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F0921
E

Failure to Maintain Clean, Odor-Free, and Well-Repaired Environment

Indianapolis, Indiana Survey Completed on 09-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to maintain a clean, odor-free, and well-repaired environment for residents, staff, and the public. During multiple tours and observations, strong urine odors were detected in the main entry, Meridian Hills Unit, and Mapleton Unit. The floors in the Meridian Hills Unit were found to be sticky, with a six-inch black spot present between the entrance and the nurse's station. The Mapleton Unit was also noted to have a persistent strong urine odor during several visits. Interviews with staff and residents confirmed the presence of these odors and described the floors as dirty and linens as worn with holes. Further inspection of resident rooms revealed additional deficiencies in the physical environment. Resident rooms had chipped and scratched door frames, scrapes and missing pieces on chair rails, and walls with missing paint. Used gloves and dirty items were found discarded on the floor, and bed linens were observed to have holes. The maintenance supervisor indicated that repairs were made on an as-needed basis, and work orders were submitted by staff or families when issues were noticed. The facility did not have a policy in place for maintaining a homelike environment.

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