Evergreen Crossing: Cold Water Forces Basin Baths - IN
Resident N said the water in her bathroom stayed cold even after running for 20 minutes. She had complained to management more than once about the problem.
Federal inspectors found water temperature failures in all 16 resident bathrooms they tested on one hallway at Evergreen Crossing and the Lofts. During their August visit, temperatures in rooms 200 through 215 ranged from 64 to 98 degrees Fahrenheit, well below the required minimum of 100 degrees.
A visitor witnessed the cold water problem firsthand. After turning on the tap for five minutes, the water remained cold.
The facility's own temperature monitoring showed the problem had persisted for weeks. On August 7, water temperatures in the affected rooms ranged from 64 to 76 degrees. The next morning, temperatures climbed slightly to 76 to 80 degrees, but by afternoon had dropped again to between 63 and 98 degrees in some rooms.
CNA 8 had resorted to warming water in a basin at the nurse's station to wash Resident N. The workaround highlighted how staff tried to maintain basic hygiene care despite the facility's infrastructure failures.
Resident N filed a formal grievance about the water problems on August 5. Inspectors found the facility lacked documentation showing they had monitored individual room water temperatures before August 6, despite ongoing complaints.
The administrator told inspectors the problem came to her attention on August 5, when she learned water temperatures were "intermittently not hitting proper temperatures" on the affected hallway. A service report dated August 6 revealed a heat sensor wasn't working properly and a replacement part had been ordered.
The facility offered room changes to some residents but not others. Residents in rooms 205 through 209 were offered alternative accommodations on August 6. Those in rooms 203, 204, 210, and 211 weren't offered moves until August 8, after daily monitoring confirmed hot water problems in their rooms.
All residents declined to move.
The administrator said residents weren't forced to change rooms because "there was no threat of them getting burned, and the facility knew the problem was in the process of being fixed." The logic ignored the regulation requiring water temperatures between 100 and 120 degrees for basic hygiene and comfort.
Federal regulations require nursing homes to provide a safe, clean, comfortable environment for residents. Water temperature monitoring at other areas of the facility showed inconsistent compliance even before the sensor failure. On July 28, temperatures ranged from 110 to 112 degrees across different hallways. By August 4, they varied between 110 and 120 degrees.
The administrator acknowledged the facility had no specific policy for monitoring hot water temperatures. She said they followed state regulations requiring automatic control valves and temperatures between 100 and 120 degrees at point of use.
The temperature failures affected basic dignity and hygiene for residents who depend on staff for bathing assistance. Resident N's experience of waiting 20 minutes for water that never warmed illustrated how equipment failures translated into daily discomfort for vulnerable residents.
The basin workaround also created additional work for already busy nursing assistants, who had to carry warm water from the nurse's station to provide basic care that should have been available at the tap.
Inspectors documented the violations as causing minimal harm with potential for actual harm to some residents. The citation related to the facility's failure to honor residents' right to a comfortable environment and proper treatment for daily living needs.
The broken heat sensor and delayed response left an entire hallway of residents without proper hot water access for weeks. While the facility knew repairs were needed, residents like N continued living with cold water and makeshift bathing arrangements until the problem was addressed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Crossing and the Lofts from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
EVERGREEN CROSSING AND THE LOFTS in INDIANAPOLIS, IN was cited for violations during a health inspection on August 11, 2025.
Resident N said the water in her bathroom stayed cold even after running for 20 minutes.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.