Evergreen Crossing And The Lofts

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

showers in POC (Point of Care - an electronic documentation system) when completing their daily charting.

But there were staff that would document showers on skin/shower sheets or in nursing progress notes.During an interview on 8/8/25 at 11:30 a.m., CNA 14 indicated nursing staff were required to document showers both on paper and in POC for the same day of service. It was double documentation, but that was the expectation.During an interview on 8/11/25 at 9:57 a.m., the Administrator indicated, on 8/5/25, it was brought to her attention that water temperatures on [NAME] 1 were intermittently not hitting proper temperatures. There was no centralized shower room in the Lofts 1 hallway. All resident rooms had a shower in their private bathrooms, and on 8/5/25 an empty resident room had been designated as a shower room where residents could be taken for showers.On 8/11/25 at 12:37 p.m., the Administrator (ADM) provided a Daily Skin Care policy, undated, and indicated the policy was the one currently being used by

the facility. The policy indicated, skin care included bathing.1. Discuss the resident/patient preferences for bathing and skin care. 2. Document preferences on the care plan. 3. Communicate resident/patient preferences to the care giving staff. 4. Monitor resident/patient's ability to care for self, including appropriate skin care. Offer assistance or provide care as needed.This citation relates to Intake 2581409.3.1-3(v)(1)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Crossing and the Lofts

5404 Georgetown Road Indianapolis, IN 46254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to provide comfortable water temperatures of more than 100 degrees Fahrenheit (F) and less than 120 degrees F in 16 of the 16 residents' bathrooms on

the [NAME] 1 hallway reviewed for comfortable temperatures (Rooms 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, and 215) . Findings include: During the initial tour, on 8/6/25 at 12:03 p.m., Resident N indicated that the water in her bathroom was cold, she could not take a shower in her room, and CNA 8 had to warm up water in a basin at the nurse's station so she could be washed. A visitor observed the water being cold after having been turned on for 5 minutes. The resident indicated she had notified management more than once that her water did not always warm up after being turned on for 20 minutes.Documentation of water temperature monitoring included:a. On 7/7/25, water temperatures were 120 Fahrenheit (F) in the Health hallway nurse's station, Heritage hallway nurse's station, [NAME] 1 hallway, and [NAME] 2 hallway.b. On 7/14/25, water temperatures were 120 F in the Health hallway nurse's station, Heritage hallway nurse's station, [NAME] 1 hallway, [NAME] 2 hallway, and the frill (upstairs dining area).c. On 7/21/25, water temperatures ranged from 115 - 120 F in the Health hallway, Heritage hallway, [NAME] 1 hallway, [NAME] 2 hallway, and the frill.d. On 7/28/25, water temperatures ranged from 110 - 112 F in the Health hallway, Heritage hallway, [NAME] 1 hallway, [NAME] 2 hallway, and the frill.e. On 8/4/25, water temperatures ranged from 110 - 120 F in the Health hallway, Heritage hallway, [NAME] 1 hallway, [NAME] 2 hallway, and the frill.A grievance documented from Resident N on 8/5/25, indicated she had water concerns.The facility lacked documentation resident specific room water temperatures were being monitored before 8/6/25.Documentation of water temperature monitoring on [NAME] 1 hallway included,a.

On 8/6/25, rooms 200 - 215 ranged from 76 - 82 F.b. On 8/7/25, rooms 200 - 215 ranged from 64 - 76 F.c.

On 8/8/25 in the morning, rooms 202 - 215 ranged from 76 - 80 F.d. On 8/8/25 in the afternoon, rooms 203 - 211 ranged from 63 - 98 F.A service report, dated 8/6/25, indicated a heat sensor was not working properly, and a replacement part was ordered.During an interview on 8/11/25 at 9:57 a.m., the Administrator indicated, on 8/5/25, it was brought to her attention that water temperatures on [NAME] 1 were intermittently not hitting proper temperatures. On 8/6/25 the residents/resident representatives in rooms 205 - 209 were offered rooms. The residents in rooms 203, 204, 210, and 211 were offered room moves on 8/8/25 after daily water temperature monitoring had identified hot water concerns in their rooms.

Residents had declined a room move and were not made to make a room change as there was no threat of them getting burned, and the facility knew the problem was in the process of being fixed.During an

interview on 8/11/25 at 3:30 p.m., the Administrator indicated the facility did not have a specific policy for monitoring hot water temperatures but followed current state regulation regarding water temperatures. The regulation indicated, Hot water temperatures for all bathing and hand washing facilities shall be controlled by an automatic control valve. Water temperature at point of use must be maintained between one hundred [100] degrees Fahrenheit and one hundred twenty [120] degrees Fahrenheit.This citation relates to Intake 2581409.3.1-19(r)(1)3.1-19(r)(2)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Crossing and the Lofts

5404 Georgetown Road Indianapolis, IN 46254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident supplements, and monitoring food brought from outside the facility and stored in the resident refrigerators. The UM was responsible for monitoring that staff were not storing personal food in the resident refrigerators.On 8/11/25 at 2:10 p.m., the Administrator (ADM) provided a Storage of Resident Food policy, undated, and indicated the policy was the currently being used by the facility.A. The facility maintains a pantry for resident food, dry storage, and a dedicated resident refrigerator for cold storage for those residents who have food brought in from visitors.1. Refrigerator/freezers for storage of foods brought

in by visitors will be properly maintained. 2. Daily monitoring for refrigerator storage duration and discard of any food items that have been stored for [more than] 7 days.3. Cleaned weekly.D2. Food not for immediate consumption, will be properly contained and labeled for storage to be consumed at a later time.II. Food and liquid consumables may be brought into the facility for the resident's using the following guidelines.B. Foods will be stored in a closed container with sealable lids. C. Staff will provide plastic or other closed containers with sealable lids, if needed.E. Staff will date the container when food or beverages are brought into the facility and discard food when non-safe.III. The dietary staff will monitor refrigerator contents for food safety and reserve the right to dispose of expired, unsafe foods. A. Dry storage foods may be stored at resident's bedside in amounts that maintain a safe environment.D. The dietary staff will monitor refrigerator storage areas for resident's food monitoring for outdated, unsafe or otherwise food unfit for consumption.3.1-21(i)(3)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Crossing and the Lofts

5404 Georgetown Road Indianapolis, IN 46254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm

sign daily for each room cleaned. The 5-step daily cleaning schedule of the resident room included pull trash/replace liner, horizonal surfaces, vertical surfaces, and dust mop and damp mop. The 7-step daily cleaning schedule for the bathroom included check/refill supplies, pull trash/replace liner, dust mop/sweep, clean sink area/tub, clean commode/basin, clean wall/particians, and damp mop.This citation relates to Intakes 1835279, and 2581409.3.1-19(f)(5)

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Crossing and the Lofts

5404 Georgetown Road Indianapolis, IN 46254

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident JJ's head as she sat in a manual WC outside her doorway in Heritage hallway.On 8/8/25 at 3:21 p.m., observation of gnats in the medical records office with the Director of Nursing (DON).On 8/11/25 at 9:45 a.m., gnats observed flying around the kitchen, dietary staff was observed to swat them away from a food prep station near cut up wedges of potatoes.Documentation of contracted pest control services, dated 7/3/25 - 8/5/25, indicated routine services to treat for gnats and/or ants, and spiders, had been provided on 7/3, 7/17, and 8/5.During an interview on 8/11/25 at 9:57 a.m., the Administrator (ADM) indicated it was not unusual for family members to bring food into the residents, and residents could keep food in their rooms with or without a refrigerator. The ADM indicated, the facility had not attempted interventions for food storage in the resident rooms such as plastic baggies or bowls with lids. On 8/11/25 at 12:37 p.m., the Administrator (ADM) provided a Pest Control policy, dated 9/15/21, and indicated the policy was the one currently being used by the facility. The policy indicated, A. All areas in the center will be sprayed monthly by a duly licensed agent. B. If a problem should develop, the Environmental Services Director will contact [pest control company] personnel to review before starting so special attention can be given to this area.On 8/11/25 at 2:10 p.m., the Administrator (ADM) provided a Storage of Resident Food policy, undated, and indicated the policy was the currently being used by the facility. The policy indicated, .1. Foods will be stored

in a closed container with sealable lids. C. Staff will provide plastic or other closed containers with sealable lids, if needed.E. Staff will date the container when food or beverages are brought into the facility and discard food when non-safe.III. A. Dry storage foods may be stored at resident's bedside in amounts that maintain a safe environment.This citation relates to Intakes 1835271, 1835279, and 2581409.3.1-19(f)(4)

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Facility ID:

If continuation sheet