Evergreen Crossing: Wound Care Failures Caused Harm - IN
Federal inspectors cited Evergreen Crossing and The Lofts following a complaint investigation completed November 14, 2025. The citation carries a Level of Harm designation of actual harm, meaning inspectors concluded that real residents suffered real consequences — not theoretical ones.
The inspection report does not name the residents who were harmed. It does not describe their wounds in detail, or say how long those wounds went unaddressed. What it does show is what the facility found when it finally looked: a workforce that needed to be retrained from scratch on how to assess skin, how to measure a wound, how to document what they saw, and who to call when something went wrong.
That training happened on October 24, 2025 — weeks before inspectors arrived.
The timeline matters. On that date, nursing management sent education materials to 130 staff members covering wound assessment, documentation requirements, measurement techniques, care planning, and the steps a nurse should take if she believed a provider's wound description was inaccurate or a wound was being mismanaged. Over the following three days, managers met with staff in person. Nurses and aides signed forms confirming they had received the training, that they understood it, and that they had no remaining questions.
The fact that this training was necessary tells its own story.
On October 25, staff conducted what the facility called a skin sweep — a head-to-toe review of all 97 residents then living at Evergreen Crossing. The sweep found no new pressure wounds. But it also found that roughly 25 percent of residents already known to have wounds still did not have updated care plans. That same day, the facility notified physicians, nurse practitioners, resident representatives, and a wound care nurse practitioner about residents with skin issues, and obtained new treatment orders where needed.
Two days later, on October 27, the facility replaced its wound nurse. LPN 15 was out; LPN 9 was hired into the position and began conducting skin assessments on newly admitted residents on her first shift.
By October 31, the facility had launched weekly audits: ten residents with wounds were to be visually checked each week for four weeks, with staff verifying that families had been notified, that wound treatments were being completed as ordered, that daily monitoring was happening, that wound care recommendations were being followed, and that care plans were current.
When inspectors arrived on November 14, the Regional Vice President of Risk Management presented this documentation and argued the violations were past noncompliance — meaning the facility had identified the problems and corrected them before the survey began. Inspectors agreed. The citation was written as past noncompliance, with a correction date of October 31.
That designation does not erase the actual harm finding. It means the harm happened, was eventually addressed, and was resolved before inspectors walked through the door. It does not mean inspectors found the care to be adequate when they arrived — it means the deficient practice had, by their assessment, stopped.
The facility's own skin care policy, which a vice president provided to inspectors during the visit, calls for residents to be evaluated upon admission and weekly thereafter for any changes in skin condition. It lists the risk factors that should trigger heightened attention: diabetes, poor nutrition, decreased mobility, cognitive impairment, previous pressure ulcers, and others. It describes a Braden Scale assessment, individualized care plans, and communication to the care team at each step.
The policy is undated.
What the record shows is a gap between what the policy described and what was actually happening in the building — a gap wide enough that management had to essentially rebuild its wound care program in the span of a week. A new nurse. A facility-wide skin sweep. Retraining for more than a hundred employees. Audits that had to be created because the existing oversight hadn't caught what was going wrong.
The residents whose wounds went undocumented or undermanaged during that period are not named in the report. Their outcomes are not described. The inspection record closes with a compliance date and a policy summary, not with what happened to the people whose care prompted the complaint in the first place.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Crossing and the Lofts from 2025-11-14 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 22, 2026 · Our methodology
EVERGREEN CROSSING AND THE LOFTS in INDIANAPOLIS, IN was cited for violations during a health inspection on November 14, 2025.
Federal inspectors cited Evergreen Crossing and The Lofts following a complaint investigation completed November 14, 2025.
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.