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Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harbour Manor Health & Living Community during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including post-surgical hip fracture, cognitive impairment, incontinence, and unilateral lower extremity impairment, was admitted and did not have a 72-hour care plan meeting or baseline person-centered care plan completed within the required timeframe. The initial care conference occurred nine days after admission. Staff interviews showed that social services typically contacted representatives 24–48 hours after admission and did not routinely document unsuccessful contact attempts, and that the care conference for this resident was delayed to accommodate the representative’s schedule. This practice did not align with facility policy requiring a baseline care plan within 48 hours of admission and completion of key care planning elements by the initial IDT care conference.
A cognitively impaired resident with a history of falls and poor safety awareness was transported by a facility driver to an orthopedic office for a follow-up visit, based on hospital discharge orders and facility-entered appointment information that had been changed and not clearly communicated. The driver left the resident at the office without a caregiver, despite office records indicating the resident should be accompanied, and did not notify the facility when informed there was no current appointment. The resident, who arrived confused and agitated, remained unsupervised at the office for an extended period until the facility was contacted, and staff later acknowledged a communication breakdown, lack of discussion of transportation arrangements at care conference, and absence of a transportation policy.
Staff failed to accurately document controlled substance administration and inventory for multiple residents, resulting in mismatches between the controlled medication binder and blister card counts for medications such as pregabalin, hydrocodone-acetaminophen, tramadol, lorazepam, and clonazepam. An LPN acknowledged not recording that morning’s controlled medication doses, and subsequent review showed each affected resident’s binder count was one pill higher than the actual blister card count. The residents involved had complex medical conditions, including cognitive impairment, seizure disorder, Parkinson’s disease, cardiovascular disease, COPD, diabetes, and chronic pain, and facility leadership confirmed that this practice did not follow the policy requiring immediate documentation of controlled drug administration and remaining doses.
A resident with severe cognitive impairment and a history of combative behavior was physically restrained by an RN, who held the resident's hands and attempted to administer oral medications while the resident screamed and resisted. The incident, witnessed by a CNA, involved the resident spitting out the medication and applesauce, and was reported as staff-to-resident abuse due to the RN's failure to respect the resident's refusal and escalating the situation.
A CNA did not intervene when witnessing an RN attempt to administer medication to a severely cognitively impaired resident who became combative, resulting in the resident being restrained and distressed. The CNA, present for one-to-one observation, did not act to protect the resident, which was contrary to the facility's abuse prevention policy.
A resident with multiple medical conditions and a history of making false accusations required care to be provided by two staff members, as documented in the care plan and CNA assignment sheet. However, a CNA provided care alone, contrary to the care plan intervention, which was confirmed by the DON and other staff during interviews.
The facility failed to ensure proper narcotic count reconciliation for the Rehab 1 medication cart, missing required documentation on several dates. Staff interviews confirmed the absence of necessary signatures and count numbers, posing a potential risk for drug diversion. Despite frequent education on narcotic reconciliation, the facility's policy was not followed, leaving the facility unable to verify if any narcotics were missing.
A resident reported that the Activities Director yelled at her, causing humiliation and distress. Despite the incident being reported to the Physical Therapy staff and allegedly to the Director of Nursing, no investigation was conducted, and the facility's policy on reporting abuse was not followed.
The facility failed to report allegations of sexual abuse involving a resident to law enforcement and adult protection agencies. Despite the resident's report and the facility's policy requiring such notifications, the facility did not contact the police, citing the family's request as the reason. However, a family member later indicated that they did not request the police not to be called.
Failure to Complete Timely Baseline Care Plan and Initial Care Conference
Penalty
Summary
The deficiency involves the facility’s failure to initiate and conduct a 72-hour care plan meeting and develop a person-centered baseline care plan within the required timeframe following a resident’s admission. The resident, who had diagnoses including a right femur neck fracture post-surgical repair, cognitive symptoms following a cerebrovascular accident, repeated falls, hypertension, conversion disorder with seizures or convulsions, osteoporosis, and chronic pain, was admitted on an identified date. The admission MDS showed moderate cognitive impairment, wheelchair use for mobility, frequent urinary incontinence, occasional bowel incontinence, and impairment of one lower extremity. The clinical record lacked documentation that a 72-hour care plan meeting was initiated or conducted within the required timeframe, and the initial care conference did not occur until nine days after admission. Interviews with staff revealed that the Social Service Director typically called resident representatives 24 to 48 hours after admission to set up a care conference and generally did not document unsuccessful attempts to reach representatives. The Admission Coordinator reported leaving a voicemail for the resident’s representative on the first available business day after admission due to a holiday, and the Transitional Care Nurse acknowledged that the care conference for this resident was delayed to accommodate the representative’s schedule, who wanted to be present. The facility’s policy required development of a person-centered baseline care plan within 48 hours of admission, including medications, dietary instructions, services, treatments, and pertinent updates by the date of the initial IDT care conference, but this was not completed as required for this resident.
Failure to Supervise Cognitively Impaired Resident During Off-Site Appointment Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and protection from accident hazards for a cognitively impaired resident during transport to an outside orthopedic appointment. The resident had diagnoses including a right femur neck fracture post-surgical repair, cognitive impairment following cerebrovascular disease, repeated falls, conversion disorder with seizures, osteoporosis, and chronic pain. The most recent MDS showed moderate cognitive impairment, wheelchair use, incontinence, and lower extremity impairment. Progress notes documented multiple recent falls, with root causes identified as poor safety awareness and confusion, and a physician note described the resident as confused and a poor historian. Hospital discharge orders included a follow-up orthopedic appointment, and the facility entered an appointment order; however, there were conflicting orders and a discontinued date that indicated a change in the appointment. On the day of the incident, the resident was transported by the facility’s transportation driver to the orthopedic office for what was believed to be a scheduled appointment. The orthopedic office reported that the resident arrived confused and agitated, without a current appointment, and that the office chart specified the resident should be accompanied by a caregiver. The driver left the resident at the office and went to get something to eat, did not confirm the appointment with the facility, and did not notify the facility when informed there was no appointment. The resident remained at the office unsupervised for approximately 2.5 hours until the facility was contacted and the resident was picked up. Facility staff, including the Unit Manager and Clinical Support Consultant, acknowledged a communication breakdown regarding the cancelled appointment, that the resident was not safe to be unsupervised due to periods of confusion, that transportation arrangements were not discussed at the initial care conference, and that the facility had no policy related to transportation or conduct for resident transport.
Failure to Accurately Document Controlled Substance Administration and Inventory
Penalty
Summary
The deficiency involves the facility’s failure to accurately document controlled substance administration on individual narcotic record sheets in accordance with its policy. During an observation of a medication cart serving 18 residents, an LPN stated she had not documented the controlled medications administered that morning in the controlled medication binder. Review of the binder and comparison with blister card counts for six residents showed consistent discrepancies: for each resident, the number of pills recorded as remaining in the controlled medication binder was one higher than the actual number of pills remaining in the blister card. This included pregabalin and hydrocodone-acetaminophen for one resident, tramadol for two residents, lorazepam for one resident, hydrocodone-acetaminophen for another resident, and clonazepam and pregabalin for a sixth resident. The residents involved had various medical conditions, including severe cognitive impairment, seizure disorder, depression, Parkinson’s disease, coronary artery disease, cerebrovascular accident history, anemia, hypertension, chronic obstructive pulmonary disease, neurogenic bladder, hyperlipidemia, type 2 diabetes mellitus, pain, and cardiomyopathy. Interviews with the Unit Manager and DON confirmed that the expectation and written policy required nurses to document controlled drug administration immediately after dosing, including date, time, dose, nurse signature, and remaining doses. The observed discrepancies and the LPN’s admission that she had not documented the morning controlled medication administrations demonstrated noncompliance with the facility’s controlled substance management policy.
Resident Physically Restrained and Forced Medication Administration by RN
Penalty
Summary
A deficiency occurred when a registered nurse (RN) physically restrained the hands of a severely cognitively impaired resident and attempted to administer oral medications while the resident was screaming and resisting. The resident, who had diagnoses including encephalopathy, memory deficit, and a history of combative behaviors, was under one-to-one observation due to unsafe and combative actions. During the medication administration, the resident became combative, yelled, and refused the medication, but the RN continued to attempt administration, resulting in the resident spitting out the medication and applesauce. A certified nursing assistant (CNA) witnessed the incident and reported that the RN escalated the situation instead of stopping the attempt. The incident was documented in the resident's clinical record and reported to facility leadership. The facility's policy on abuse prevention emphasizes maintaining an abuse-free environment and ensuring staff are knowledgeable about individual resident care needs, including rotating staff for residents with challenging behaviors. The actions of the RN in physically restraining the resident and forcing medication administration were identified as staff-to-resident abuse, as they did not respect the resident's right to refuse care and contributed to the resident's distress.
Failure to Intervene During Observed Resident Abuse
Penalty
Summary
A staff member (CNA) failed to intervene when witnessing another staff member (RN) attempting to administer medication to a severely cognitively impaired resident who became combative during the process. The RN sat on the resident's bed, held the resident's hands, and placed medication in the resident's mouth while the resident was screaming and subsequently spat out the medication and applesauce. The CNA, who was providing one-to-one observation for the resident at the time, did not intervene or attempt to protect the resident, later stating that the incident happened too quickly for her to act. The resident involved had significant medical conditions, including encephalopathy, anemia, hypertension, cerebrovascular disease, dysphagia, stage 4 chronic kidney disease, pain, and memory deficit, and was assessed as severely cognitively impaired. The facility's policy required any individual observing or suspecting resident abuse to promptly report the incident after ensuring the resident's safety. However, the CNA did not take immediate action to protect the resident during the incident, resulting in a failure to implement the facility's abuse prevention policy.
Failure to Follow Care Plan for Paired Staff During Resident Care
Penalty
Summary
The facility failed to follow a care plan intervention for a resident who required care to be provided by staff in pairs due to a history of making false accusations against staff members. On the night shift of 12/26/24, the resident, who was cognitively intact and had multiple medical diagnoses including multiple sclerosis, diabetes with polyneuropathy, depressive disorder, and dysphagia, reported to staff that a CNA had touched him inappropriately during incontinence care. The resident's care plan, updated on 4/28/23, specifically required that care be provided by two staff members at all times, an intervention that was also listed on the CNA Assignment Sheet and confirmed by other CNAs during interviews. Despite this documented intervention, the DON confirmed that the CNA provided care to the resident alone while another CNA was in the hallway, thus not adhering to the care plan requirement. The CNA involved did not indicate in their written statement whether another staff member was present during care. This failure to follow the care plan intervention was identified during interviews and record reviews, and was cited as a deficiency related to the facility's obligation to implement and follow individualized care plans.
Failure to Reconcile Narcotic Counts on Rehab 1 Cart
Penalty
Summary
The facility failed to ensure proper shift-to-shift narcotic count reconciliation for one of the medication carts, specifically the Rehab 1 cart. During an observation, it was found that the Nurse Narcotic Sign in/out Sheet lacked reconciliation numbers for controlled medications on several dates. Interviews with staff, including LPNs and the Rehab Unit Manager, confirmed that the required signatures and count numbers were missing for October 17, 18, 19, and 20, 2024. This omission was identified as a potential opportunity for drug diversion, as the absence of count verification made it impossible to determine if any narcotics were missing. The facility's policy on Controlled Substance Reconciliation mandates that the quantity of controlled substances and the number of accompanying count sheets be verified at the end of each nursing shift. Despite frequent education provided to staff regarding the importance of complete narcotic reconciliation, the required documentation was not completed as per policy. The Director of Nursing acknowledged the deficiency, noting the lack of count numbers on the Nurse Narcotic Sign in/out Sheets for the specified dates, which left the facility unable to ascertain if drug diversion had occurred.
Failure to Investigate Allegation of Verbal Abuse
Penalty
Summary
The facility failed to complete an investigation of an allegation of verbal abuse involving Resident D. During an interview, Resident D reported that the Activities Director (AD) yelled at her loudly, accusing her of rejecting another resident from sitting at her table. This incident left Resident D feeling humiliated, embarrassed, and hurt, causing her to cry for several days. Despite this, the AD did not follow up with Resident D or apologize. Resident D, who has diagnoses including major depressive disorder and morbid obesity, was cognitively intact and able to communicate effectively, as indicated by her quarterly Minimum Data Set (MDS) assessment. Physical Therapy staff (PT) 2 reported that Resident D was extremely upset when she recounted the incident and that PT 2 had informed her supervisor, who then reported it to the Director of Nursing (DON). However, during an interview, the DON indicated she was unaware of the allegation. The facility's policy requires immediate reporting of any alleged mistreatment, neglect, or abuse to the Indiana Department of Health, but this procedure was not followed in this case.
Failure to Report Allegations of Sexual Abuse
Penalty
Summary
The facility failed to report allegations of sexual abuse involving a resident to law enforcement and adult protection agencies. The incident involved Resident B, who reported an allegation of staff-to-resident sexual abuse during incontinent care by CNA 1. The facility's investigation into the allegation lacked documentation of notification to law enforcement or adult protection agencies. Despite the resident's report and the facility's policy requiring such notifications, the facility did not contact the police, citing the family's request as the reason. However, a family member later indicated that they did not request the police not to be called. Interviews with the Administrator, Director of Nursing, and Corporate Consultant confirmed that law enforcement was not notified. The facility's current policy, dated 10/14/2014, mandates reporting any reasonable suspicion of a crime against a resident to local law enforcement and state agencies within 24 hours. The failure to report the incident as required by the policy resulted in a deficiency citation related to Complaint IN00428301.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Noblesville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverwalk Village | 0.7 mi | — | 20 | 0 |
| Prairie Lakes Health Campus | 4.3 mi | — | 3 | 0 |
| Maple Park Village | 5.1 mi | — | 8 | 0 |
| Bridgewater Healthcare Center | 5.4 mi | — | 3 | 0 |
| Mcgivney Health Care Center | 5.9 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.