Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Northwest Manor Health Care Center during CMS and state inspections, most recent first.
A resident who required a Hoyer lift for all transfers was moved without the lift and later had severe right knee swelling and an acute proximal tibia fracture. Staff interviews confirmed the resident was dependent for transfers, and the resident had severe dementia, epilepsy, and limited verbal communication. In a separate issue, a resident with dementia and cataracts had medications left at the bedside even though a self-medication assessment showed he could not self-administer and an LPN confirmed he could not take his own meds.
An LPN failed to clean vital sign equipment between two residents, and another LPN did not clean a glucometer between blood glucose checks for two residents while also placing supplies and equipment directly on resident surfaces without barriers. The facility also failed to follow EBP for a resident with a g-tube when an LPN administered medication without wearing a gown, despite a sign and physician order indicating EBP for high-contact care.
Inconsistent Advance Directive Documentation: A resident with stroke-related diagnoses had an OOH DNR on file, but the medical record was inconsistent because the home page banner showed full code, an active order listed full code, and the care plan identified the resident as DNR. The DON stated she was unaware of the discrepancies in the resident’s advance directive status.
Failure to Provide Bed Hold Notifications: The facility failed to provide written bed hold notification to two residents or their representatives when the residents were transferred to the hospital. One resident had CHF, DM2, and HTN and was sent out for abdominal pain with a distended abdomen; another resident with DM2 and CKD was sent out for critically low potassium. The DON could not locate documentation of the required bed hold notices, and the facility policy required written notice at transfer or within 24 hours for an emergency transfer.
A resident’s annual MDS was coded as having one fall with a major injury, but the chart lacked any documentation of such a fall. The DON confirmed the MDS was not accurate and stated the resident had not had a fall with major injury. The facility used the CMS RAI manual for MDS accuracy, and the manual’s J1900 coding instructions were cited in the report.
PASRR assessments were not re-evaluated for two residents when one assessment contained inaccurate psychiatric diagnoses and another resident later received new mental health diagnoses. The ED acknowledged that a new PASRR should have been completed for the inaccurate assessment and that the facility did not complete a new PASRR when the second resident’s diagnoses changed, despite policy requiring resident review when SMI, ID, or related conditions change.
A resident who fell was found on the floor with head pain, slight neck swelling, low BP, and dizziness, but the record did not clearly show whether he was moved before the assessment and before EMS arrived; staff interviews indicated a resident with neck pain and swelling should not be moved until EMS arrives. In a separate issue, a resident with CHF had daily weights showing significant gains that met the provider-notification threshold, but the record lacked documentation that the physician was notified as ordered.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
Three residents with a history of falls did not have required fall prevention interventions in place, including missing or inaccessible reachers and storage pouches, lack of supervision, absence of a perimeter mattress, and nonfunctional bed alarms. Documentation of comprehensive assessments and informed consent for alarm use was also missing, and care plan interventions were not consistently followed by staff.
A resident with multiple chronic conditions was inaccurately coded on the MDS as having a fall with major injury, despite no documentation of such an event in her record. The DON confirmed only one fall without injury, and the MDS Coordinator identified the entry as an error.
A resident with total dependence and immobility was admitted without a thorough skin assessment, resulting in a large, necrotic pressure ulcer on the back of the head being missed during initial evaluations. The wound was only discovered days later when staff attempted to wash the resident's matted hair, leading to a delay in treatment.
Surveyors observed that multiple medications on two medication carts were not dated to indicate when they were opened, including eye drops and nasal spray for several residents. Some medications were also not stored according to manufacturer recommendations, such as a bottle of latanoprost that should have been refrigerated until opened. The DON acknowledged challenges in maintaining proper dating of medications, contrary to facility policy.
The facility failed to properly prepare and sanitize pureed food items, with Cook 13 not following recipes, using unmeasured ingredients, and inadequately cleaning equipment. The Dietary Manager confirmed the need for proper sanitization and consistency, which was not achieved.
The facility failed to discard expired medications and properly label a resident's supplements in two medication storage areas. An undated bottle of tuberculin serum and an unlabeled pro-stat supplement were found. The DON confirmed the labeling requirements and the need to discard the TB serum.
A resident with multiple medical conditions had inconsistent documentation of a pressure ulcer on her sacrum, with varying stages recorded in different assessments and reports. The facility's policy lacked guidance on reverse staging, and the DON indicated that MDS did not downstage pressure ulcers according to current assessments.
Unsafe Transfer and Bedside Medication Storage
Penalty
Summary
The facility failed to prevent an accident when a resident who required a Hoyer lift for all transfers was transferred into bed without the lift and with only one staff member. The resident had diagnoses including severe vascular dementia, epilepsy, and speech and language deficits following a cerebrovascular disease, and her care plan and physician orders specified that she was dependent for all ADLs and required a Hoyer lift for all transfers. Staff interviews confirmed that the resident had been transferred without the Hoyer lift on more than one occasion, including by a CNA who admitted she transferred the resident into bed without the lift. After the transfer issue, the resident was observed with significant swelling of the right knee and was unable to explain what happened. Facility records showed that she developed severe right knee pain and swelling, and an x-ray later identified an acute proximal tibia fracture. Notes documented that she screamed with movement, had limited range of motion, and continued to have pain with bed mobility and touch to the knee. The administrator stated the investigation into how the fracture occurred was ongoing, and staff interviews confirmed the resident required the Hoyer lift for all transfers. The facility also failed to prevent an accident when a resident’s medications were observed left at the bedside in a cup with water nearby. The resident had diagnoses including dementia and cataracts, and a self-medication assessment indicated he was not to administer his own medications. An LPN confirmed the resident could not administer his own medications, yet the medications were still left at the bedside. The facility policy stated that medication cannot be left at the patient bedside and that licensed staff must witness ingestion of prescribed medication.
Failure to Clean Equipment and Follow Infection Control Practices
Penalty
Summary
The facility failed to ensure vital sign equipment was cleaned between residents. On 5/12/26 at 8:12 a.m., an LPN used a portable vital signs machine to obtain Resident 28’s blood pressure and oxygen saturation with the attached pulse oximeter and did not clean the blood pressure cuff or pulse oximeter before or after use. At 8:23 a.m. the same LPN used the same equipment for Resident 83 and again did not clean the blood pressure cuff or pulse oximeter before or after use. The DON stated the equipment should have been cleaned between each resident, and the facility policy stated reusable resident-care items such as blood pressure cuffs are cleaned and disinfected between residents. The facility also failed to follow infection control techniques during blood glucose checks. On 5/12/26 at 11:13 a.m., an LPN brought a basket containing lancets, glucometer strips, and a glucometer into Resident 125’s room, placed the basket directly on the bedside table without a barrier, cleaned the resident’s finger with an alcohol swab, reached into a communal container of glucometer strips with gloved hands, and completed the blood glucose check without cleaning the glucometer before or after use. At 11:18 a.m., the same LPN used the same basket and glucometer for Resident 31, placed the basket on the bedside table and the glucometer on the bed without barriers, used gloved hands to obtain a strip from the communal container, and again did not clean the glucometer before or after use. The LPN stated she thought the glucometer needed to be cleaned every third resident, while the DON stated it should have been cleaned between each resident. The facility policy stated the nurse performs the blood glucose test safely and thoroughly cleans the meter. The facility also failed to follow enhanced barrier precautions for Resident 93. On 5/12/26 at 2:15 p.m., an LPN administered medication via the resident’s g-tube while a sign outside the room indicated enhanced barrier precautions were required during high-contact care, but the LPN did not wear a gown. The LPN stated she did not think the resident required EBP, while the DON stated EBP should have been used with administration of medications via g-tube. The resident’s record included a physician order dated 10/21/25 for enhanced barrier precautions related to the g-tube, and the facility policy identified feeding tube care or use as a high-contact activity requiring gown and glove use.
Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that one resident’s chosen advance directive was documented consistently throughout the medical record. Resident 59, a rehab resident with diagnoses including cerebral infarction and hemiplegia, had an Out of Hospital Do Not Resuscitate (OOH DNR) declaration dated and signed on 2/20/26 uploaded into the record. Despite the OOH DNR being on file, the resident’s medical record home page banner indicated he had elected to be a full code, an active order dated 4/19/26 listed him as full code, and the active care plan identified him as a DNR with a signed OOH DNR form on file dated 2/23/26. During interview, the DON stated she was unaware of the discrepancies in the resident’s advance directive status in the medical record.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notification to residents or resident representatives for 2 of 4 residents reviewed for appropriate discharge process. For Resident 114, a record review showed diagnoses including CHF, type 2 diabetes mellitus, and hypertension. On 4/23/26 at 1:07 a.m., a progress note documented that the resident complained of abdominal pain throughout the shift, rated it 8 out of 10, and had a distended abdomen. The physician was notified and an order was noted to send the resident to the hospital for further evaluation. The resident's medical record lacked documentation of a bed hold. For Resident 82, a record review showed diagnoses including type 2 diabetes and chronic kidney disease. A progress note dated 2/24/26 indicated the facility sent the resident to the hospital due to a critically low blood potassium level. The medical record lacked documentation that a bed hold notification was provided to the resident or a resident representative. During interviews, the DON stated she could not find documentation related to Resident 114's discharge and was unable to find a signed bed hold notification for Resident 82's hospitalization. The facility policy titled Bed-Holds and Returns stated residents and/or representatives are informed in writing of the facility and state bed-hold policies, including notice at the time of transfer or within 24 hours if the transfer is an emergency.
Inaccurate MDS Fall Coding
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for one resident. The resident’s annual MDS, dated 2/6/26, indicated the resident was cognitively intact and had one fall with a major injury, but the electronic record did not contain documentation of any fall with major injury. During interview, the DON stated the annual MDS was not accurate and confirmed the resident had not had a fall with major injury. The facility used the CMS RAI manual as its policy for MDS assessment accuracy, and the CMS MDS RAI Manual states that J1900 code 1 is used if the resident had one non-injurious fall since admission/entry or reentry or prior assessment.
PASRR assessments were not updated when diagnoses changed or were inaccurate
Penalty
Summary
The facility failed to ensure PASRR assessments were re-evaluated when the information in the assessment was inaccurate and when new psychiatric diagnoses were added for two residents. One resident had a PASRR dated 3/27/26 that listed schizophrenia, major depression, bipolar disorder, and paranoid disorder, but the medical record did not contain documentation of active diagnoses of schizophrenia, major depression, or bipolar disorder on the date of the PASRR assessment. The Executive Director stated the Director of Nursing was initiating a new PASRR assessment to correct the inaccuracies and acknowledged that a new Level 1 should have been completed because of the inaccurate assessment information. A second resident had a PASRR dated 2/13/26 that indicated no current mental health diagnoses, but later diagnoses of other specified mental disorders due to known physiological condition and hallucinations were added to the record. The record did not show that a new PASRR assessment was completed after those mental health diagnoses were added. During interview, the Executive Director stated the facility did not complete a new PASRR when the new diagnoses were added and that the DON was initiating a new assessment immediately. The facility policy stated a resident review is required if there is a significant change in status indicating the presence of or change in SMI, ID, or related conditions, and that the state PASRR authority must be notified and a new evaluation requested if warranted.
Failure to Assess Fall Injury Before Moving Resident and Failure to Report Significant CHF Weight Gain
Penalty
Summary
The facility failed to ensure a resident who fell and complained of neck pain with slight neck swelling was assessed before being moved. Resident 7, a long-term care resident with diagnoses including chronic kidney disease and hypertension, was found sitting on the floor beside his bed after an unwitnessed fall. The nursing note documented that he complained of pain at the back of his head, had slight swelling to the neck, and was hypotensive with a blood pressure of 73/42 and dizziness. He was assisted back into bed with two CNAs, and the record did not clearly show whether he was moved before or after the assessment, vital signs, and seizure activity were completed. The same record showed that while vital signs were being taken, the resident had a seizure lasting about 1 minute, returned to baseline afterward, and was positioned on his side. The on-call NP was notified and gave a verbal order to send him to the ER. Before EMS arrived, the resident had another seizure lasting 15 seconds. Surveyor interviews with an LPN, a QMA, and the DON indicated that a resident with neck pain and neck swelling should not be moved and should be kept as still as possible until emergency medical personnel arrived. The facility policy on fall assessment stated that a resident found on the floor should be evaluated for possible injuries to the head, neck, spine, and extremities. The facility also failed to follow physician orders related to CHF for Resident 114, who had diagnoses including CHF and hypertension. She had an order to weigh daily and notify the provider when weight increased more than 2 pounds in a day or 5 pounds in a week. Her record showed a 5-pound weight gain from 132.0 to 137.0 pounds and later a 3.4-pound gain from 133.2 to 136.6 pounds, but the record lacked documentation that the physician was notified for either weight change. The DON stated she could not find documentation of notification, and the facility policy on reporting weight changes directed staff to report significant weight gain to the nurse supervisor and physician.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Implement and Maintain Fall Prevention Interventions
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions as outlined in the care plans for three residents with a history of falls. One resident, with repeated falls and fractures, was observed multiple times without a reacher or accessible storage pouch, despite care plan interventions requiring these items to prevent her from leaning forward and falling. She was also left unattended in the dining room, contrary to her care plan, and her wheelchair and bed alarms were installed without documented comprehensive fall risk assessment, education, or informed consent. Another resident, diagnosed with dementia and psychosis, was found to have a regular mattress on his bed instead of the perimeter mattress with bolsters that was ordered as a fall intervention after a previous fall. Observations confirmed the absence of the required mattress, despite its inclusion in the care plan following an interdisciplinary team review. A third resident, with diabetes, weakness, and repeated falls, was found with her call light on the floor and her bed alarm pad unplugged, rendering the alarm nonfunctional. The care plan required the use of a bed alarm and education on call light use, but these interventions were not in place at the time of observation. Facility policies required comprehensive assessment, consideration of alternatives, and informed consent for alarm use, but documentation of these steps was lacking.
Inaccurate MDS Coding of Resident Fall Status
Penalty
Summary
The facility failed to accurately code a resident's fall status on the Minimum Data Set (MDS) assessment. A resident with multiple diagnoses, including chronic kidney disease, heart failure, high cholesterol, hypertension, and overactive bladder, was documented in her most recent MDS quarterly assessment as having experienced a fall with major injury. However, a review of her medical record did not contain any documentation of such a fall. The DON confirmed that the resident had only one fall, which did not result in injury, and the MDS Coordinator acknowledged that the entry was likely an error. The facility's policy addressed how to correct MDS errors but did not prevent the initial inaccurate coding.
Failure to Identify Pressure Ulcer on Admission
Penalty
Summary
The facility failed to conduct a thorough skin assessment upon admission for a resident who was admitted with a history of stroke, resulting in full body hemiparesis/hemiplegia and total dependence for all activities of daily living. Initial admission assessments documented that the resident did not have any pressure ulcers, but did note excoriation, bruises, and a laceration. The resident was bedbound and required tube feeding. Several days after admission, staff discovered a large, necrotic wound on the back of the resident's head while attempting to wash her hair, which had been matted. The wound was subsequently identified as an unstageable pressure ulcer and later reclassified as a stage IV pressure ulcer after debridement. The wound was not documented or identified during the initial admission assessments, despite the resident's immobility and high risk for pressure injuries. The wound was only discovered after a delayed inspection, and there was no evidence in the hospital records that the wound was present prior to admission. The facility's policy required a comprehensive head-to-toe skin assessment within 24 hours of admission, but the wound was missed during this process, resulting in a delay in implementing appropriate pressure ulcer treatment.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly labeled and stored according to accepted professional principles. During observation of two medication carts on the 100 hall, several medications were found without dates indicating when they were opened. Specifically, one resident had a bottle of latanoprost that should have been refrigerated until opened and a bottle of ofloxacin eye drops with no opening date. Another resident had a bottle of fluticasone nasal spray without an opening date, and a third resident had a bottle of Systane balance also lacking an opening date. The Director of Nursing acknowledged the difficulty in keeping up with the dating of medications. The facility's policy requires medications to be stored under proper temperature controls and in accordance with state and federal laws, but these requirements were not met in the observed instances.
Improper Preparation and Sanitization of Pureed Food
Penalty
Summary
The facility failed to ensure puree food items were properly prepared and mixed according to the recipe and that the equipment was thoroughly washed and sanitized. Cook 13 was observed preparing pureed lunch without conducting hand hygiene, using unmeasured quantities of water, and not following the recipe, resulting in a thin and watery mixture. Additionally, Cook 13 did not properly wash and sanitize the blender, using only tap water and detergent with his bare, unwashed hands, and then placing the wet blender back onto the base without proper drying or sanitization. The Dietary Manager confirmed that all dishes, utensils, and equipment should be run through the dishwashing machine to ensure proper cleaning and sanitization, and that pureed foods should have a consistency similar to applesauce or pudding, which was not achieved in this case. Further observations revealed that Cook 13 continued to fail in following the recipes for pureed foods, adding unmeasured quantities of bread, gravy, and thickener to achieve the desired texture. The Dietary Manager provided the recipes, which detailed specific instructions and measurements that were not followed. The Executive Director provided a copy of the facility policy, which stated that pureed food should contain the same nutrient value as a regular diet, be seasoned appropriately, and served at the correct temperature and texture. The policy also emphasized the importance of following the recipe book for preparation and serving size, which was not adhered to during the observations.
Failure to Discard Expired Medications and Label Supplements
Penalty
Summary
The facility failed to ensure expired medications were discarded and a resident's supplements were labeled correctly in two medication storage areas. During an observation, a bottle of tuberculin serum in the Wing 1 medication room refrigerator was found undated and was a multidose vial. Additionally, a bottle of pro-stat supplement belonging to a resident in the Wing 2 medication cart was not labeled with the required minimum information. The Director of Nursing confirmed that all medications should be properly labeled and that the TB serum should have been discarded. The facility's policy on medication storage, dated 9/18, was provided, indicating that drugs in the manufacturer's original container should carry the manufacturer's expiration date and specific conditions for multi-dose vials and other medications.
Inconsistent Staging of Pressure Ulcer
Penalty
Summary
The facility failed to accurately stage a pressure ulcer for a resident with multiple medical conditions, including anemia, hypertension, hyperlipidemia, type 2 diabetes, hypothyroidism, history of stroke, difficulty speaking, and depression. The resident's pressure ulcer on her sacrum was inconsistently documented across various assessments and reports. Initially, the ulcer was referred to as unstageable, then as stage IV, stage III, and even stage II at different times. This inconsistency in staging was observed in the resident's care plan, wound assessment reports, and Minimum Data Set (MDS) assessments over several months. During an interview, the Director of Nursing (DON) indicated that the MDS did not downstage pressure ulcers for the purpose of the MDS, but rather according to the current assessment of pressure ulcers. The facility's policy on Pressure Ulcer Prevention and Managing Skin Integrity lacked documentation on reverse staging or back staging. The NPUAP Position Statement and CMS RAI manual both indicate that pressure ulcers do not heal in reverse sequence and that reverse staging is not supported as it does not accurately characterize the healing process. This discrepancy in staging led to the deficiency noted in the report.
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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) |
|---|---|---|---|---|
| Eagle Valley Meadows | 1.6 mi | ★★★★★ | 3 | 0 |
| Evergreen Crossing And The Lofts | 2.8 mi | ★★★★★ | 27 | 0 |
| Westside Retirement Village | 3.3 mi | ★★★★★ | 31 | 0 |
| Envive Of Indianapolis | 3.4 mi | ★★★★★ | 16 | 0 |
| Westpark A Waters Community | 3.7 mi | ★★★★★ | 2 | 0 |
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