Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at American Village during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was grabbed by the neck by another resident with dementia, psychosis, and a documented history of aggressive and threatening behavior. Staff witnessed the incident and separated the residents, but surveyors cited the facility for failing to protect the resident from physical and mental abuse based on the reasonable person concept.
The facility failed to keep behavior care plans current and did not document non-pharmacological interventions before giving PRN anti-anxiety meds or the effectiveness of behavior interventions for two residents with dementia. One resident with dementia and psychosis had repeated aggressive outbursts, including threats, flipping furniture, and choking another resident, while staff reported using snacks, drinks, and redirection that were not captured in the care plan. Another resident with dementia, anxiety, and depression had wandering, refusal of care, restlessness, and aggression, but the chart did not show what non-drug interventions were tried before PRN lorazepam, and staff-described calming approaches such as reassurance, a stuffed cat, quiet time, and bathroom checks were not added to the plan.
An LPN administered another resident’s scheduled metoprolol 100 mg and metformin 500 mg to a resident with heart failure. The resident reported he had to monitor staff during med passes because of the prior medication error, and the nurse documented overnight BP and pulse monitoring for hypotension after the mistake.
A CNA failed to doff soiled gloves and perform HH timely during incontinent care for a resident with dementia, then later removed the gloves and cleaned hands after helping the resident dress. In a separate event, a resident with an indwelling urinary catheter and a care plan directing tubing not to touch the floor was observed wheeling around with the catheter tubing dragging on the floor while nursing staff were nearby.
Failure to provide grooming assistance: Two residents who needed ADL support were observed with long fingernails, and one also had facial hair that staff had not offered to remove. One resident was moderately cognitively impaired and dependent on staff for hygiene, while the other had weakness, repeated falls, and needed substantial help with showers and personal hygiene. Both residents stated staff had not provided or offered the grooming care they wanted, and documentation showed nail care was not recorded.
Pain was not properly assessed, monitored, or documented for two residents. One resident with pain, OA, CKD, and DM with neuropathy requested PRN hydrocodone, but an LPN gave the medication without assessing pain location or level before or after administration, and the resident said staff did not ask about the pain and the medication did not always work. Another resident with severe cognitive impairment and pain had scheduled acetaminophen and PRN tramadol, but the record lacked documentation of pain assessment, pain location or level, or medication effectiveness, even when bruising, swelling, and pain behaviors were observed.
Two residents were allowed to have medications at their bedside and self-administer without timely IDT assessment or documentation confirming clinical appropriateness, as required by facility policy. One resident had an assessment only for self-administering lotion, not pills, and the other had no assessment at all. Both were observed with medications left at their bedside without nursing supervision.
The facility failed to properly manage medications in two medication carts. An insulin pen was not refrigerated, and several medications lacked open date labels. Discontinued medications were not removed. LPNs were unaware of labeling and storage requirements.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in care. A resident with gangrene had arterial ulcers not documented in the MDS, another with Parkinson's disease had dental issues unreported, and a third with anxiety disorder had a PASRR Level II evaluation omitted. These inaccuracies were acknowledged by the MDS Coordinator, highlighting a lack of thorough documentation.
A resident with dementia and mild intellectual disabilities was observed wearing the same clothes over several days, indicating a failure by the facility to develop a timely person-centered care plan addressing his refusal to change clothing. Interviews revealed the resident's preference for certain clothing items, but no care plan was in place to manage this behavior.
The facility failed to administer lidocaine patches as ordered for a resident with pain due to unavailability and lack of timely order clarification. Additionally, another resident with congestive heart failure and diabetes was not weighed as ordered, and a significant weight gain was not reported to the physician. The Director of Nursing and Unit Manager acknowledged these deficiencies.
A resident with limited ROM and multiple diagnoses, including Alzheimer's and multiple sclerosis, was not provided with a prescribed splint as per her care plan. Observations showed the resident without the splint on multiple occasions, and staff interviews confirmed the oversight. The facility's policy requires resident-specific interventions, which were not followed in this instance.
A resident with dementia exhibited fluctuating emotions and behaviors, but the facility failed to develop a timely, person-centered care plan. Despite observations of tearfulness and agitation, the facility relied on pharmacological interventions without documenting non-pharmacological approaches. The lack of a care plan for behavior monitoring, especially during visits from the resident's husband, highlighted a deficiency in aligning with the facility's policy for individualized interventions.
A facility failed to ensure appropriate social services follow-up for a resident with dementia who was allegedly abused by her husband. Despite initial measures for supervised visits, the resident continued to experience distress during her husband's visits, and there was a lack of consistent supervision. Interviews revealed communication gaps between facility units regarding the supervision protocol.
A facility failed to ensure proper infection control during wound care for a resident with a pressure ulcer. The LPN did not use the required gown and gloves, despite Enhanced Barrier Precaution signage in the room. The LPN was unaware of the precautions, indicating a lapse in adherence to infection control policies.
Failure to Protect Resident from Peer-to-Peer Abuse
Penalty
Summary
The facility failed to protect a resident from physical and mental abuse by another resident after an altercation in which one resident grabbed the other resident by the neck. The cited concern was based on the reasonable person concept, with surveyors determining that the event would likely cause fear and distress. The resident who was grabbed had severely impaired cognition and a diagnosis of Alzheimer’s disease, with a quarterly MDS showing significant cognitive impairment. The record showed that the resident who initiated the incident had diagnoses including dementia and psychosis and had a documented history of verbally and physically aggressive behavior, threatening remarks, charging at residents and staff, and other disruptive actions. His care plan identified that he could become aggressive and make threats, and another care plan addressed keeping other residents out of his room. Prior to the neck-grabbing incident, he had already displayed threatening and violent behaviors, including yelling, flipping over a dining table and chairs, and making threats toward others. On the day of the incident, the aggressive resident became verbally aggressive toward the other resident and put his hands around the resident’s neck. A CNA witnessed the event and immediately separated the residents. The incident report stated there were no injuries and that the resident who was grabbed had no recollection of the event. A nurse practitioner note also described the aggressive resident as having choked another resident and being impossible to redirect, with 911 called because no other acute options were available.
Behavior Care Plans and PRN Medication Documentation Not Updated
Penalty
Summary
The facility failed to timely update individualized plans of care for residents with dementia-related behaviors, failed to document non-pharmacological interventions attempted before giving as-needed anti-anxiety medication, and failed to document the effectiveness of interventions used to reduce behaviors for two residents reviewed for dementia care. One resident had diagnoses including dementia and psychosis, severely impaired cognition, and a history of verbal and physical aggression, threatening behavior, and disruptive actions such as throwing items, flipping tables, and charging at staff or other residents. His behavioral reviews noted new or worsening behaviors, but the care plan was not updated with effective interventions after those events, and the record did not capture the specific calming measures staff reported using, such as snacks, drinks, or other individualized redirection strategies. For this resident, the record showed multiple acute behavioral episodes in which he became upset when another resident entered his room or when he was otherwise distressed. He yelled, made threats, flipped over tables and chairs, and at one point choked another resident. Staff and the NP intervened during these episodes, and he received clonazepam on one occasion and one-to-one monitoring on another. Interviews with staff indicated that he was usually redirectable, that he responded to routine and preferred foods, and that snacks and drinks were used to calm him, but those interventions were not reflected in the behavioral care plan. The behavioral review documentation also marked care plan updates with effective interventions as not applicable, despite the documented incidents. The second resident had dementia with anxiety and depression and severely impaired cognition, along with wandering, refusal of care, restlessness, and aggression. Her care plan addressed wandering and refusal of care, but the record did not show what non-pharmacological interventions were attempted before PRN lorazepam was administered on multiple occasions. The chart also lacked behavior progress notes for several days despite psychiatry noting ongoing anxiety, restlessness, and delusions. Staff interviews described interventions such as offering reassurance, rubbing her back, using a stuffed cat for redirection, taking her to a quiet place, and checking whether she needed the bathroom, but these approaches were not added to the behavioral care plan. The record also showed episodes of combative behavior, wandering into other residents’ rooms, falls associated with attempts to get up, and an incident in which she punched a staff member and another resident.
Wrong Medications Administered to a Resident
Penalty
Summary
The facility failed to ensure a resident received the correct medications when an LPN administered another resident’s scheduled medications to Resident 51. Resident 51’s record showed a diagnosis that included heart failure, and during interview he stated he had to monitor staff during medication administration because the nurse had previously given him his roommate’s evening medications in error. A nursing progress note documented that the nurse administered metoprolol 100 mg and metformin 500 mg, which were scheduled for another resident, to Resident 51. The note also stated new orders were received to monitor blood pressure and pulse every 4 hours overnight for hypotension, and that the resident remained sitting on the side of the bed conversating with his roommate with no concerns noted at that time.
Infection Control Lapses During Incontinent Care and Catheter Management
Penalty
Summary
The facility failed to ensure gloves were doffed and hand hygiene was performed timely during incontinent care for a resident with dementia. During observation, a CNA performed hand hygiene, donned gloves, removed the resident’s pants and opened the brief, and found the resident incontinent of stool. The CNA assisted the resident to turn and completed incontinent care, but did not doff the soiled gloves or perform hand hygiene before putting on a clean brief and assisting the resident with dressing. The CNA later doffed the gloves and performed hand hygiene, and stated during interview that he normally changed gloves and performed hand hygiene after incontinent care and before assisting a resident to dress in clean items. The facility also failed to keep a resident’s indwelling urinary catheter tubing from touching the floor. The resident had obstructive and reflux uropathy and a care plan directing staff not to allow the catheter tubing or any part of the drainage system to touch the floor. During observation in the common area near the nurses station, the resident’s catheter tubing was dragging on the floor while she wheeled herself around, and she ran over the tubing with her wheelchair. The tubing continued to drag on the floor as she wheeled behind the nurses station and later while she rolled in the hallway, even though nursing staff were present nearby. The Assistant Director of Nursing stated that the catheter tubing should not be on the floor.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to assist two residents with ADL-related grooming needs, including fingernail care and facial hair removal. Resident K had diagnoses including stroke and dementia, was moderately cognitively impaired, and was dependent on staff for hygiene care. Although her care plan directed staff to assist with hygiene and provide showers twice weekly with partial bed baths on other days, observations showed her fingernails were long on multiple occasions. Resident K stated she wanted her nails trimmed, shaped, and painted, and her representative said the nails were very long and unkept. Staff had only trimmed her toenails, and the shower documentation did not include nail care. The DNS stated the shower sheets did not have a place to document nail care services. Resident J had diagnoses including weakness and repeated falls and was assessed as moderately impaired for daily decision making, with substantial assistance needed for showers and partial to moderate assistance for personal hygiene. During observations, Resident J had moderately long fingernails with black substance underneath them and a full mustache. The resident stated staff had not offered to shave her face or clean her nails, and said she normally shaved facial hair at home and would be willing to use facial hair removal cream if that was what the facility used. The plan of care included offering showers twice weekly and assisting with grooming as needed. A unit manager stated CNA staff were responsible for cleaning and trimming Resident J's fingernails and shaving her facial hair, and the facility's A.M. care policy stated staff were to assist residents with washing hands and shaving during morning care.
Pain Not Assessed or Documented for Two Residents
Penalty
Summary
The facility failed to ensure pain was assessed, monitored, and addressed for 2 residents who required pain management. One resident had diagnoses including pain, osteoarthritis, kidney disease, and type 2 diabetes mellitus with diabetic neuropathy, and was moderately cognitively impaired. The resident’s pain care plan directed staff to administer pain medications as ordered, assess and document the effectiveness of PRN medications, notify the medical provider if pain was not relieved or worsened, and provide nonpharmacological interventions. However, when the resident requested pain medication, an LPN administered hydrocodone without observing any assessment of pain location or pain level before or after administration. The resident stated staff did not ask where the pain was or how bad it was, and that the pain medication did not work at times. The LPN later stated he was supposed to assess and document the location and level of pain when giving a PRN pain medication. Another resident with severe cognitive impairment and a diagnosis of pain had a pain care plan directing staff to notify the medical provider if pain was not relieved or worsened and to assess for signs of pain related to nonverbal behaviors. The resident had scheduled acetaminophen and PRN tramadol ordered for pain, and records showed episodes of right leg bruising, swelling, and pain when the foot was touched, including yelling in pain when the foot was touched. The record lacked documentation that the resident’s pain was assessed for location, level, or effectiveness after pain medications were given, and there was no documentation that pain was monitored or addressed on the days the bruising and swelling were noted. The DON stated pain assessments should have been conducted for residents receiving scheduled pain medications and that staff should have assessed the resident every shift, but she could not provide information showing the resident’s pain was addressed beyond administration of scheduled acetaminophen.
Failure to Assess and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that the interdisciplinary team (IDT) timely determined and documented whether self-administration of medications and treatments was clinically appropriate for two residents. For one resident with chronic obstructive pulmonary disease and other diagnoses, the clinical record showed she was cognitively intact and had multiple physician orders for daily medications. She was observed in her room with medication cups containing her morning medications left at her bedside without a nurse present. The resident confirmed she had not yet taken the medications. The nurse later confirmed the resident had taken them after being prompted. The Director of Nursing (DON) stated that while there was a self-medication assessment for the resident regarding lotion, there was no documentation supporting her ability to self-administer pill medications. For another resident with dementia who was also assessed as cognitively intact, multiple physician orders for daily medications were present. This resident was observed with a medication cup at his bedside and no nurse present. He could identify some, but not all, of the medications in the cup. The nurse reported that the resident refused to let her remove the medications from his room. The DON confirmed there was no self-administration assessment for this resident. The facility's policy requires an IDT assessment and physician order for self-administration, as well as secure storage and quarterly reassessment, none of which were documented for these residents.
Medication Management Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to proper medication management protocols, as observed in two medication carts. In the 200-hall medication cart, an insulin degludec pen for a resident was found opened without an open date label, and another insulin pen was not refrigerated as required by the manufacturer. Additionally, a bottle of lactulose for another resident was open without an open date label, and a bottle of liquid guaifenesin dextromethorphan, which had been discontinued, was not removed from the cart. Another bottle of lactulose for a different resident was also open without an open date label. The LPN responsible for this cart was unaware of the need for open date labels and the refrigeration requirement for the insulin pen. In the 400-hall medication cart, two bottles of nitroglycerin pills for a resident were open without open date labels, and a bottle of liquid ibuprofen for another resident was similarly unlabeled. The LPN overseeing this cart was unsure about the necessity of open date labels. The facility's Medication Storage and Expiration Policy mandates that staff record the date opened on medication containers and store medications according to manufacturers' recommendations. The policy also requires that expired, discontinued, or medications belonging to hospitalized patients be stored separately until destroyed or returned.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in their care. For Resident 329, the clinical record review revealed a diagnosis of gangrene and pain, with a wound progress note indicating arterial insufficiency on both feet. However, the Admission MDS assessment did not reflect the presence of arterial ulcers, which was an oversight acknowledged by the MDS Coordinator during an interview. This discrepancy highlights a failure to accurately document the resident's condition, which is crucial for appropriate care planning. Resident 22, diagnosed with Parkinson's disease, had a Nurse Practitioner Progress Note indicating issues with two broken teeth affecting her eating. Despite this, the Significant Change MDS assessment did not report any dental issues, contradicting the care plan that identified a risk for dental problems. Similarly, Resident 49, with anxiety disorder and PTSD, had a PASRR Level II outcome indicating approval for long-term care without specialized services. However, the Significant Change MDS assessment failed to capture this evaluation, as confirmed by the MDS Coordinator. These inaccuracies in the MDS assessments reflect a lack of thoroughness in documenting residents' conditions and evaluations, which are essential for ensuring comprehensive care.
Failure to Develop Timely Care Plan for Clothing Refusal
Penalty
Summary
The facility failed to develop a timely person-centered care plan for a resident who refused to change clothes. The resident, who has diagnoses including dementia and mild intellectual disabilities, was observed wearing the same clothing over several days. Despite being cognitively impaired and requiring supervision and setup assistance during dressing, the resident's clinical record did not contain a care plan addressing his refusal to change clothing. Interviews with facility staff revealed that the resident often refused to change clothes due to a preference for certain items. The Director of Nursing confirmed that the resident becomes fixated on favorite clothing items, which contributed to the refusal. The facility's Comprehensive Care Plan Policy requires that each resident have an interdisciplinary care plan based on their needs and preferences, but this was not implemented for the resident in question.
Failure to Administer Medication and Monitor Weight as Ordered
Penalty
Summary
The facility failed to administer lidocaine patches as ordered for a resident with pain and neuropathy. The physician's order required the application of lidocaine patches twice daily to the resident's feet. However, the Treatment Administration Record (TAR) showed multiple instances where the patches were not administered due to unavailability. The pharmacy indicated that the order needed clarification regarding the timeframe the patches should not be worn, but the nursing staff did not seek clarification promptly. The Director of Nursing acknowledged that the order should have been clarified sooner. Additionally, the facility did not adhere to a physician's order for another resident with congestive heart failure and diabetes, which required weighing the resident three times weekly and notifying the physician of any weight gain of three pounds or more. The Medication Administration Record (MAR) lacked documentation of weights on specified dates, and a significant weight gain of 5.2 pounds was not reported to the physician. The Unit Manager confirmed that the weights should have been obtained and the physician notified as per the order. The facility's Resident Weight Monitoring policy was provided, indicating the requirement to weigh residents per physician order.
Failure to Apply Splint as Care-Planned for Resident with Limited ROM
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion (ROM) by not applying a splint as care-planned. Resident 40, who has diagnoses including Alzheimer's disease, multiple sclerosis, osteoarthritis, and chronic pain, was observed multiple times without the prescribed left hand resting splint/brace. The care plan indicated that the resident was on a Passive Range of Motion (PROM) program and could tolerate wearing the splint for four hours each morning to reduce the risk of contractures. Despite the care plan, observations on three separate occasions revealed that the resident was without the splint while sitting in her wheelchair. Interviews with a Certified Nurse Aide (CNA) and the Director of Nursing (DON) confirmed that the splint should have been applied as per the care plan. The CNA was unable to locate the splint, suggesting it might be in the laundry, and the DON acknowledged the oversight. The facility's Comprehensive Care Plan Policy emphasizes the need for resident-specific interventions to promote the highest level of functioning, which was not adhered to in this case.
Failure to Develop Person-Centered Care Plan for Resident with Dementia
Penalty
Summary
The facility failed to develop a timely, person-centered behavior management care plan for a resident diagnosed with dementia, depression, and cognitive communication deficit. The resident, who was severely cognitively impaired, exhibited fluctuating emotions, crying, and yelling, as noted by a hospice MSW. Despite these observations, the facility did not document these behaviors or initiate interventions on the date they were reported. The resident was later transferred to a memory care unit due to increasing behaviors such as agitation, restlessness, and wandering. The facility's response to the resident's behaviors primarily involved pharmacological interventions, including scheduled and as-needed lorazepam, without documented non-pharmacological interventions. The resident's husband expressed concerns about the resident's drowsiness and anxiety, leading to changes in medication administration. However, the facility did not develop a care plan for monitoring the resident's behavior, particularly when the husband was present, nor did they document daily behavior monitoring. Interviews with facility staff revealed that the resident often became tearful and sought physical comfort, yet these observations were not reflected in a care plan. The facility's behavior management policy emphasized individualized and non-pharmacological interventions, but these were not implemented for the resident. The lack of a care plan addressing the resident's mood and behaviors related to dementia was a significant deficiency, as it did not align with the facility's policy to provide supportive interventions for residents with distressing behaviors.
Failure to Ensure Supervised Visitation for Resident with Alleged Abuse
Penalty
Summary
The facility failed to ensure appropriate social services follow-up for a resident with dementia, depression, and cognitive communication deficit, who was involved in an incident of alleged abuse by her husband. The resident, identified as severely cognitively impaired, was observed in distress during interactions with her husband, who was reported to exhibit aggressive behavior towards her. Despite the facility's initial response to the incident, which included supervised visitations, the resident continued to experience emotional distress during her husband's visits. The incident report and subsequent notes indicated that the resident's husband was overheard yelling at her and was resistant to staff intervention. The facility staff had to call the police to escort him out after he refused to leave. Despite these measures, the resident's emotional state fluctuated, and she exhibited increased anxiety and agitation during her husband's visits, as noted in a psychiatry progress note. The facility's social services and nursing staff were aware of the husband's behavior, yet there was a lack of consistent supervision during his visits, as observed on multiple occasions. Interviews with facility staff revealed that there was a lack of communication and coordination between the Assisted Living unit and the Skilled Nursing Facility regarding the supervision of the resident's husband. The Memory Care Support Specialist was unaware of the supervised visitation protocol that was initially implemented. The facility's visitation policy allowed for supervised visits in cases of suspected abuse, but this was not consistently enforced, leading to ongoing distress for the resident during her husband's visits.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed during a wound dressing procedure for a resident with Alzheimer's disease and a pressure ulcer on the sacrum. The care plan for the resident indicated the need for Enhanced Barrier Precautions, which require the use of gown and gloves during high-contact care activities such as wound care. However, during an observation, it was noted that the LPN only donned gloves and was unaware of the Enhanced Barrier Precautions required for the resident. The Director of Nursing confirmed that Enhanced Barrier Precaution signage was present in the resident's room, but the trash can did not contain discarded PPE, indicating non-compliance with the policy. The LPN admitted to not using the required PPE, highlighting a lapse in adherence to the facility's infection control policy. This deficiency was identified through observation, interview, and record review, emphasizing the need for staff awareness and compliance with infection prevention protocols.
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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 Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside Health And Rehabilitation Center | 1.1 mi | ★★★★★ | 11 | 0 |
| Tranquility Nursing And Rehab | 2.4 mi | — | 0 | 0 |
| Hooverwood | 3.3 mi | ★★★★★ | 12 | 1 |
| North Capitol Nursing & Rehabilitation Center | 4.4 mi | ★★★★★ | 5 | 0 |
| Allison Pointe Healthcare Center | 4.4 mi | ★★★★★ | 19 | 0 |
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