Robin Run Health Center: Unreported Fall, Hidden Bruising - IN
Resident E, a hospice patient at Robin Run Health Center on the city's northwest side, had facial redness and bruising that her own care team had not reported to her doctor, her family representative, or the facility's director of nursing. It took a visitor asking questions on August 15 to prompt the director of nursing to open an investigation. By then, the injury was days old.
The resident had already fallen once. On July 31, she had rolled out of her bed, a fall the facility documented. She had no trunk control and required two staff members to help her stand and pivot. She did not walk on her own.
Sometime around August 5, inspectors believe she fell again, this time from her wheelchair. Nobody wrote it down.
A QMA working the evening of August 11 noticed something and passed the information to LPN 8, the nurse in charge on the healthcare hallways that night. What LPN 8 did with that information, nobody could say. LPN 13, who received the report from night shift the following morning on August 12, said she was told there was bruising on the resident's face and that staff did not know when it had occurred. LPN 13 said her standard practice would have been to notify the wound nurse, document a progress note, complete a skin assessment, and then alert the physician, the director of nursing, and the resident's representative. Whether any of that happened for Resident E, she could not confirm.
The director of nursing told inspectors on August 18 that she had known nothing about the facial redness and bruising until a visitor raised it with her on August 15. She started her own investigation that day. By the time inspectors arrived three days later, she had pieced together what she believed had happened: the resident had experienced a second fall, rolling from her wheelchair, and the fall had never been documented as an incident. No one had notified the physician. No one had notified the resident's representative.
The director of nursing confirmed there was no documentation showing that anyone in a supervisory or medical role had been told about either the second fall or the bruising at the time it occurred.
Hospice had since stepped in. By the inspection date, the resident had been given a Broda chair that allowed her to recline rather than sit upright, and her bed had been fitted with a new mattress and a bolster overlay. The equipment changes came after the injury, not before.
The facility provided inspectors with two internal policies. One, on skin assessment and pressure injury prevention, called for daily skin inspection during personal care and documentation of any changes. The other, on acute condition changes, directed staff to contact the physician based on the urgency of the situation and to monitor and document the resident's progress. Both policies were described as currently in use. Neither had been followed in the days after Resident E's second fall.
The gap between what the policies required and what actually happened ran to at least ten days, from the estimated date of the fall on August 5 to the visitor's questions on August 15, and arguably longer, since the QMA had flagged something on the evening of August 11 and the information still went nowhere.
Inspectors rated the deficiency as causing minimal harm or potential for actual harm, affecting a small number of residents. The citation covered two separate complaint intakes filed with the state.
Resident E was on hospice. She had no trunk control. She had already fallen out of her bed once. The people responsible for her care learned about her bruised face from someone who came to visit her.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Robin Run Health Center from 2025-08-18 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: July 3, 2026 · Our methodology
ROBIN RUN HEALTH CENTER in INDIANAPOLIS, IN was cited for violations during a health inspection on August 18, 2025.
It took a visitor asking questions on August 15 to prompt the director of nursing to open an investigation.
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.