Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Clearvista Lake Health Campus during CMS and state inspections, most recent first.
Dishwasher sanitation monitoring was not maintained and kitchen flooring was not kept clean. The dishwasher had ongoing pressure problems and was being used as a low-temp unit, but staff were not consistently documenting wash and sanitation temperatures as required, with logs missing dates and later entries. During kitchen observations, black debris was seen along the back wall flooring in the dishwasher, prep, and cooking areas, and the DM stated the flooring had last been deep cleaned months earlier and the debris was stuck on the floor.
Delayed Self-Medication Assessments for Residents Self-Administering Medications: Two residents were observed self-administering meds without timely self-medication assessments in place. One resident with HTN swallowed pills left by the nurse, and another resident with COPD self-administered an inhaler and Biotene rinse kept in the room. Staff could not locate a self-medication assessment in the chart for one resident, and the assessment for the other was completed after the observation.
A resident with dementia, muscle weakness, RA, and osteoporosis was transferred inconsistently using a gait belt, stand-up lift, or mechanical lift based on conflicting care records and staff judgment. During a bed-to-wheelchair transfer with a gait belt, her legs buckled, her body shifted downward, and she sustained an acute shoulder fracture near prior surgical hardware. Staff interviews showed the transfer method was not clearly standardized across the chart, and different staff used different methods.
Pain management was not properly documented or carried out for two residents. One resident with chronic back pain and an intrathecal pain pump missed scheduled Lyrica doses because the pharmacy had not delivered the medication, and the record did not show physician notification or non-pharmacological interventions despite repeated severe pain and an EMS transfer for pain control. Another resident receiving scheduled acetaminophen and PRN hydrocodone had no documented pain scale, pain location, or non-pharmacological interventions before PRN administration, even though the resident reported ongoing severe pain.
The facility failed to apply TED hose as ordered for a resident with edema and did not adhere to physician orders for blood pressure medication for two residents. One resident received carvedilol despite a low heart rate, and another was given metoprolol tartrate even when their systolic blood pressure was below the specified threshold.
A facility failed to assess the pain severity of a resident with diabetic polyneuropathy before administering oxycodone, as required by their pain management policy. The resident, who had a care plan indicating a risk for pain, did not have documented pain severity assessments on specific dates when pain medication was given. The resident later reported significant pain despite receiving medication, highlighting a lapse in adherence to the facility's policy.
The facility was found to have expired supplies in both the central supply and medication storage rooms. Observations revealed 16 cartons of expired Osmolite 1.5 and ten expired COVID tests. The facility's policy requires checking expiration dates and removing expired items, but this was not followed.
The facility failed to maintain complete and accurate medical records for residents, particularly in documenting urine characteristics after Foley catheter changes and behavior monitoring for those on medications for depression, anxiety, and insomnia. A resident's urine characteristics were not recorded, and behavior monitoring was marked as not applicable during certain shifts, contrary to physician orders requiring documentation three times a day.
A facility failed to maintain infection control during Foley catheter care for a resident with neuromuscular dysfunction of the bladder. The CRCA did not perform hand hygiene after touching the faucet and bed remote before continuing with the procedure, contrary to the facility's infection control and catheter care policies.
The facility failed to maintain resident rooms in good repair, as observed in two cases. A resident's room had unpainted, uneven drywall due to repeated repairs from a trapeze stand, while another resident's room had worn paint from bed scraping. The Director of Plant Operations noted repairs were typically done for new admissions or upon work order submission, but issues persisted.
A resident's room was found to have an ant infestation, with insects observed crawling on the walls and floor. The facility's pest control measures were inadequate, as they only treated the building's exterior and relied on internal maintenance to address the issue. A previous work order had documented ants in the same room, but the problem persisted, indicating a failure to maintain a comfortable, homelike environment.
A resident with a traumatic brain injury and seizure disorder, receiving hospice care, had ants found on his wound and dressing despite the facility's efforts to spray the room for ants. The facility attributed the ant problem to food dropped by the resident's roommate. The presence of ants in the wound dressing indicated a failure to adhere to the facility's guidelines for regular assessment of wounds and skin integrity.
A resident's wound treatment order was not updated timely due to a lapse in entering new physician instructions into the system. An LPN discovered the oversight during an audit and entered the new orders, but noted further updates were needed to match the prescribed treatment frequency.
A facility failed to maintain proper infection control practices, as an LPN did not perform hand hygiene while handling medication for a resident, and a CRCA provided incontinence care without wearing a gown, despite the resident being on enhanced barrier precautions. The lack of available gowns and adherence to PPE protocols highlighted deficiencies in the facility's infection prevention measures.
A resident with a history of stroke, fibromyalgia, hypertension, and dementia experienced an unwitnessed fall. The facility failed to conduct timely post-fall neurological assessments as required, missing several scheduled checks and delaying others, thereby not adhering to their Falls Management Program Guidelines.
Dishwasher sanitation monitoring and kitchen flooring cleanliness not maintained
Penalty
Summary
The facility failed to ensure monitoring of dishwasher sanitation and to maintain clean kitchen flooring. During observation of the kitchen with the Dietary Manager, the dishwasher was seen running through wash and rinse cycles, and the Dietary Manager stated the machine had been having trouble for several months. A service technician had previously worked on the machine and, because the dishwasher was a high-temperature unit with pressure problems, recommended using it as a low-temperature dishwasher until replacement. Staff were using chemical strips to check sanitation, and one staff member stated he checked dishwasher sanitation nightly, but the dishwasher wash and sanitation logs provided later showed no dates and only one temperature recorded for each meal. Record review and interview showed the dietary staff were supposed to record sanitation temperatures twice a day, but the records were not being completed. The dinner log had no documented temperatures after 12/28/25. A service report stated the dishwasher pressure would not stay up and that it had been set up to function as a low-temperature machine. During kitchen observations, black debris was seen along the back wall flooring in the dishwasher area, food preparation area, and cooking area. The Dietary Manager stated the flooring had last been deep cleaned in November 2025 and that the black debris was stuck on the floor and could not be removed.
Delayed Self-Medication Assessments for Residents Self-Administering Medications
Penalty
Summary
The facility failed to ensure self-medication assessments were completed timely for 2 residents who were observed self-administering medications. Resident 14, whose diagnosis included hypertension, was observed sitting in her room with a plastic medication cup containing 4 pills on her overbed table. She stated the nurse had left her medication for her to take, and she swallowed the pills with water. A self-administration of medication assessment for this resident was dated later that same day, and prior to that time the clinical record did not contain a self-administration assessment. Resident 4, whose diagnosis included COPD, had physician orders for Biotene Dry Mouth Oral Rinse and an albuterol inhaler. During medication administration observations, staff indicated the resident self-administered both the inhaler and the Biotene rinse, and the medications were observed in the resident's room. The resident stated the inhaler was in a plastic container on her bedside table and the Biotene rinse was in her bathroom. An LPN reviewed the chart and could not find a self-medication assessment, and the NC stated that residents who store and self-medicate their medications should have self-medication assessments completed.
Unsafe Transfer Method Led to Resident Fracture
Penalty
Summary
The facility failed to ensure a safe method of transfer for a resident with vascular dementia, muscle weakness, rheumatoid arthritis, and osteoporosis. The resident’s record showed she needed extensive assistance with transfers and, in different parts of the care record, was identified for transfer with a mechanical lift, stand-up lift, or 1 to 2 staff with a gait belt. Staff interviews and record review showed the resident’s transfer method was not consistently clear across the chart, and staff relied on different sources of information when deciding how to transfer her. On the morning of the incident, the resident was transferred from bed to wheelchair using a gait belt. During the transfer, her legs buckled and her body shifted downward while the staff member held the gait belt. The staff member reported hearing a snap in the shoulder area as the resident’s weight shifted. The resident was found on the floor with a gait belt around her waist, unable to move her left arm, and with a firm bulge on the upper inner left arm. She was sent to the emergency room and returned the same day with a new order for an immobilizer sling to the left arm and a hoyer lift for all transfers going forward. The investigation showed the resident had a history of degenerative arthritis and osteoporosis in both shoulders, with prior surgical repair of both shoulders and screws in the left shoulder. The reportable incident stated the acute fracture occurred just distal to the hardware after the transfer. Staff interviews indicated some staff had always used a stand-up lift, while others used a gait belt based on the electronic record, and one staff member stated the resident’s transfer method depended on whether she was having a “good day” or “bad day.”
Pain Assessment and Medication Administration Deficiencies
Penalty
Summary
The facility failed to provide safe, appropriate pain management for two residents who required pain services. For one resident with chronic back pain, lumbar post-laminectomy syndrome, and an intrathecal pain pump delivering hydromorphone, scheduled Lyrica doses were not administered because the medication was on hold pending pharmacy delivery. The record showed missed doses over multiple shifts, and the resident’s pain was documented as ranging from 0 to 10 on a 0-to-10 scale during the admission period. The record did not include documentation of non-pharmacological interventions attempted or that the physician had been notified of the resident’s pain. That resident reported severe uncontrolled pain after admission and called emergency medical services to go to the hospital for pain management. The emergency room record noted she had not received her medications and had been told there would be a delay in medication administration. She later reported that her pain remained 10 out of 10 until she was seen by a nurse practitioner, and she stated that the pain had prevented her from participating in therapy. Therapy documentation also reflected that pain interfered with functional activities and sleep, and that she declined mobility and transfers due to pain. For the second resident, who had diabetes, a toe amputation, and stroke, the MAR showed administration of scheduled acetaminophen and PRN hydrocodone, but the record did not include nursing assessments documenting pain location, pain intensity, or non-pharmacological interventions attempted before giving the PRN medication. The resident stated she was always in pain even after medication and rated her pain as 9 out of 10. The DON stated the pain scale had not been clicked in error in the electronic record and that nursing staff should know how to assess pain when giving PRN medications, but the documentation in the record did not show those assessments.
Failure to Follow Physician Orders for TED Hose and Blood Pressure Medication
Penalty
Summary
The facility failed to apply TED hose as ordered for a resident diagnosed with edema. Despite a care plan indicating the resident was to wear TED hose daily, observations on multiple occasions revealed the resident was not wearing them. A Certified Resident Care Associate confirmed that the resident would wear the TED hose if staff applied them, indicating a lapse in adherence to the care plan. Additionally, the facility did not adhere to physician orders regarding the administration of blood pressure medication for two residents. One resident with hypertension and congestive heart failure received carvedilol even when their heart rate was below the threshold specified in the physician's order. Similarly, another resident with hypertension was administered metoprolol tartrate despite their systolic blood pressure being below the ordered threshold. These actions were contrary to the physician's instructions and were confirmed by a Nurse Consultant during an interview.
Failure to Assess Pain Severity in Resident with Diabetic Polyneuropathy
Penalty
Summary
The facility failed to ensure proper assessment of a resident's pain severity for a resident with diabetic polyneuropathy, depression, and a history of repeated falls. The care plan for the resident included observing and recording verbal and non-verbal signs of pain. However, the clinical record did not document the severity of the resident's pain on specific dates when oxycodone was administered for pain management. The resident's pain was not assessed for severity prior to administering the medication, as confirmed by the Director of Nursing. On one occasion, the resident was observed complaining of leg and arm pain, rating it at a nine on a scale of one to ten, despite having received pain medication earlier that morning. The facility's pain policy requires documentation of each resident's pain, including its severity, but this was not adhered to in the case of this resident. The Director of Nursing was unable to provide assessments of the severity of the resident's pain prior to administering the medication, indicating a lapse in following the facility's pain management policy.
Expired Supplies Found in Medication and Supply Storage Rooms
Penalty
Summary
The facility failed to ensure that medication and supply storage rooms were free of expired supplies. During an observation of the central supply room on the [NAME] unit, conducted with the Director of Nursing (DON), it was found that there were 16 cartons of Osmolite 1.5, a feeding solution, with an expiration date of 11/1/24. The DON confirmed that no residents were currently receiving Osmolite 1.5, and the Scheduler was responsible for supply storage. Additionally, an observation of the medication storage room on the Hinkle unit, conducted with an LPN, revealed a cabinet containing ten COVID tests that had expired in 2023. The facility's policy on medication storage, revised in 11/18, states that medication administration personnel must check expiration dates before administering medications, and expired medications should be removed from active supply and destroyed. However, this policy was not adhered to, leading to the presence of expired supplies in the facility.
Incomplete Medical Records and Behavior Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure that residents' medical records were complete and accurate, particularly concerning behavior monitoring and documentation of urine characteristics after Foley catheter insertion. For Resident 25, the clinical record lacked documentation of urine characteristics at the time of the Foley catheter change, despite a policy requiring such documentation. The Director of Nursing indicated that the urine characteristics were chronic, but this information was not recorded in the resident's medical record. Additionally, the facility did not adequately document behavior monitoring for residents receiving medications for depression, anxiety, and insomnia. Resident 25 had a physician order for behavior monitoring related to depression, but the November 2024 Medication/Treatment Administration Record (MAR/TAR) showed that behavior monitoring was marked as not applicable (NA) on several occasions. Similarly, Resident 11's behavior monitoring for aggressive behavior and social isolation was also marked as NA during specific shifts, despite physician orders requiring documentation three times a day. Resident 26's clinical record also showed deficiencies in behavior monitoring documentation. The resident had physician orders for monitoring anxiety, insomnia, and depression, but the MAR/TAR indicated that monitoring was marked as NA during certain shifts. An interview with Clinical Support 4 revealed that NA meant the behavior was not observed, but this was not adequately documented as per the nursing job description, which requires accurate recording of all care provided.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control during Foley catheter care for a resident diagnosed with neuromuscular dysfunction of the bladder and stage 3 kidney disease. The care plan for the resident indicated the use of a suprapubic or Foley catheter due to a neurogenic bladder, with catheter care to be provided three times a day as per physician orders. During an observation of catheter care performed by a Certified Resident Care Associate (CRCA), it was noted that the CRCA washed his hands and donned gloves before starting the procedure. However, after touching the faucet and bed remote, the CRCA did not remove his gloves or perform hand hygiene before continuing with the catheter care. An interview with Clinical Support staff revealed that the CRCA should have set up the supplies, performed hand hygiene, and donned gloves prior to providing catheter care. The facility's infection control policy aims to prevent the development and transmission of communicable diseases and infections, while the urinary catheter care policy specifies the need for washing and drying hands thoroughly before the procedure. The failure to adhere to these protocols during the observed catheter care led to the deficiency noted in the report.
Deficiency in Room Maintenance for Two Residents
Penalty
Summary
The facility failed to ensure that resident rooms were maintained in good repair, as evidenced by observations and interviews regarding two resident rooms. In the case of Resident 15, the drywall behind her bed was patched but left unpainted, appearing bumpy and uneven. The Executive Director (ED) confirmed that the wall had been repaired multiple times due to scratches caused by the trapeze stand used by Resident 15 for bed mobility. This indicates a recurring issue with maintaining the wall in good condition. Similarly, Resident 29's room had an irregularly shaped white area on the wall behind the bed, where the paint had been worn away due to the bed scraping against the wall. The Director of Plant Operations (DOP) was unsure of how long the area had been in this condition. The DOP mentioned that room repairs were typically conducted when a room was being prepared for a new admission or when a work order was submitted. However, the work order for Resident 29's room, dated earlier in the year, indicated that the room had been made ready for a resident, suggesting that the issue had not been addressed in a timely manner.
Failure to Maintain a Homelike Environment Due to Ant Infestation
Penalty
Summary
The facility failed to provide a comfortable, homelike environment for Resident C, as evidenced by the presence of ants in the resident's room. During an observation, small crawling insects resembling ants were seen on the wall and floor of Resident C's room. The ants were observed crawling up the wall between the air conditioner/heating unit and the windowsill, and another ant was seen on the floor, disappearing between the flooring planks. This issue was corroborated by an interview with the Nurse Consultant, who acknowledged the presence of ants in the resident's room and stated that the facility had not engaged their pest control company to address the issue inside the room, opting instead for the maintenance department to spray internally. Further investigation revealed that a work order dated earlier in the month had documented a previous ant issue in the same room, including ants in the resident's bed. The work order indicated that maintenance had sprayed bug killer around the air unit at that time, and no ants were observed then. However, the facility's pest control policy, which aims to maintain a pest-free environment, was not fully adhered to, as the pest control company only treated the exterior of the building. Additionally, Resident C's significant other reported that debris on the floor had remained there for a week, suggesting a lack of thorough cleaning and maintenance in the resident's room.
Failure to Maintain Wound Free of Contamination by Ants
Penalty
Summary
The facility failed to maintain a resident's wound free of contamination by ants, which was identified for one of the three residents reviewed for wounds. Resident B, who had a traumatic brain injury and seizure disorder, was receiving hospice care and passed away on June 6, 2024. A physician's order from April 5, 2024, outlined specific wound care instructions for Resident B's left knee, which included cleansing with normal saline, applying skin prep, Therahoney, and a dry dressing, with changes every three days. However, on June 5, 2024, a Hospice LPN discovered ants on Resident B's wound and dressing during a routine visit, despite the room being sprayed for ants the previous day. The facility's Director of Nursing and wound nurse were notified, and the wound care was completed by the Hospice LPN. Interviews and records revealed that Resident B's room had been treated for ants multiple times, and the facility attributed the ant problem to food dropped by Resident B's roommate. Despite these measures, ants were found in Resident B's bed and on his person, causing distress to his family. The facility's investigation file included witness statements and work orders indicating that the room had been sprayed daily for ants, but the problem persisted. The facility's policies required regular assessment of wounds and skin integrity, but the presence of ants in the wound dressing indicated a failure to adhere to these guidelines, contributing to the deficiency.
Delayed Wound Treatment Order Entry
Penalty
Summary
The facility failed to ensure timely placement of a wound treatment order for a resident with wounds on the buttocks. During an observation, an LPN was seen preparing to perform wound care on the resident, who had visible open areas on the buttocks that were red in color. The resident's clinical record showed a physician's order dated several days prior, which included specific instructions for applying various creams to the wounds. However, a subsequent physician's note indicated a change in the treatment plan, which involved using collagen and foam border dressings, but this new order was not entered into the system until several days later. The delay in updating the wound care orders was discovered when the LPN audited the orders and found that the new instructions had not been placed into the computer system. The LPN indicated that the Scribe, who usually enters such orders, had not done so in this instance. As a result, the LPN entered the new orders into the system, but noted that the frequency of dressing changes needed further updating to align with the physician's note. This oversight led to a failure in providing the updated wound care treatment as prescribed by the physician.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by improper handling of medication and inadequate use of personal protective equipment (PPE) during resident care. An LPN was observed preparing to complete wound care for Resident C, during which he touched the tip of a medication tube with his bare finger without performing hand hygiene. The LPN also failed to perform hand hygiene before donning and after doffing gloves while handling medication and supplies. This lack of proper hand hygiene and handling of medication compromised the infection control measures in place. Additionally, a CRCA was observed providing incontinence care to Resident C, who was on enhanced barrier precautions due to the risk of multi-drug resistant organisms. The CRCA was only wearing gloves and admitted to forgetting to wear a gown, which was required according to the facility's infection control policy. The room had a sign indicating the need for enhanced barrier precautions, but there were no gowns available outside or inside the room. This oversight in PPE usage further demonstrated the facility's failure to adhere to its infection prevention and control protocols.
Failure to Conduct Timely Post-Fall Neurological Assessments
Penalty
Summary
The facility failed to ensure timely care and services in accordance with professional standards for a resident who experienced an unwitnessed fall. Resident M, who had a history of cerebrovascular accident, fibromyalgia, hypertension, and dementia, was found on the floor between her bed and bedside table by a staff member. Although no injuries were noted at the time, the facility's protocol for post-fall neurological assessments was not followed as required. The assessments were to be conducted every 30 minutes for 4 times, every hour for 4 hours, and every 4 hours for 5 times. However, the records indicated that several of these assessments were either missed or conducted late, failing to monitor the resident's condition adequately post-fall. The March 2024 Medication Administration Record (MAR) showed that the initial 30-minute assessments were completed, but the subsequent hourly and four-hourly assessments were not conducted as scheduled. Specifically, the 11 a.m. hourly assessment was missed, and the first four-hourly assessment was delayed until 11 p.m. instead of 6 p.m. Additionally, only one four-hourly assessment was completed on 3/21/24, and the 7 a.m. assessment lacked documentation of the neurological check. An interview with Clinical Support confirmed that these assessments should have been completed to minimize or prevent injury. The facility's Falls Management Program Guidelines emphasize the importance of such assessments to mitigate fall risks and prevent injuries, but these guidelines were not adhered to in this case.
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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) |
|---|---|---|---|---|
| Waters Of Castleton Skilled Nursing Facility, The | 0 mi | ★★★★★ | 24 | 0 |
| Castleton Health Care Center | 0.3 mi | ★★★★★ | 36 | 0 |
| Allisonville Meadows | 1.9 mi | ★★★★★ | 25 | 0 |
| Allison Pointe Healthcare Center | 2.3 mi | ★★★★★ | 19 | 0 |
| Hamilton Trace Of Fishers | 4.1 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.