Content warning: This story includes detailed descriptions of psychiatric hospitalization, involuntary confinement, death and allegations of medical neglect and sexual assault.
When Amy Pawlus finally saw her mother, she said it was clear something was “terribly wrong.”
Her mother, Shelby Boaz, who had been diagnosed with dementia, was recovering in a local hospital after fracturing her hip. After her mother began acting out, staff recommended transferring her to a psychiatric hospital in Indianapolis, saying the facility could stabilize her.
That facility was run by NeuroPsychiatric Hospitals, a for-profit chain of psychiatric hospitals based in Indiana that takes patients with both medical and psychiatric needs — patients many psychiatric hospitals are not equipped to care for.
On her mother’s first full day at the Indianapolis hospital, Pawlus said she reached a nurse who said her mom was “a hoot,” chatting with other patients and trying to help them. It was exactly what Pawlus expected from her mom, a retired nurse’s aide who had spent her life caring for patients.
Pawlus said she was told not to visit for at least a week, but that she could call for updates. But she said after an early update from a nurse, the phone line went quiet.
She said she redialed “hundreds” of times over the next week and a half. Finally, she stopped waiting and drove to the facility herself.
She demanded to see her mother, and finally, she said, staff wheeled her into a conference room. But she was slumped over, bruised and unconscious, with dried orange sludge crusted around her mouth.
"I just burst into tears," Pawlus said. "What in the hell is going on?"
Her mother was sent to the emergency room, then transferred to hospice. She died on New Year’s Eve of 2018 — just over two weeks after leaving the psychiatric hospital, Pawlus said.
Pawlus began legal action against the hospital in 2020, alleging that medical staff failed to monitor her mother for sedation and failed to track her fluid and food intake. The lawsuit claimed those failures caused “dehydration, hypernatremia, encephalopathy and death.” Court records show the case was settled in March 2026.
Pawlus took her case to the Indiana Patients Compensation Fund, a state program that helps victims recover excess damages in medical malpractice cases.
A review board of medical providers unanimously concluded the facility failed to provide the “appropriate standard of care,” based on the evidence submitted by both parties.
Pawlus, who works in a mental healthcare facility herself, said the experience left her questioning how the facility continued to operate.
“There's something terribly wrong here,” she said.
NeuroPsychiatric Hospitals said the care Pawlus's mother received was from a “materially different organization than exists today,” pointing to a leadership overhaul in 2022 as a turning point — a claim the company also made in WFYI's previous reporting about its Indiana hospitals.
But this investigation, based on inspection records, court filings, police reports and interviews with more than 40 former patients, families and staff, found some of the chain's most serious alleged failures came after the leadership change. That included a patient death, allegations of abuse and two "immediate jeopardy" findings — what the Centers for Medicare & Medicaid Services refers to as the "most serious deficiency type," used when patients face an imminent risk of harm or death.
The state agencies responsible for catching those failures rarely acted. Of 151 complaints state health inspectors referred to the Indiana Attorney General's office in recent years, only 11 advanced past initial review.
Measures to increase oversight at the state level have faltered. The independent office Indiana law created to investigate complaints about mental health care facilities sat unstaffed from 2022 until 2025, and a bill that would create more oversight for psychiatric hospitals failed in the last legislative session.
NeuroPsychiatric Hospitals did not dispute many of the specific incidents WFYI documented, though it challenged how some were characterized.
The company said its hospitals care for some of the most medically and psychiatrically complex patients in the healthcare system. It also pointed to its inspection record, saying its five Indiana hospitals averaged 4.8 deficiencies cited by inspectors per inspection from 2010 through 2025, compared with 6.3 at other Indiana psychiatric hospitals.
"The question is not whether isolated incidents exist," the company wrote. "The question is whether those incidents accurately reflect the organization's overall performance."
The company pointed to patient reviews as evidence of that broader record: in the second quarter of 2026, NPH said it received 155 patient reviews, including a record 36 five-star reviews — about 23% of the total and a 44% increase from the previous quarter. It declined to provide a breakdown of the remaining reviews.
Jimmy Burroughs has served as the company’s chief executive officer since the leadership transition in 2022. NPH offered to make Burroughs available for an interview, but only off the record, meaning his answers or information provided could not be attributed to him or used in the story. WFYI declined the offer.
“Positive outcomes do not erase adverse events,” the company wrote. “But the reverse is equally true: adverse events do not erase the thousands of patients NPH has helped, the lives that have been stabilized or the people who received care when they desperately needed it.”
The company also told WFYI: "No healthcare organization should be judged solely by its worst days."
The promise
Indiana's shortage of mental health providers has long been described as “a crisis.”
Over more than two decades, NeuroPsychiatric Hospitals built its business around a specific patient population other psychiatric facilities often won’t take: people with psychiatric needs who also have complex medical conditions, such as dementia or Parkinson's disease, requiring both types of care at once. The company operates facilities across the country — including Indiana, Arizona, Texas and Michigan.
The chain has long faced scrutiny, from allegations of insurance fraud dating back to a federal False Claims Act complaint filed in 2016, which the company has denied, to allegations over lapses in patient care so serious that the state tried to revoke the Indianapolis location’s license in 2017. Company leaders have argued that many of those allegations belonged to an earlier era, before new leadership took over in early 2022.
But the years after the leadership transition generated their own trail of complaints, lawsuits and inspection findings.
By November of 2022, investigators from the Indiana Department of Health, or IDOH, reviewed an internal investigation by the chain that substantiated abuse allegations against a behavioral health assistant at the Crown Point hospital.
One victim, identified in records as Patient 1, told investigators that a “tall person had his/her fingers inside my private area, and it hurt.” A staff witness told investigators they had told the assistant it “was unnecessary to be that rough and go that deep.” A second patient reported that the same assistant had inserted gloved fingers into their vagina, and investigators documented that both patients experienced bleeding.
Inspectors from the Indiana Department of Health found that over two weeks later, the hospital hadn’t reported either incident to state regulators and Adult Protective Services, despite the hospital’s own policies requiring it.
In response, NeuroPsychiatric Hospitals told WFYI that it “promptly conducted an internal investigation, and took action consistent with its policies and applicable legal and regulatory requirements.”
The company also added that incontinence care procedures are “performed thousands of times each year,” and that one incident should not be used to “mischaracterize either the medically necessary procedure itself or the quality of care provided across the organization.”
Months later, in March of 2023, staff at the Mishawaka facility found an elderly man face down on the floor of his room. Progress notes confirmed to investigators from the Indiana Department of Health that he had fallen from his bed around 1 a.m.
Staff could not lift him into bed, but instead of calling for immediate backup or emergency services, they slid a mattress underneath him. He was left there, waiting for roughly eight hours, until hospital staff called 911 at 7:40 a.m. and fire department staff were able to get him on the way to the emergency room at 9 a.m., according to inspection records.
Multiple staff members later admitted to inspectors that the incident was “not acceptable,” and IDOH investigators concluded the hospital “failed to ensure care in a safe setting.”
NPH confirmed a nurse involved was no longer employed at the hospital, and told WFYI that the company has “zero tolerance for conduct that jeopardizes patient safety.” In the plan of correction, the hospital was required to implement multiple corrective actions — including retraining staff on policies governing patient rights, fall prevention, clinical assessment and additional oversight over patient falls.
By fall 2023, a patient in the Crown Point hospital said they no longer felt safe inside the facility, pleading to be moved after reporting that other patients had sexually harassed them, according to hospital records.
“Men keep hitting on me,” the patient said according to a nursing note, adding that they keep “seeing naked people.”
That same year, in August, a 77-year-old patient with dementia who had been admitted to the Crown Point hospital without bruising around their eyes was later found with bruises around both eyes and across their face. Staff never investigated how they were injured, according to an IDOH inspection report.
Over a week later, they were found unresponsive. They were then transferred to another hospital, where they died.
Inspectors documented that staff failed to follow multiple policies intended to monitor and respond to changes in the patient's condition.
Inspectors also found significant gaps in the patient's medical record — including weight tracking and intake and output data. A staff member told inspectors that “someone at the corporate level removed it from the charting.”
NeuroPsychiatric Hospitals pushed back on the allegation, arguing that the inspection “does not conclude that medical records were improperly altered or removed, nor does it identify any individual as having done so.”
The facility was also operating without the required numbers of staff both before and after the patient was admitted. Inspection records show at least nine shifts over a nine-day stretch with no registered nurse on duty, in violation of hospital policy.
Inspectors concluded that the cumulative effects left the hospital unable to “promote patient rights in a safe setting.”
In a 2023 interview with inspectors, an unnamed administrator identified as the Crown Point hospital’s CEO acknowledged that staff never filed an incident report after the patient was found unresponsive.
“We missed it,” the administrator said.
The oversight
State oversight of psychiatric facilities like NeuroPsychiatric Hospitals remains fractured among agencies with limited enforcement power.
The Indiana Department of Health, or IDOH, whose inspectors documented many of the allegations, is responsible for federal routine and complaint surveys. The agency’s reports are then sent to the Centers for Medicare & Medicaid Services, or CMS, and to Indiana’s Family and Social Services Administration’s Division of Mental Health and Addiction, or DMHA.
Since 2022, over 400 allegations involving the company's Indiana hospitals have been “included in a complaint that was approved by CMS for an investigation,” according to IDOH.
In response to WFYI’s requests for comment about incidents at NeuroPsychiatric Hospitals, IDOH said that any penalties resulting from complaints, other than a required plan of correction for a condition-level citation, would be imposed by the Centers for Medicare and Medicaid Services and Indiana’s Division of Mental Health and Addiction.
The agency said its primary goal is conducting surveys to “establish whether a facility is in substantial compliance with federal conditions of participation.”
Between 2022 and 2024, the Indiana Department of Health submitted 151 complaints to the Indiana Attorney General’s office, which represents the state in cases in the state's interest and often pursues cases against hospitals alleging things like insurance fraud and patient neglect and abuse.
But out of the 178 complaints the AG’s office received in those years, only 11 advanced past the initial review. The rest were either rejected or “closed based on recommendation.”
The Indiana Attorney General’s office would not provide WFYI a comment on the record about its role overseeing NeuroPsychiatric Hospitals, including questions about its handling of complaints and coordination with other agencies that have brought issues to its attention.
Indiana’s Division of Mental Health and Addiction, or DMHA, housed within the state’s Family and Social Services Administration, holds some of Indiana’s most powerful authority over psychiatric hospitals: enforcement authority over the hospital’s license.
In 2017, the agency tried to revoke the Indianapolis facility's license. DMHA cited allegations that the hospital failed to keep patients safe, including failing to verify prescriptions, maintaining poor records and breaching patient confidentiality.
The hospital ultimately settled with the state in 2020. Under the agreement, previously reported by WFYI, the hospital agreed to staffing requirements, training and outside monitoring. That oversight was limited to a maximum of 15 months.
WFYI requested all records related to the monitoring. FSSA said that it could not locate any responsive records.
In response to a request for comment from WFYI, FSSA did say it holds enforcement authority over licensed Private Mental Health Institutions under Indiana law, but that outside of routine licensing and inspections, DMHA does not maintain any additional oversight relationship with NeuroPsychiatric Hospitals.
But the agency did not respond to detailed questions about specific incidents and oversight, including answering why there were no responsive records to WFYI’s requests.
Sam Adams, a senior attorney with Indiana Disability Rights, the state's federally authorized protection and advocacy agency for people with disabilities, said that Indiana’s fragmented oversight system leaves people unsure where to turn when something goes wrong. Multiple agencies oversee different parts of psychiatric hospitals, causing uncertainty over which agency is responsible for investigating a complaint and which agency is ultimately responsible for enforcement, he said.
"It really seems to be a lot of siloing rather than collaboration," Adams said.
That kind of fragmented oversight isn't unique to Indiana. Morgan Shields, an assistant professor at Washington University in St. Louis who studies the quality and accountability of behavioral health care, said many states treat oversight of psychiatric hospitals like a game of "hot potato," passing responsibility from one agency to the next.
On top of that, Shields said because there are so few providers — especially for people with more complex needs, there’s often little incentive for hospitals to improve care or for states to meaningfully hold them accountable.
“The hospitals don't face any sort of natural consequences for providing care that is low quality or even abusive,” Shields said. “They essentially become too big to fail.”
NeuroPsychiatric Hospitals has also faced allegations before federal labor regulators. A union election at the Indianapolis facility in 2024 ended in a tie after registered nurse Peter Moore, who worked at NeuroPsychiatric Hospitals from 2023 to 2024, led a union campaign over working conditions — largely, he said, driven by understaffing and insufficient attention to patient needs.
Moore later filed unfair labor practice charges alleging retaliation, and a National Labor Relations Board hearing officer recommended the election be rerun. NeuroPsychiatric Hospitals appealed, then settled the case privately with Moore in July 2024 under undisclosed terms. Moore resigned at the same time.
In a statement, NeuroPsychiatric Hospitals confirmed that during the rerun election, employees voted against union representation and the NLRB certified those results. Moore said the rerun election was held after he left, effectively, he said, ending much of the internal momentum for the union in the first place.
“I've never seen a place that made it so blatantly obvious that they were in the position to make money, not better patients' lives,” Moore said.
NeuroPsychiatric Hospitals said it “strongly disagrees” with Moore’s statement, arguing that the hospital chain has provided millions of dollars of care that was not reimbursed. They added that in the vast majority of these cases, “NPH knew in advance it would not be reimbursed and delivered best-in-class care regardless.”
“An organization prioritizing profit over patients does not knowingly absorb tens of millions of dollars in losses to treat patients other facilities are unable or unwilling to take,” the company wrote.
The ‘tragedy’
The Crown Point hospital in northwest Indiana has drawn some of the chain's most serious allegations in recent years, including legal action by local officials.
In 2023, the city of Crown Point sued NeuroPsychiatric Hospitals, alleging emergency services responded to the facility 691 times since it opened in 2018 — more than any other location in the city.
NeuroPsychiatric Hospitals told WFYI that number is not a meaningful comparison, arguing it is like “comparing the number of emergency calls from a trauma center to those from a shopping mall,” since NPH is the “only hospital of its kind in Crown Point,” the company wrote.
In the lawsuit, the city claimed the hospital was using the city and its fire and police departments as its “personal security force” and "personal medical personnel.”
Fire and police officials alleged the volume of calls was straining public resources and putting first responders at risk, citing incidents involving combative patients housed with dementia patients, situations where police were not allowed inside the hospital to assist emergency responders and the facility's lack of security measures.
The lawsuit pointed to comments the chain’s former president and founder, Cameron Gilbert, told the city during the hospital’s request to rezone the property for the psychiatric hospital. Those included statements that the facility would be “very safe for the public due to the amount of security and locks,” according to meeting records from June 26, 2017.
The city’s lawsuit was eventually settled in early 2026, with the hospital agreeing to use "reasonable efforts" to contact the city's emergency services solely for emergencies and train staff to de-escalate situations “where the risk of violence may warrant intervention of law enforcement."
In a response to WFYI, NeuroPsychiatric Hospitals defended its use of the city’s emergency services, arguing that “activating emergency medical services is the “appropriate clinical response to ensure the patient receives the necessary level of care.”
But public records from the Crown Point Police Department reveal more about what police were being called for. They include reports of battery between patients and staff, families asking for police to check on their loved one after not being able to get a hold of the hospital and reports of sexual abuse and patients escaping the facility.
When police responded after a patient escaped in December 2022, the hospital's director of social services told police that the facility had “no security on site” and that owners were "trying to remodel the ambulance bay doors to prevent further escapes."
In response to a request for comment, the hospital confirmed it now has a secure ambulance bay for EMS personnel to use during patient transport.
But when asked by WFYI if the Crown Point hospital or any of its other facilities in Indiana had dedicated security personnel, which Crown Point officials had pointed to as a contributing factor for the hospital’s reliance on the city’s emergency services, NeuroPsychiatric Hospitals argued that behavioral health hospitals are “hospitals, not correctional facilities.”
In a statement, the company said that “introducing uniformed security into the treatment environment can increase fear, undermine trust, and interfere with treatment.”
Two former Crown Point employees said the conditions they witnessed matched what the city’s lawsuit alleged and state inspectors would later document.
Toni Little, a former behavioral health aide at the Crown Point hospital, said she left in late 2022 as conditions deteriorated. Staff, she said, were stretched too thin and lacked the training to safely care for patients with complex psychiatric and medical needs.
"It got to the point where we're so unsafe for just everybody," Little said. "It's a tragedy, really."
Two years later, registered nurse Alexis described a similar environment. Alexis, who worked at Crown Point in 2024, asked that only her first name be used because she fears retaliation. She described the facility as “severely understaffed,” and said she was sometimes one of only two nurses responsible for “almost 30 patients” on a unit.
"If something were to happen — you're alone," she said. "No one's going to find you."
In response, NeuroPsychiatric Hospitals said that the hospital’s largest unit can hold 28 patients, and that staff can never be fully “alone,” because at a minimum, a 28-bed unit is staffed with “two registered nurses and multiple Behavioral Health Assistants assigned to that unit, in addition to a nursing supervisor overseeing the units.”
But inspection records corroborate what the employees both described. Health department inspectors also documented understaffed units and repeated gaps in records showing that a patient hadn’t been offered showers or baths for days at a time.
And in 2024, inspectors from IDOH found a 70-year-old patient with diagnoses of “dementia, inappropriate sexual behaviors, suicidal ideation, and delusions,” according to inspection records, had been left in a seclusion room for nearly nine hours without the required physician's order.
By April of 2025, the Indiana Department of Health issued an “immediate jeopardy” finding for the Crown Point hospital — the government’s most serious warning.
According to inspection records, multiple employees told inspectors that in March, they witnessed the hospital's interim director of nursing place their hands around a patient's throat during a restraint after the patient repeatedly attempted to bite staff. One employee said the patient's face turned dark red, then blue and purple after hearing the nursing director tell the patient, "You will be okay ... you will be able to breathe once I let you go."
"We all have been bit before but never took it that far," one employee told inspectors.
"That was too far."
Inspectors also found that a week before the incident, a licensed staff member emailed the hospital's CEO, saying they believed the nursing director was acting inappropriately toward the patient and recommended moving the staff member to another unit.
The incident was not reported to the required agencies, inspection records said, and an administrative staff member confirmed the interim director of nursing refused to complete the required “handle with care” refresher course. Despite this, the staff member had “been on over 6 codes” since the initial incident.
IDOH inspectors lifted the immediate jeopardy finding when the survey was completed.
But one year later, the hospital chain received another immediate jeopardy finding at the Indianapolis facility after inspectors found “systemic problems” with patient medications — including findings that two patients did not receive their insulin dosages.
One patient was transferred to the emergency room and admitted for hyperglycemia after their blood sugar levels were measured at 531, more than five times the normal limit.
The immediate jeopardy order was lifted the next day.
The only option
David Denton was placed on an emergency detention order and transferred to the chain's Greenwood facility in May 2024 after developing psychosis.
His wife, Carrie, said staff told her it was the only psychiatric hospital in the area equipped to handle his more complex medical needs after surviving Stage 4 colon cancer.
"That was our only option," she said. "He had to go there."
David said staff did not provide supplies for his ostomy bag when it began to separate from his skin, leaving him waiting more than two hours while it leaked. During that time, he said, nurses mocked him and told him to "step away" because of the smell.
"It was only taken care of because it was an inconvenience," David said. "It wasn't because of my well-being whatsoever."
Carrie said she rarely got anyone on the phone. Desperate, she finally called 911.
"I feel like this is criminal confinement at this point," she told Greenwood Police in a call obtained by WFYI through a public records request. "It's a bed quota, and they're not wanting to release."
NeuroPsychiatric Hospitals declined to speak about David’s allegations on the record, arguing that “even where a patient chooses to speak publicly about their care, NPH does not believe it is appropriate to publicly discuss or debate a former patient's mental health treatment.”
But in further communication with WFYI ahead of publication, the company criticized WFYI for not making a “meaningful effort” to seek out patients and families who had positive experiences with NPH.
David remained for nine days — longer than the five to seven days staff first estimated — before being discharged after his attorney threatened legal action.
“There’s no kindness. There’s no empathy,” David said. “You were there until your time was up.”
The fight
Legislative attempts to add oversight of Indiana's psychiatric hospitals have repeatedly stalled, even as complaints and lawsuits against the industry mount.
During the 2025 legislative session, state Sen. Andrea Hunley (D-Indianapolis) introduced Senate Bill 131, which would have established a mental health ombudsman — an independent advocate with the power to investigate complaints and access patient records at for-profit psychiatric facilities like NeuroPsychiatric Hospitals.
The bill died in the Senate without a hearing in the Committee on Health and Provider Services.
“There is no transparency,” Senator Hunley told WFYI during the legislative session. “We have no idea how many complaints or issues there are. We don't know where they're happening.”
“We need to be able to look at patterns and then make changes.”
But the state already has a mental health ombudsman, which last year, reporters found, hadn’t been operating since June of 2022. The Indiana Family and Social Services Administration signed a contract to resume the ombudsman program in July of 2025.
Amy Pawlus says she hoped her mother’s death would bring real change. But she says she keeps hearing similar stories again and again — and she’s worried other people will go through what she went through.
In July, Fox 32 Chicago reported that a patient’s family had reported him missing after NeuroPsychiatric Hospitals discharged him from its Crown Point hospital and sent him in an Uber to a homeless shelter in Chicago. That same month, police charged a Greenwood staff member with felony battery after she allegedly attacked a patient with disabilities, Fox 59 reported.
“I’m scared to death that there are people behind those closed doors right now who are not treated well and who will likely die when we can do something about it,” Pawlus said.
Edited by Eric Weddle
Farrah Anderson is an investigative health reporter with WFYI. You can follow her on X at @farrahsoa or by email at fanderson@wfyi.org.
