
The facility failed to maintain the dignity of Resident #7 by not ensuring her urinary catheter bag was covered with a privacy cover. Resident #7, who has severe cognitive impairment, was observed on two separate occasions with her catheter bag exposed, contrary to her care plan which specified the use of a privacy cover. Interviews with staff, including a CNA, RN, and the DON, confirmed that it is the facility's expectation to cover catheter bags to maintain resident dignity, although the facility's catheter care policy did not explicitly mention the use of covers. Resident #47 experienced a delay in being served lunch compared to other residents at her table on two consecutive days. Despite being present in the dining room and seated with other residents, she had to wait approximately 20 to 25 minutes longer than her tablemates to receive her meal. Interviews with the DON, Kitchen Manager, and RN A revealed that the facility's policy is to serve all residents at a table simultaneously when possible, but communication lapses between dining room staff and kitchen staff led to Resident #47 being overlooked. Both deficiencies highlight the facility's failure to adhere to its own policies and procedures, impacting the residents' dignity and quality of life. The lack of a privacy cover for Resident #7's catheter bag and the delayed meal service for Resident #47 were attributed to staff oversight and communication issues, respectively, as confirmed by staff interviews and observations.
Failure to Follow Wound Care Orders and Notify Physician
Penalty
Summary
The facility failed to immediately inform the resident's physician when a nurse was unable to follow wound care orders for a resident with a Stage 4 pressure ulcer. The resident, who had moderate cognitive impairment, was supposed to have a wound vacuum attached to his coccyx wound, but the nurse applied a wet to dry dressing instead. The nurse did not notify the physician or document the change in treatment, which could have delayed the healing process of the resident's wound. The nurse, identified as RN C, was a weekend supervisor and not specialized in wound care. She admitted to having difficulty with the wound vacuum and decided to use a wet to dry dressing without consulting the physician. RN C also failed to document her actions and did not request assistance from the on-call nurse. The resident expressed concern about the change in treatment and the lack of proper wound care, indicating that this was not the first time the wound vacuum was not replaced as ordered. The Director of Nursing (DON) and the facility's administration acknowledged the failure to follow physician orders and the lack of documentation. The DON stated that the nurse should have notified the physician and family of any changes in wound care. The facility's policy on skin integrity management requires wound care to be performed as ordered by the physician, which was not adhered to in this case.
Failure to Follow Physician's Orders for Wound Care
Penalty
Summary
The facility failed to provide necessary treatment and services consistent with professional standards of practice for Resident #49, who had a Stage 4 pressure ulcer on the coccyx. The resident was supposed to have a wound vacuum dressing applied as per the physician's orders, but RN C applied a wet to dry dressing instead. This deviation from the prescribed treatment was not documented, and the physician was not notified of the change in wound care. Resident #49, a male with moderate cognitive impairment, was admitted with a diagnosis of a Stage 4 pressure ulcer. The care plan specified the use of a wound vacuum to be changed three times a week to promote healing. However, during an observation, the resident reported that the wound vacuum was not applied, and a wet to dry dressing was used instead. The wound vacuum machine was observed at the bedside, unattached and without a reservoir. Interviews revealed that RN C, who was not a specialized wound care nurse, decided to use a wet to dry dressing due to difficulties with the wound vacuum and did not document the care provided. The DON and other staff confirmed that supplies were available, and the nurse should have followed the physician's orders. The failure to adhere to the prescribed wound care regimen could have delayed the healing process for Resident #49.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper wound care provided to Resident #49, who had a Stage 4 pressure ulcer on the coccyx. During an observation, RN A was seen contaminating supplies prior to wound care and using contaminated scissors to cut foam, which was then placed into the open wound. This breach in standard precautions occurred despite the facility's policy that required a clean and dirty area to be maintained during wound care procedures. Resident #49, a male with moderate cognitive impairment, was admitted with a diagnosis of a Stage 4 pressure ulcer. The care plan required the use of a wound vac to be changed three times a week. RN A, who was not wound care certified and had received informal training, was temporarily assigned to perform wound care. The Director of Nursing and the Administrator acknowledged the failure to follow infection control protocols, which posed a risk of infection and delayed wound healing for the resident.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, leading to deficiencies in the maintenance and replacement of respiratory equipment. Resident #1, a female with dementia and dysphagia, was observed receiving oxygen therapy via nasal cannula from an air concentrator. The facility did not replace her oxygen tubing and humidifier bottle every seven days as required, and the air concentrator filter was found to be covered in dust and debris. Despite having orders to change the respiratory concentrator water and clean the filter weekly, these tasks were not consistently completed, as evidenced by the dates recorded on the equipment. Resident #2, a female with athetoid cerebral palsy, cystic fibrosis, and dementia, was also not provided with proper respiratory care. Her nebulizer tubing and mask, including the nebulizing chamber, were not replaced every seven days as required. The nebulizer equipment was found bagged at her bedside with outdated markings, indicating a lack of adherence to the facility's schedule for equipment changes. The facility's records did not show any indication of treatment or completion of the required changes for the dates reviewed. Interviews with facility staff, including an LVN, RN, and the ADON, confirmed that respiratory equipment should be changed weekly or more frequently if soiled. However, observations and interviews revealed that these procedures were not followed, leading to potential risks of respiratory infection for the residents. The facility's policies and procedures manual also outlined the need for weekly cleaning and replacement of respiratory equipment, which was not adhered to, as confirmed by the ADON and the Administrator.
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice. This deficiency was identified for three residents who were reviewed for medication and treatment errors. The facility did not follow physician's orders for providing wound care to these residents on a regular basis, which could place them at risk of delayed wound infection and healing processes. Resident #1, a male with multiple diagnoses including osteomyelitis and protein-calorie malnutrition, had a stage 3 pressure ulcer on his right heel. The care plan required specific treatments, including wound vac and dressing changes, which were not consistently administered as per the physician's orders. The Wound Administration Record (WAR) indicated missed treatments on several dates in April and May 2024. Resident #2, a female with severe cognitive impairment and multiple pressure ulcers, also did not receive prescribed wound care treatments on several occasions. Her care plan included cleansing and dressing of various wounds, which were not performed as ordered. Similarly, Resident #3, a female with a stage 3 pressure ulcer, did not receive the required treatments on multiple dates. Interviews with the LVN and DON suggested that the omissions might be due to documentation errors rather than neglect in care, but the incomplete WAR made it difficult to confirm this.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure the privacy of a resident during wound care, as observed by surveyors. The incident involved a female resident with multiple diagnoses, including psychotic disturbance, anxiety, hemiplegia, and a stage 3 pressure ulcer. During a wound care procedure, the Director of Nursing (DON), an RN, and a CNA entered the resident's shared room, closed the door, but neglected to draw the privacy curtain. This oversight exposed the resident's chest area to the room, potentially visible to anyone entering unexpectedly. Interviews with the involved staff confirmed the lapse in privacy protocol. The CNA acknowledged the privacy curtain should have been closed, while the RN admitted the resident's privacy and dignity were compromised. The DON explained that the wound care team was nervous and forgot to draw the curtain, despite the resident's roommate being frequently in and out of the room. The facility's in-service records showed no training on residents' privacy or rights during the relevant period, and the facility's policy emphasized the resident's right to privacy and dignity.
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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 Hearne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Franklin Nursing Home | 12.7 mi | — | 8 | 0 |
| Lampstand Nursing And Rehabilitation | 20.1 mi | — | 5 | 2 |
| St. Joseph Manor | 20.3 mi | — | 5 | 0 |
| Crestview Retirement Community | 20.3 mi | — | 0 | 0 |
| Legacy Nursing And Rehabilitation | 20.8 mi | — | 5 | 0 |
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