Citations in Indiana
Statistics, citations and compliance trends for long-term care facilities in Indiana.
Statistics for Indiana (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in Indiana
Resident Face Shown in Staff Social Media Video: The facility failed to ensure a resident was free from abuse when a CNA posted videos on social media while working, and one video briefly showed the resident’s face. The Administrator confirmed the video included the CNA complaining about her assignment and showing facility hallways and the resident, who had severe cognitive impairment and diagnoses of anxiety and depression. Staff stated that taking or posting resident photos or videos on social media was a violation of abuse, privacy, and resident rights.
Inadequate supervision during nightly smoking activities was identified when a resident who was supposed to wear a fire-resistant apron and be supervised was observed smoking outside at night without the apron and with no staff present. Other residents reported that staff did not come out to monitor smoking in the courtyard at night, and observations showed multiple residents smoking in a dark courtyard area with minimal lighting and no staff present. Interviews also indicated that some residents drank alcohol, became intoxicated, or passed out while outside smoking, despite the facility policy requiring supervised smoking by staff.
Improper Storage and Cleaning of Bedpans in Shared Bathroom: A resident’s shared bathroom had a bedpan stored directly on the floor and another uncovered bedpan stored in an armoire, along with wet underwear on the sink ledge and stained non-skid strips and toilet surfaces. Staff interviews confirmed bedpans should be bagged and not placed on the floor or furniture, and the facility policy required bedpans and urinals to be stored in a clean disposable bag between uses.
Failure to protect a resident from physical abuse occurred when two cognitively intact residents got into a verbal argument that escalated into a physical altercation near the smoking area. One resident alleged the other grabbed her by the throat and pushed her against a wall, while staff observed the residents yelling, cussing, and overturning each other’s rollators, with one resident appearing to push the other. The incident was documented as a resident-to-resident abuse allegation.
A resident with significant mobility dependence and intact cognition developed bilateral buttock/coccyx friction injuries during routine care. The care plan identified risk for skin breakdown and directed staff to avoid shearing during positioning, turning, and transfers, but the resident later had partial-thickness friction/shearing wounds with purple, red areas and blood blister-like findings. Staff and the DON believed the injury occurred during brief removal, sheet handling, or pulling the resident up in bed.
Failure to Provide Scheduled Showers: A cognitively intact resident with orthopedic aftercare, Charcot's joint, and an external fixator was dependent on staff for ADLs and had a care plan for showers on a set schedule. Record review showed multiple missed or undocumented showers, incomplete shower sheets, and no documentation supporting the claim that the resident could not shower because of the external fixator. Progress notes also reflected the resident and his friend complained about not receiving showers, while the DON said the resident often refused showers and an LPN described the facility's refusal-signature process.
Resident Face Shown in Staff Social Media Video
Penalty
Summary
The facility failed to ensure residents were free from abuse for 1 of 3 residents reviewed, Resident B. An incident report dated 7/20/26 indicated someone reported to the Administrator that CNA 2 posted videos on social media while working at the facility, and one of the videos briefly showed Resident B’s face. Resident B’s record showed diagnoses of generalized anxiety disorder and depression, and an admission MDS indicated a BIMS score of 06/15, reflecting severe cognitive impairment. During interview, the Administrator stated the video posted on TikTok included CNA 2 complaining about her work assignment, showed facility hallways, and included Resident B’s face. The Administrator stated staff should not take or post videos or pictures of residents or the facility because it violates privacy and resident rights. QMA 3 stated it was a violation of abuse, privacy, and resident rights to take pictures or videos of residents and post them on social media, and that personal phones were only to be used during break hours in the break room or outside the facility. The facility policy titled Abuse Prohibition, Reporting and Investigation stated that photos or recordings taken of residents were a form of exploitation and abuse.
Inadequate Supervision During Nightly Smoking Activities
Penalty
Summary
The facility failed to provide adequate supervision during nightly smoking activities in the courtyard. A smoking assessment for Resident M, who had diagnoses including heart failure and was cognitively intact on the quarterly MDS, indicated he was to wear a fire-resistant apron and receive staff supervision while smoking. During an observation of the courtyard smoking area at night, Resident M was seen smoking on the porch without an apron and with no staff present outside. Resident M stated he had not ever seen staff come out at night to monitor residents' smoking in the courtyard. Additional interviews and observations showed that residents routinely smoked in the courtyard at night without staff supervision. Residents reported that they could remain outside all night, that staff did not come out at night, and that some residents drank alcohol while smoking. During a nighttime observation, six residents were seen in the gazebo and four on the courtyard porch smoking in a dark area with minimal lighting and no staff present. Residents and staff also stated that residents had been intoxicated, passed out, or sneaked alcohol into the courtyard, and one smoking aide stated that after 11:00 p.m. nurses knew which residents went out to smoke and checked on them in the courtyard. The facility policy stated supervised smoking would be performed by a staff member.
Improper Storage and Cleaning of Bedpans in Shared Bathroom
Penalty
Summary
The facility failed to ensure infection control practices were maintained in a shared bathroom used by Resident B. During observation, a bedpan was stored directly on the floor between the sink and the wall, a rolled-up wet pair of underwear was on the left sink ledge, three non-skid white strips in front of the toilet had numerous small areas of dark brown dried stains, and a dried dark yellow substance was present on the toilet seat riser. An uncovered bedpan was also stored directly on the second shelf inside Resident B’s armoire behind her door. During interviews, QMA 3 stated bedpans should not be stored directly on the floor and should be covered with a bag, and said the three non-skid strips appeared to have dried feces on them. LPN 4 stated the bedpan was directly on the floor and that bedpans should always be placed in a bag, and the non-skid strips needed to be removed and replaced. Housekeeping Aid 5 identified the wet underwear on the sink ledge, the bedpan on the floor, and dried urine on the toilet seat riser. CNA 6 stated bedpans should not be placed directly on the floor or dressers and should be covered with a plastic bag. The ADON later stated bedpans should be stored in plastic bags. The facility policy titled Guidelines for Washing/Cleaning Bedpans and Urinals stated bedpans or urinals should be stored in a clean, disposable bag between uses.
Failure to Protect Resident from Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse during a resident-to-resident altercation involving two cognitively intact residents. One resident had diagnoses including anxiety disorder and a behavior care plan noting anger outbursts toward others, while the other resident had diagnoses including paranoid schizophrenia, anxiety disorder, and depressive disorder, with a care plan noting agitation. During the incident, the residents exchanged words near the smoking area after one resident told the other to stay out of his room and used profanity. The account of what occurred differed across statements, but both residents reported a physical confrontation, and staff observed the altercation in the hallway. The nursing note and incident report documented that the residents were separated immediately after the altercation. In the investigation, one resident stated the other grabbed her by the throat, pushed her against the wall, and threw her buggy, while the other resident stated he turned over her buggy, she turned over his, and he pushed her. A smoking aide stated she saw one resident knock over the other resident’s rollator and then saw the other resident knock over his rollator before he appeared to push her; she also observed one resident pinned against the wall with hands at her neck area. The facility’s abuse policy stated it was intended to prevent abuse, mistreatment, or neglect of residents.
Shearing Injury During Routine ADL Care
Penalty
Summary
The facility failed to ensure skin injuries did not occur during routine ADL care for one resident who was dependent for toileting, rolling, hygiene, positioning, and transfers. The resident had diagnoses including central cord syndrome, arthrodesis status, spinal stenosis of the cervical region, and a wedge compression fracture of the fifth lumbar vertebra with routine healing. The resident’s admission MDS indicated cognition was intact, toileting was dependent, rolling left and right was dependent, and there were no pressure ulcers on admission. The resident’s care plan identified risk for skin breakdown related to Foley catheter placement, need for assistance with mobility and toileting, and altered skin integrity due to shearing, with instructions to avoid shearing during positioning, turning, and transferring. Physician orders included a foam dressing to the coccyx, observation of the dressing each shift, and incontinence care with cleansing and protective ointment after each episode. Progress notes documented that the resident developed friction/shearing injuries to both sides of the coccyx, with purple and red areas noted and measurements entered into wound management. The wounds were described as partial thickness and later as elongated friction injuries with areas that appeared to be blood blisters. Staff interviews and documentation indicated the injuries were believed to have occurred from shearing during routine care, including removing a brief or pulling the resident up in bed. The DON stated the injury appeared to be from removing sheets or a brief, with a line across the buttocks suggesting rubbing. The facility’s turning and repositioning procedure stated that proper turning techniques and body mechanics should be used to prevent injury to the resident and caregiver, and that turning and repositioning is performed in accordance with the resident’s care plan.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure a resident received scheduled showers. Resident D was cognitively intact, had diagnoses including orthopedic aftercare, Charcot's joint of the right ankle and foot, and acquired absence of the left leg below the knee, and was dependent on staff for ADL care related to a right mid-foot osteotomy and external fixation. The care plan identified bathing and showers as preferred on Monday and Thursday day shift, but the plan did not document a history of refused ADL care, including showers. Record review showed Resident D had eight bathing opportunities from admission to discharge, but the documentation did not support that the scheduled showers were provided as planned. In May 2026, the resident should have received showers on 5/25 and 5/28; the CNA task for bathing had no documentation on 5/25, a refusal was documented on 5/27, and resident unavailable was documented on 5/28. No shower sheets were provided for May. In June 2026, the resident should have received showers on 6/1, 6/4, 6/8, 6/11, 6/15, and 6/18; the CNA task had no documentation for 6/1 or 6/4, a refusal was documented on 6/8, a bed bath was documented on 6/11, a shower was documented on 6/15, and a refusal was documented on 6/18. Shower sheets provided for 6/1 and 6/4 did not include the resident's signature, and shower sheets were not provided for the refusals on 6/8 and 6/18. Progress notes showed the resident's friend reported the resident had not had a shower since admission, and later asked when the last shower occurred. A nurse told the friend the resident was not allowed to have a shower because the pins in his legs were rusting and that bed baths with rags and water had been offered. There was no documentation in the progress notes, physician notes, podiatrist notes, wound care notes, resident assessments, or care plan showing the resident was unable to shower because of the external fixator. Another progress note documented the resident complained about not receiving a shower and was told he had been out of the facility during the scheduled shower time and would need to speak with management to change the shower schedule. During interviews, the DON stated the resident often refused showers, and an LPN stated that when a resident refused a shower, the CNA, nurse, and resident would sign the shower sheet to show attempts were made and refused.
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Compliance trends in Indiana
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 3 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 3-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 3 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 3 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 3 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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