Above 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 University Heights Health And Living Community during CMS and state inspections, most recent first.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
A resident with cognitive intactness and risk for skin breakdown, who had diagnoses including traumatic brain injury and gait abnormalities, consistently refused to wear physician-ordered Prevalon heel protection boots due to discomfort. Despite repeated refusals and staff awareness, the care plan was not updated to address the resident's non-compliance or preferences, contrary to facility policy requiring person-centered, regularly revised care plans.
A resident with a history of traumatic brain injury, TIA, and mobility issues, who was at risk for skin breakdown, was observed multiple times without the prescribed Prevalon heel protection boots while in bed. Despite the resident's repeated refusals to wear the boots, staff documented in the TAR that the boots were applied as ordered. Interviews with staff confirmed the resident's non-compliance was not accurately recorded, resulting in inaccurate clinical documentation.
The facility failed to accurately reconcile controlled medications for four medication carts, as observed during a survey. The Nurse's Narcotic Sign In/Out Sheets for the 200, 100, 400, and 700/800 hall medication carts had numerous blank spaces where nurses were required to document the number of controlled medication packets at the beginning and end of each shift. The Director of Nursing provided the current document used for reconciliation, which mandates that controlled medications be counted at the beginning and end of every shift, with discrepancies reported immediately. However, the facility did not adhere to this protocol, leading to the cited deficiency.
A facility failed to use proper PPE during wound care for a resident on enhanced barrier precautions (EBP). The DON and an RN did not wear gowns while treating a resident with a stage three pressure ulcer, despite a physician's order and a care plan indicating the need for gowns and gloves. The resident reported that staff rarely wore gowns, and the RN was unaware of the requirement until reviewing the resident's orders.
The facility failed to conduct self-medication administration assessments for four residents observed with medications at their bedside. Residents were found with various medications without proper assessments, and staff sometimes left medications unsupervised. The facility's policy required medications to be administered by licensed personnel, which was not followed.
A resident with depression was not given written notice before being assigned a new roommate who was receiving hospice care and actively dying. The resident was only verbally informed the day before the new roommate's admission, and the facility's policy requiring written notification was not followed. The clinical record lacked documentation of the required notice.
A facility failed to refer a resident for a Level II PASARR screening after a new diagnosis of bipolar disorder. Despite being cognitively intact, the resident did not receive the necessary evaluation to identify specialized needs, as confirmed by the Social Service Director and the DON.
A resident requiring assistance with ADLs was not provided help with shaving, resulting in visible facial hair. Despite being cognitively intact and receiving regular showers, the resident's care plan for hygiene assistance was not followed. The DON confirmed that facial hair should have been addressed during shower days.
A resident with edema and CHF did not receive consistent care as per physician orders, including daily weights, edema monitoring, and compression stockings. Despite being cognitively intact, the resident's condition was not effectively managed, with multiple observations of swollen lower extremities and gaps in documentation. The resident frequently refused compression stockings, and staff failed to consistently record required interventions, leading to a deficiency in care.
A resident with chronic conditions did not receive the recommended pneumococcal conjugate vaccine, despite having received the pneumococcal polysaccharide vaccine prior to admission. The facility's policy and CDC guidelines require both vaccines for adults aged 65 and older and those with certain chronic conditions, but the facility failed to comply, leading to a deficiency.
The facility failed to develop a comprehensive person-centered care plan for a resident who required a hand brace. Despite physician orders and documentation of the brace being applied and removed, the clinical record lacked a care plan addressing the use of the brace and the resident's refusal to wear it. Staff interviews confirmed the deficiency.
The facility failed to ensure a knee brace was applied to a resident while in bed, as required by the physician's order. The resident, who had hemiplegia and hemiparesis following a stroke, was observed without the knee brace on multiple occasions. Staff confirmed the existence of the order but were unable to locate the brace, indicating a lapse in following the resident's care plan and facility policy.
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to Update Care Plan for Resident's Refusal of Pressure-Relief Boots
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan addressing a resident's refusal to wear physician-ordered Prevalon heel protection boots. Multiple observations over several days showed the resident resting in bed with non-skid socks and without the prescribed Prevalon boots, which were not visible in the area. The resident, who was cognitively intact and at risk for skin breakdown, reported refusing the boots because they were too hot. The clinical record included diagnoses such as traumatic brain injury, history of TIA, and gait abnormalities, and contained a physician order for the use of Prevalon boots while in bed with no end date. Despite the resident's ongoing refusal, the care plan was not updated to reflect this non-compliance or to address the resident's preferences and needs regarding the prescribed intervention. Staff interviews confirmed the resident's consistent refusal and acknowledged that the care plan should have been revised accordingly. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, and for care plans to be revised as resident information or condition changes, which was not followed in this case.
Inaccurate Documentation of Prescribed Heel Protection for At-Risk Resident
Penalty
Summary
The facility failed to ensure accurate clinical record documentation for a resident at risk for skin breakdown who was prescribed heel protection. Multiple observations over several days showed the resident resting in bed with only non-skid socks on, and the prescribed Prevalon heel protection boots were not in use or visible in the area. Despite this, the Treatment Administration Record (TAR) indicated that staff had documented the resident as wearing the Prevalon boots on all shifts for several days. Interviews with staff, including a Qualified Medication Aide and the Director of Nursing, confirmed that the resident usually refused to wear the boots and that the TAR should have reflected these refusals. The resident involved had diagnoses including traumatic brain injury, history of transient ischemic attack, and abnormalities of gait and mobility, and was assessed as cognitively intact and at risk for skin breakdown. Physician orders required the application of Prevalon boots while the resident was in bed, with no end date specified. Facility policies provided by the Director of Nursing required accurate medical records and administration of treatments as prescribed. The documentation in the clinical record did not accurately reflect the resident's non-compliance with the prescribed heel protection, resulting in a deficiency.
Failure to Reconcile Controlled Medications
Penalty
Summary
The facility failed to ensure accurate reconciliation of controlled medications for four out of eight medication carts, as observed during a survey. The Nurse's Narcotic Sign In/Out Sheets for the 200, 100, 400, and 700/800 hall medication carts were reviewed, revealing numerous blank spaces where nurses were required to document the number of controlled medication packets at the beginning and end of each shift. For the 200 hall medication cart, several shifts from November 1 to November 7 had incomplete documentation, with missing entries for both the number of medication packets and nurse signatures. Similar issues were found with the 100 hall medication cart, where multiple shifts had blank spaces, indicating a lack of proper reconciliation. The 400 hall medication cart also showed incomplete documentation, with missing entries for several shifts. The 700/800 hall medication cart had the most significant deficiencies, with all shifts from November 1 to November 6 lacking any documentation. The Director of Nursing provided the current document used for reconciliation, which mandates that controlled medications be counted at the beginning and end of every shift, with discrepancies reported immediately. However, the facility did not adhere to this protocol, leading to the cited deficiency.
Failure to Use PPE During Wound Care for Resident on EBP
Penalty
Summary
The facility failed to ensure the proper use of personal protective equipment (PPE) during a dressing change for a resident with an open wound who was on enhanced barrier precautions (EBP). During an observation, the Director of Nursing (DON) and a registered nurse (RN 1) applied hand sanitizer and clean gloves but did not wear gowns while providing wound care to Resident B, who had a 5 cm by 5 cm wound on the left heel. The DON acknowledged that they should have worn gowns, as Resident B was on EBP, which was confirmed by a physician's order and a sign in the resident's room. Resident B, who was cognitively intact, had a stage three pressure ulcer and was on EBP as indicated in the care plan and physician's order. The facility's policy required the use of gowns and gloves for residents with wounds requiring dressing changes. However, Resident B reported that staff rarely wore gowns during wound care, and RN 1 was unaware of the need for a gown until reviewing the resident's orders. The facility's policy and the EBP sign in the resident's room both specified the requirement for gowns and gloves during wound care.
Failure to Conduct Self-Medication Assessments
Penalty
Summary
The facility failed to ensure that self-medication administration assessments were completed for four residents who were observed with medications at their bedside. Resident 53 was observed with multiple medications on an overbed table on two separate occasions, and their clinical record lacked a self-medication administration assessment. The Director of Nursing confirmed the absence of such an assessment for Resident 53. Similarly, Resident 1 was seen holding a medication cup with a capsule, and their clinical record also lacked the necessary assessment. The Director of Nursing confirmed the absence of a self-medication administration assessment for Resident 1 as well. Resident 105 was observed with a medication cup containing various tablets and capsules, and their clinical record did not include a self-medication administration assessment. The Director of Nursing confirmed this omission. Resident 39, who was cognitively intact according to their Minimum Data Set assessment, was observed with multiple medications on their overbed table. The resident indicated that staff sometimes left medications in their room without supervision. The Unit Manager confirmed that Resident 39 had not been assessed for self-administration of medications. The facility's policy, dated December 2012, stated that medications should be administered safely and only by licensed personnel, which was not adhered to in these cases.
Failure to Provide Written Notice of New Roommate
Penalty
Summary
The facility failed to provide a written notice to Resident 25 prior to assigning a new roommate, which is a violation of the resident's rights. Resident 25, who has a diagnosis of depression, was observed to be nervous and fidgeting in her wheelchair. She expressed distress over the unexpected arrival of a new roommate who was receiving hospice care and actively dying. The resident was only informed verbally the day before the new roommate's admission, and this was due to preparations for room cleaning. There was no written notice provided to Resident 25 about the new roommate. The clinical record review confirmed the absence of documentation indicating that Resident 25 was informed in writing about the new roommate. Interviews with the Social Services Director and the Director of Nursing (DON) revealed that the facility's policy required residents to be informed and documented in the clinical record when a new roommate is assigned. However, the DON admitted that the facility did not notify residents in writing about new roommates. The facility's current policy, titled 'Resident Discharge and Transfer Policy,' was reviewed, but it did not address the specific issue of written notification for new roommates.
Failure to Conduct Level II PASARR Screening for New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was referred for a Level II PASARR screening following a new diagnosis of bipolar disorder. Resident 53, who was cognitively intact according to a Quarterly Minimum Data Set assessment, received this new diagnosis on December 9, 2021. However, the facility did not refer the resident for a Level II screening, which is required to identify the specialized needs of individuals with mental illness. This oversight was confirmed during an interview with the Social Service Director, who acknowledged that a PASARR Level II should have been conducted for the resident. The Director of Nursing Services indicated that the facility follows Indiana Guidelines for PASARR Level II assessments.
Failure to Assist Resident with Personal Grooming
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for a dependent resident, specifically in the area of personal grooming. Resident 62, who was cognitively intact but required partial to moderate assistance for shaving due to weakness, was observed on multiple occasions with facial hair that had not been addressed. Observations on three separate dates revealed that the resident had multiple half-inch gray hairs protruding from her chin, indicating a lack of assistance with shaving. Interviews and record reviews further highlighted the deficiency. During an interview, Resident 62 expressed that staff had not offered assistance with the removal of her facial hair and was unaware of its length. The Director of Nursing confirmed that facial hair should have been removed during the resident's shower days. Despite the resident receiving regular showers as documented in the CNA Shower Review Sheets, the care plan's intervention to assist with hygiene was not adequately followed, leading to the observed deficiency.
Failure to Provide Adequate Care for Resident with Edema and CHF
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident diagnosed with edema and congestive heart failure. The resident, who was cognitively intact, was observed multiple times with swollen lower extremities, indicating a lack of effective management of her condition. Despite physician orders for daily weights, monitoring for edema, and the application of compression stockings, these interventions were inconsistently implemented. The resident reported that the prescribed diuretic was not as effective as before, and she was not wearing compression stockings as required. The clinical records revealed significant gaps in the documentation of daily weights and monitoring of edema. The Medication Administration Record/Treatment Administration Record (MAR/TAR) showed numerous instances where staff failed to record daily weights and monitor edema as per physician orders. Additionally, the resident was identified as non-compliant with wearing compression stockings, and there were days when the stockings were not applied, contrary to the care plan. Interviews with the Director of Nursing and Unit Manager highlighted that the resident frequently refused to wear compression stockings, and there was confusion regarding the documentation of these interventions. The Director of Nursing acknowledged that if no initials were listed on the MAR/TAR, the action had not been completed. This lack of adherence to physician orders and inconsistent documentation contributed to the deficiency in the resident's care.
Failure to Administer Recommended Pneumococcal Vaccines
Penalty
Summary
The facility failed to adhere to the current vaccine administration guidelines for the pneumococcal vaccine for one resident. Resident 27, who was reviewed for vaccination records, did not receive the recommended pneumococcal conjugate vaccine (PCV 13, 15, or 20) despite having received the pneumococcal polysaccharide 23 (PPSV 23) vaccine at an outside care setting prior to admission. The resident's immunization records lacked documentation of any pneumococcal conjugate vaccines, which are recommended by the CDC for adults aged 65 years and older, as well as for adults with certain chronic conditions. Resident 27's medical history included peripheral vascular disease and chronic kidney disease, conditions that further necessitate the administration of both types of pneumococcal vaccines according to CDC guidelines. The Director of Nursing (DON) confirmed that the resident should have received both vaccines. The facility's policy, dated 11/8/16, also indicated that both vaccines should be administered routinely to adults aged 65 years and older and those with chronic conditions. However, the facility did not follow these guidelines, resulting in the deficiency.
Failure to Develop Comprehensive Care Plan for Hand Brace
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was developed for a resident who required a hand brace. During observations, the resident was seen with the hand brace on the bedside table and indicated that staff applied the brace at times, but it had been a while since it was last used. The resident's clinical record showed diagnoses including hemiplegia and hemiparesis following a stroke, spastic hemiplegia, and contracture of the left hand and wrist. Physician orders indicated the hand brace should be worn for three hours at a time, with skin checks before application and removal, and the May 2024 Treatment Administration Record showed the brace had been applied and removed on every shift from May 1 to May 22, 2024. However, the clinical record lacked a comprehensive care plan for the utilization of the hand brace and did not address the resident's refusal to wear it. Interviews with staff, including an LPN, the Director of Nursing Services, and the Rehabilitation Supervisor, confirmed that the resident had a history of refusing to wear the brace and that the clinical record should have included a care plan for the brace and the refusal to wear it. The facility's policy on comprehensive person-centered care plans, dated December 2016, was reviewed and indicated that such care plans should include measurable objectives and timetables to meet the resident's needs and prevent or reduce decline in functional status. The lack of a comprehensive care plan for the hand brace and the resident's refusal to wear it was identified as a deficiency in the facility's care planning process.
Failure to Apply Knee Brace as Ordered
Penalty
Summary
The facility failed to ensure a knee brace was applied to a resident while in bed, as required by the physician's order. Resident C, who had diagnoses including hemiplegia and hemiparesis following a stroke, was observed without the knee brace on multiple occasions. The resident's clinical record indicated a physician's order for the left knee brace to be worn every shift while in bed, but the brace was not applied as required. The resident's care plan also specified the need for the knee brace to prevent further decline in range of motion, but staff failed to adhere to this plan. During interviews, staff members, including an LPN and the DNS, confirmed the existence of the physician's order and the resident's need for the knee brace. However, the brace was not found in the resident's room, and staff were unsure of its whereabouts or how long it had been missing. The Rehabilitation Supervisor also confirmed the necessity of the knee brace for the resident's condition. The facility's policy on resident mobility and range of motion, which mandates treatment to prevent a decrease in range of motion, was not followed 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) |
|---|---|---|---|---|
| Greenwood Health And Living Community | 0.6 mi | ★★★★★ | 5 | 0 |
| Greenwood Meadows | 1.2 mi | ★★★★★ | 4 | 0 |
| Greenwood Healthcare Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Hawthorne Healthcare Center | 1.7 mi | ★★★★★ | 10 | 0 |
| Majestic Care Of Southport | 2.3 mi | ★★★★★ | 5 | 0 |
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