Castleton Health Care Center
CASTLETON HEALTH CARE CENTER in INDIANAPOLIS, IN — inspection on September 23, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
while residing at the Facility.
Policy.
Each resident shall be cared for in a manner that promotes and
choice…XII.
Demeaning practices and standards of care that compromise dignity are
A resident rights policy was provided by the ED on 9/22/25 at 2:46 p.m. It indicated, “…Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights…” This citation relates to Intakes 2605799 and 2613777. 3.1-3(t)
155245 09/23/2025
Castleton Health Care Center 7630 E 86th St Indianapolis, IN 46256
include:The clinical record for Resident N was reviewed on 9/17/25 at 12:30 p.m.
Her diagnoses
heart failure, and arthritis.
The ADL (activities of daily living) care plan, revised 8/18/25, indicated he had an ADL self-care performance deficit related to impaired balance, limited mobility, pain, and shortness of breath, and she would refuse to get out of bed. An intervention was to encourage her to use bell to call for assistance.
The 8/29/25 Quarterly MDS (Minimum Data Set) assessment indicated she was moderately cognitively impaired. An observation and interview were conducted with Resident N in her room on 9/17/25 at 12:18 p.m.
She was lying in bed.
Her call light cord was tied around the right side rail, hanging down the right side of her bed, eight inches from the floor.
Resident N had a wooden stick, one inch wide, one and half feet long on her bedside table in front of her.
She used it to attempt to reach her call light, but she was unsuccessful.
She indicated staff were in the room about an hour and a half earlier, but they didn't adjust her call light to be within reach.
She stated, Most of the time I can't reach my call light. I don't suffer too much [sic] not being able to reach it. I take my stick and start beating on the table, and they can hear me, and then they come.
She indicated she couldn't get her hand around to reach the call light cord, and she couldn't turn over to reach the light.
Resident N again tried to reach her call light cord, but she couldn't.
She stated, I can't get it in my hand and do anything.
When she soiled her brief, she hit the bedside table or side rail with her wooden stick to get staff's attention.
Resident N demonstrated this at this time. An observation and interview with Resident N were conducted on 9/17/25 at 1:55 p.m.
She was lying in bed, eating her lunch. No one else was in the room at this time.
Her call light remained in the same position, wrapped around the right side rail of her bed, hanging down, eight inches from the floor.
Resident N indicated she wasn't sure who brought her lunch tray to her, but they did not ensure her call light was in reach. An observation of Resident N and interview with UM (Unit Manager) 6 was conducted on 9/17/25 at 1:57 p.m. UM 6 untangled her call light from the side rail and placed it within reach of Resident N. UM 6 indicated her call light should always be within her reach, and they may need to get a clip for the call light or a different type of call light.
The Use of Call Light policy was provided by NC (Nurse Consultant) 1 on 9/19/25 at 10:54 a.m. It indicated, It is the policy of this home to ensure residents have a call light within reach that they are physically able to access and that they have been instructed on its use .All nursing personnel must always be aware of call lights.
Ensure call light is within reach of resident prior to leaving the residents room .Be sure call lights are placed near the resident, never on the floor or bedside stand.This citation relates to Intakes 2605799 and 2613777. 3.1-3(v)(1)
155245 09/23/2025
Castleton Health Care Center 7630 E 86th St Indianapolis, IN 46256
to be shaved for the past three weeks.
shaven.
The September 2025 shower sheets indicated he was last shaved on 9/15/25.
An interview was conducted with Resident Q on 9/22/25 at 3:18 p.m. He indicated staff just shaved his facial hair yesterday, but he'd been asking for last two or three weeks.
A Quality-of-life resident rights policy was provided by the Executive Director on 9/22/25 at 2:46 p.m.
It indicated, “To ensure that all residents are treated with the level of dignity they are entitled to while residing at the facility…Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect and individuality…” The Shaving policy was provided by the ED (Executive Director) on 9/23/25 at 9:52 a.m. It indicated, I.
The Facility provides for the removal of facial hair as a component of the resident's hygienic program. II.
Male residents may be shaved daily, and female resident may be shaved as needed.
This citation relates to Intakes 2605799 and 2613777. 3.1-38(a)(3)(D) 3.1-38(a)(3)(E)
155245 09/23/2025
Castleton Health Care Center 7630 E 86th St Indianapolis, IN 46256
Resident BB's interview of when he received the medication.
The September 2025 TAR was blank for
pharmacological interventions. An interview was conducted with the DON on 9/22/25 at 10:56 a.m.
or blood pressure could change.
They documented in the MAR/TAR, but not necessarily anywhere else.
The DON reviewed Resident BB's electronic clinical record and indicated she was unable to locate any verification of vital signs or non-pharmacological interventions attempted for his PRN pain medication administrations.
The Pain Management policy was provided by the ED (Executive Director) on 9/22/25 at 11:30 a.m. It indicated, The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR) .Nursing Staff will implement timely interventions to reduce the increase in severity of pain .Nursing Staff will also utilize non-pharmacological interventions by adjusting the resident's environment to reduce pain.
This citation relates to Intake 2613777. 3.1-37(a)
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.