Evergreen Crossing: Wound Care Planning Failures - IN
The findings emerged from the facility's own internal audits, conducted weeks before federal inspectors arrived on November 14. By then, the damage was already documented in the facility's own paperwork, and a complaint investigation was underway.
At the center of the inspection was a resident with a pressure injury on the coccyx, described in records as having a pink or red base. Daily wound care was listed as including no cover dressing and no documented treatment. The clinical note for this resident contained no date indicating when the injury had developed, no root cause analysis, and no description or measurement of the wound's size. It was, in the language of the inspection, a care plan that simply did not exist in any meaningful form.
A licensed practical nurse told inspectors that afternoon that the responsibility for care planning new or worsening wounds belonged to the facility's Minimum Data Set nurse. The MDS nurse is the clinician responsible for ensuring that a resident's documented needs translate into an active, updated plan of care. Whether that handoff was happening consistently, the inspection record does not say.
What the record does say is that the facility's own Regional Vice President of Risk Management handed inspectors documentation she described as evidence of past noncompliance. It was a candid admission. On October 24, care plan audits had been completed for twelve residents with known skin concerns or wounds. The RVRM told inspectors that approximately 75 percent of those residents required their care plans to be updated. She could not name which residents had actually received revisions.
Three-quarters of the residents with known wounds. And no list of who had been fixed.
The following day, October 25, staff conducted a skin sweep of every resident in the building. The sweep turned up no new pressure ulcers, but it did find residents with undocumented skin tears, bruises, and other skin conditions that had gone unrecorded. Injuries present in the building, on residents' bodies, with nothing in the chart.
On October 31, the facility initiated follow-up audits. Ten residents with wounds were to be visually checked each week for four weeks. The checklist of things to verify was detailed: whether families had been notified, whether wound treatments were being completed per physician orders, whether daily monitoring had occurred, whether recommendations from the wound nurse practitioner were being followed, whether positioning and repositioning orders were in place, and whether care plans were current.
That checklist exists because all of those things had, at some point, not been happening.
The President of Risk Management provided inspectors with two facility policies during the survey, both undated. One covered care planning. One covered skin care and wound management. Both described, in careful administrative language, exactly what the facility was supposed to do: assess residents on an ongoing basis, develop individualized care plans, communicate changes to the care team, evaluate whether interventions were actually working, and modify goals when needed.
The policies described a system. The October audits described what happened when that system broke down.
Inspectors ultimately classified the violation as past noncompliance, meaning the facility had corrected the problem before the survey began. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting a few residents. Staff education had been completed, the audits were ongoing, and the wound care plan process had been restructured.
But the correction happened because the facility audited itself and found, spread across its own hallways, residents whose wounds had no care plans, whose skin injuries had no documentation, and whose families may not have been told. The sweep on October 25 was not routine. It was a response to the realization that the facility did not know what was happening on residents' skin.
The resident with the pressure injury on the coccyx, the one whose wound note had no date, no size, no cause, and no treatment documented, had been living in that gap. How long the wound had been developing before anyone wrote it down, the inspection report does not say.
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 21, 2026 · Our methodology
EVERGREEN CROSSING AND THE LOFTS in INDIANAPOLIS, IN was cited for violations during a health inspection on November 14, 2025.
The findings emerged from the facility's own internal audits, conducted weeks before federal inspectors arrived on November 14.
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.