Citations in Indiana
Comprehensive analysis of citations, statistics, 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
The facility failed to follow physician orders and internal policies for weight monitoring and physician notification. A resident with multiple cardiopulmonary conditions had numerous missed daily weights despite an order and care plan requiring daily weighing. Two residents admitted with complex medical histories, including severe malnutrition and prior CVA, did not have admission weights obtained within the expected 24-hour timeframe, with one weight delayed several days. Another resident with DM and a right fibula fracture had an order for Humalog insulin per sliding scale with instructions to call the physician for blood glucose values outside a specified range, but a critically elevated blood sugar was not reported to the NP until days later. Staff interviews and facility policies confirmed that daily and admission weights, as well as timely provider notification, were required but not consistently carried out.
A resident with a Foley catheter and history of UTI was observed with the catheter drainage bag attached to a trash can containing trash, and the urine in the tubing appeared cloudy with sediment. The resident’s care plan identified neurogenic bladder and the need to observe catheter tubing, and the resident was on ciprofloxacin for a UTI. Facility staff, including the ADON, Medical Record Nurse, and a QMA, acknowledged that the catheter bag should be hung on the bed rail and not on a trash can, and that this practice placed the resident at risk of infection, contrary to the facility’s urinary catheter care policy.
A resident with a history of UTI and multiple comorbidities, including acute kidney failure and urinary retention, was observed with an indwelling catheter drainage bag attached to a trash can containing trash, with cloudy urine and sediment noted in the tubing. The ADON, Medical Record Nurse, and a QMA all acknowledged that the catheter bag should not be placed on a trash can and should instead be hung on the bed rail, stating that this practice placed the resident at risk of infection. This practice was inconsistent with the facility’s Infection Prevention and Control Program, which is intended to prevent the development and transmission of infections and monitor compliance with infection control procedures.
A resident with multiple medical and behavioral health diagnoses, including depression, vascular dementia, PTSD, and an adjustment disorder with anxiety, was started on diazepam twice daily for anxiety without a timely PASARR Level I screen. The PASARR assessment related to the new anxiety diagnosis and new antianxiety medication was not completed until after the survey had begun, despite the Administrator’s acknowledgement that a new Level I is required when a new psychotropic medication or mental health diagnosis is added and facility policy directing contact with the PASARR office for such behavioral health conditions.
The facility failed to provide required written transfer/discharge notices, appeal rights, and bed-hold information to representatives for three residents who were hospitalized or discharged, and did not consistently notify the LTC ombudsman as required. One resident with multiple cardiopulmonary and oncologic conditions was sent to the ER with only verbal family notification. Another resident with psychiatric and metabolic diagnoses was transferred to the hospital for a psychiatric evaluation, with documentation of verbal notification to the son but no written notice or bed-hold information at the time of transfer. A third resident with respiratory failure, CHF, dementia, and other comorbidities was discharged to memory care without documented written notice or bed-hold information to the representative, and the ombudsman was not notified of the scheduled discharge, despite facility policy requiring written notices to the resident, representative, and ombudsman.
Surveyors identified that food was not stored, prepared, and served in a safe and sanitary manner when staff prepared meal trays without hairnets, expired ranch dressing and milk were left in the walk-in refrigerator, and debris and food particles accumulated on and around the dishwasher area. These conditions occurred despite a facility policy requiring food to be stored and prepared in a clean, safe, and sanitary manner.
Surveyors found that the facility did not maintain sufficient dietary staffing as outlined in its facility assessment, resulting in one Dietary Manager functioning as the sole cook for extended periods, working very long shifts with minimal support. During meal observations, only two dietary staff were present, and the cook was unable to honor a resident’s request for an additional food item due to time constraints while preparing all trays. Several residents reported that food quality had declined, meals were repetitive or late, and alternatives were not offered, which they linked to having only one cook. Review of staffing schedules confirmed a prolonged pattern of understaffing in the kitchen, including days with only one staff member and no separate cook scheduled.
The facility failed to maintain complete and timely documentation for several residents, including missing or retroactively entered care conference notes for a resident with multiple sclerosis and another with severe cognitive impairment, where quarterly care plan conferences were not documented until much later. A resident with chronic kidney disease and diabetes had large gaps in recorded weights despite orders for monthly and then weekly weights, and the DON reported the resident refused weights but staff did not document refusals. For a resident with COPD and an indwelling catheter, the eMAR/eTAR showed multiple undocumented administrations of Lyrica, blood glucose checks, BIPAP care, and ordered small frequent meals, with the DON stating staff said they provided the care but failed to chart it. Another resident with congestive heart failure and an insulin lispro sliding scale had numerous early-morning insulin doses not documented as given, with the DON indicating that insulin administration at breakfast was sometimes missed in documentation.
Surveyors identified a failure to maintain a safe, sanitary environment when strong, persistent odors were observed in multiple common areas and units, including hallways, the main lobby, and an area outside a conference room. Odors noted included urine, sewer gas, and bowel movement smells. During an interview, the Administrator stated that odors should be controlled through routine cleaning and increased cleaning in odor-prone areas. The facility’s Environmental policy requires staff and management to promote pleasant, neutral scents and minimize institutional odors, but the observed conditions did not meet these standards.
A resident with COPD, heart failure, kidney failure, cognitive impairment, and documented skin impairments had behavioral issues addressed by an NP, who adjusted medications and ordered a follow-up visit within a few weeks, but the resident was not seen again and no follow-up visit was documented. The resident’s care plan required staff to make referrals as needed and to inspect skin every shift, while the facility’s skin policy required weekly wound assessments and ongoing documentation for open areas. Despite a blister and later venous ulcers being identified on the resident’s legs, weekly wound assessments were missing for multiple weeks, indicating the facility did not follow its own policy or ensure timely provider follow-up and wound documentation.
Failure to Obtain Ordered and Admission Weights and Notify Physician of Critical Blood Glucose
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document ordered weights and to notify the physician as ordered, as well as delays in obtaining admission weights. For one resident with acute respiratory failure with hypoxia, COPD with exacerbation, heart failure, fluid overload, chronic kidney disease, and acute pulmonary edema, a physician’s order dated 12/2/25 required a daily weight once a day, and the care plan reflected this order. However, the MAR for December and January showed multiple days on which the daily weight was not obtained or documented. Facility staff, including a QMA and the DON, stated that daily weights should be completed every day, typically in the morning before breakfast. Another resident with severe protein-calorie malnutrition, encephalopathy, pneumonia, rhabdomyolysis, atherosclerotic heart disease, ischemic cardiomyopathy, repeated falls, hypovolemic shock, and gastrostomy status had physician’s orders on consecutive days to obtain an admission weight, but the admission weight of 106.5 pounds was not obtained and documented until six days after admission, contrary to staff statements that admission weights should be completed on the day of admission or within 24 hours. A third resident with diabetes mellitus and a right fibula fracture had a care plan indicating use of hypoglycemia medication and risk for adverse effects, with interventions including administering medication as ordered. A physician’s order directed staff to administer Humalog insulin per sliding scale and to call the physician for blood sugars less than 60 or greater than 400. The clinical record showed a blood sugar of 435, but the NP was not notified until several days later, as documented in an IDT note and confirmed by the Clinical Support Nurse. A fourth resident with a history of UTI and cerebrovascular accident had an admission weight of 165 pounds obtained and documented several days after admission, despite facility policy and staff statements that admission observation and data collection, including weight, should be initiated within 12 hours and completed within 24 hours. Facility policies on admission nursing observation and weight monitoring required timely completion of admission assessments and daily review of missing admission and ordered weights, but the records for these residents showed that these processes were not followed as required.
Improper Positioning and Sanitary Maintenance of Foley Catheter Drainage Bag
Penalty
Summary
Surveyors observed that a resident with a Foley catheter had the urinary drainage bag attached to a trash can next to the bed. The trash can contained trash in the bottom, and the urine in the catheter tubing was described as cloudy with sediment. The resident’s clinical record showed diagnoses including a history of UTI, acute kidney failure, anxiety disorder, chronic pain syndrome, hypertension, heart failure, COPD, urinary retention, and atrial fibrillation. The care plan indicated the resident had a Foley catheter related to neurogenic bladder, with interventions that included observing the catheter tubing. A recent physician’s order documented that the resident was receiving ciprofloxacin 500 mg twice daily for 14 days for a UTI. Facility staff, including the ADON, Medical Record Nurse, and a QMA, each stated in interviews that the catheter bag should not be placed on a trash can and should instead be hung on the bed rail, and that placing the bag on the trash can put the resident at risk of infection. The facility’s urinary catheter care policy required checking urine for unusual appearance, keeping the drainage bag positioned lower than the bladder to prevent backflow, and ensuring the catheter and tubing were free of kinks, but did not direct staff to place the bag on a trash can.
Improper Catheter Bag Placement on Trash Can
Penalty
Summary
Surveyors observed that a resident’s indwelling urinary catheter drainage bag was improperly attached to a trash can next to the bed. The urine in the catheter tubing was described as cloudy with sediment, and the trash can being used to support the bag contained trash in the bottom. The resident’s clinical record showed diagnoses including a history of urinary tract infection (UTI), acute kidney failure, anxiety disorder, chronic pain syndrome, hypertension, heart failure, chronic obstructive pulmonary disease, urinary retention, and atrial fibrillation. A recent physician’s order documented that the resident had been prescribed ciprofloxacin 500 mg twice daily for 14 days for a UTI. During interviews, the ADON stated the catheter bag should not be placed on the trash can and acknowledged that the resident had a history of UTI and that placing the catheter bag on the trash can could contribute to infection. The Medical Record Nurse also indicated the catheter bag was not supposed to be on the trash can and that the resident was at risk of infection. A QMA confirmed that the catheter bag should be hung on the bed rail and never on the trash can, explaining that hanging the bag on a dirty trash can would put the resident at risk of developing a major infection. The facility’s Infection Prevention and Control Program policy indicated it was designed to help prevent the development and transmission of communicable diseases and infections and to monitor compliance with infection control practices and procedures, which was not followed in this instance.
Failure to Complete Timely PASARR Level I for New Mental Health Diagnosis and Psychotropic Medication
Penalty
Summary
The facility failed to ensure a timely PASARR (Preadmission Screening and Resident Review) Level I screen was completed when a resident had a new mental health diagnosis and was prescribed a new psychotropic medication. The clinical record for Resident 4 showed multiple diagnoses including depression, atrial fibrillation, heart disease, vascular dementia, pseudobulbar affect, post-traumatic stress disorder (PTSD), and adjustment disorder with anxiety. A physician’s order dated 9/19/25 directed administration of diazepam 2 mg twice daily for anxiety, but a PASARR Level I screen related to the new anxiety disorder diagnosis and the new antianxiety medication was not completed until 2/2/26, after the survey had begun. During interview, the Administrator stated that when a resident has a new psychotropic medication or a new mental health diagnosis added, a new Level I PASARR is required, confirming that this was not done until 2/2/26 for this resident. The facility’s PASARR Quick Sheet policy indicated that when an individual has a severe mental illness/behavioral health diagnosis such as major depressive disorder or anxiety disorder, and the diagnosis is given by a psychiatric provider, the PASARR office should be contacted, but this process was not followed in a timely manner for Resident 4’s new anxiety diagnosis and diazepam order.
Failure to Provide Required Written Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notices of transfer or discharge, appeal rights, and bed-hold information to resident representatives, and to notify the LTC ombudsman, for multiple residents who were hospitalized or discharged. For one resident with diagnoses including pneumonia, atrial flutter, acute respiratory failure with hypoxia, malignant neoplasm of the colon, and obstructive and reflux uropathy, nursing documentation showed the resident was transferred to the ER and the daughter was notified verbally, but there was no indication that a written notice of transfer or discharge was provided. For another resident with anxiety disorder, major depressive disorder, catatonic disorder due to a known physiological condition, mood affective disorder, type 2 DM, edema, and metabolic encephalopathy, the record showed a physician ordered transfer to the hospital for psychiatric evaluation, and a progress note documented a Zoom visit with a psychiatric physician followed by transport by family. The transfer/discharge report indicated the son was notified of the transfer but did not show that a written notice or bed-hold policy was provided at the time of transfer. A third resident, with diagnoses including metabolic encephalopathy, contusion of the right thigh, acute and chronic respiratory failure with hypoxia, pulmonary fibrosis, bronchiectasis, acute on chronic diastolic CHF, anxiety disorder, and moderate dementia with mood disturbance, was discharged to an assisted living memory care apartment. Progress notes documented the planned discharge and the actual discharge, but there was no documentation that the resident representative received a written notice of transfer or discharge or the bed-hold policy. Interviews with the Executive Director and Social Services Director confirmed that the facility had been providing only verbal notifications to resident representatives and had not consistently issuing written transfer/discharge notices, bed-hold information, or notifying the ombudsman for both emergent hospital transfers and scheduled discharges, contrary to the facility’s own “Transfer Emergency Discharge” policy requiring written notices to the resident, representative, and ombudsman.
Failure to Maintain Safe and Sanitary Food Storage and Preparation Practices
Penalty
Summary
The deficiency involves failure to ensure food was stored, prepared, and served in a safe and sanitary manner during two kitchen observations. During a kitchen tour, the Activity Director and Social Service Director were observed preparing meal trays in the kitchen without wearing hairnets. In the walk-in refrigerator, surveyors observed a one-gallon jug of ranch dressing that had an expiration date of 12/12/25 but was opened on 12/29/25, indicating it was opened after its expiration date and remained stored there. Surveyors also observed a buildup of debris and food particles on top of the dishwasher and along the floor underneath the metal dishwasher tables, indicating the dishwashing area and floors were not thoroughly cleaned. On a subsequent observation in the walk-in refrigerator, surveyors found two full one-gallon jugs of 2% milk with an expiration date of 1/29/26 that remained in storage past that date. Facility staff, including the Dietary Manager and Regional Dietary Director, acknowledged that the expired ranch dressing and milk should have been removed from the refrigerator and that the dishwashing area should have been thoroughly cleaned. The facility’s Food Storage policy, dated 11/29/19, stated that food should be stored and prepared in a clean, safe, and sanitary manner, which was not followed in these instances.
Inadequate Dietary Staffing Leading to Poor Food Quality and Service
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient food and nutrition services staff as outlined in its own facility assessment, which called for a director and three food and nutrition services staff. Surveyors reviewed a confidential statement indicating that the food from the kitchen was described as disgusting and that there were not enough kitchen workers. During a lunch observation, only two dietary staff were present: the Dietary Manager, who was also the cook, and a Dietary Aide. The Dietary Manager was the only person plating food for both the dining room and hall trays and was unable to provide an additional food item requested by a resident, stating she did not have time because she needed to prepare all the hall trays. Multiple residents reported concerns about food quality and lack of alternatives, which they attributed to insufficient kitchen staffing. One resident stated that the food had gone downhill, was repetitive, and not worth eating, and commented that there was only one cook who could not manage all the work. Another resident reported that the food was terrible and that no alternatives were offered because there was only one cook who did not have time to prepare other options. A third resident reported that meals were often late and that food quality had declined, acknowledging that there was only so much one person could do. Interviews and schedule reviews showed that the Dietary Manager had effectively been working as the only cook for an extended period. The Administrator stated the facility should have a full-time Dietary Manager, day cook, evening cook, and dishwasher, and that other non-dietary staff could help in the kitchen if needed. The Dietary Manager reported she had been performing manager duties since August 2025, had been prepping, cooking, and cleaning up all meals daily, working approximately 14 hours a day, 7 days a week, and had worked over 30 days without a day off. She also reported not being trained on the computer system for ordering food and lacking time to properly clean the kitchen or begin ServSafe certification. Review of dietary schedules over several weeks showed repeated days with only two staff in the kitchen, the Dietary Manager consistently working 13–14 hour shifts, and at least one day with only one staff member in the kitchen and no cook scheduled, demonstrating a sustained pattern of inadequate staffing relative to the facility’s own assessment.
Incomplete and Late Clinical Documentation for Care Conferences, Weights, and Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical documentation and care conference records for multiple residents. For one resident with multiple sclerosis and quadriplegia who was cognitively intact and dependent on staff for all ADLs, the record showed the most recent completed care conference on one date, with a later care conference note marked as “in progress” and not completed. The Social Services Director later produced several care conference notes for this resident that were all created and signed in the EHR on the same later date, despite being dated for earlier months, and stated she took notes in a notebook and entered them into the EHR whenever she had the chance, acknowledging she had fallen behind on documentation. Another resident with congestive heart failure and severe cognitive impairment had no quarterly care plan conferences documented since admission, and the record later showed multiple quarterly care plan conferences that were all created on the same later date, although they were dated for earlier months. The facility also failed to accurately document weights and refusals for a resident with chronic kidney disease and diabetes mellitus who was cognitively intact and dependent on staff for toileting. The care plan included monitoring weight and intake and educating and documenting refusals, and physician orders required monthly weights and then weekly weights. The weight summary showed only a single weight in October and then weights in January, with a significant decrease, and an IDT note referenced a three percent weight decrease and missing weights from October to January. The TAR for November and December had blank monthly weight entries with no staff signatures, and the DON reported the resident was noncompliant and refused to be weighed in those months, but staff did not document the refusals. Additional documentation deficiencies were identified in medication and treatment administration records for residents with chronic obstructive pulmonary disease and congestive heart failure who required insulin and other treatments. For one resident with COPD, oxygen therapy, and an indwelling catheter, the eMAR/eTAR showed multiple dates when Lyrica, blood sugar checks, BIPAP-related tasks, and ordered small frequent meals were not documented as administered or refused; the DON reported that staff working those shifts stated they had provided the medications and treatments but missed the documentation. For another resident with congestive heart failure and an insulin lispro sliding scale order, the eMAR showed numerous early-morning doses not administered, and the DON explained that night shift nurses obtained blood sugars and relayed results to day shift nurses, who then gave insulin at breakfast, but documentation sometimes was missed.
Failure to Maintain Odor-Free, Sanitary Environment in Common Areas and Units
Penalty
Summary
The facility failed to provide a safe and sanitary environment by not maintaining pleasant, neutral scents and minimizing institutional odors as required by its Environmental policy. During multiple observations, surveyors noted strong, persistent odors in several areas of the building. On 1/22/26 at 9:40 A.M., the hallways on Stocker Unit 1 and Stocker Unit 2 had a strong smell of urine. On 1/23/26 at 8:56 A.M., the main lobby, Stocker Unit 1, and Stocker Unit 2 had a strong, pungent odor consistent with sewer gas. On 1/28/26 at 9:05 A.M., the hallway outside of the conference room had an odor consistent with bowel movement. In an interview, the Administrator stated that odors in the facility should be controlled by general routine cleaning and that staff should increase cleaning in areas prone to odors. The facility’s written Environmental policy, dated 5/17 and provided by the Administrator, states that staff and management shall maximize pleasant, neutral scents and minimize institutional odors, but the observed conditions did not align with these policy expectations. No specific residents or their medical conditions were identified in the report; the deficiency was based on environmental observations in common areas and units accessible to residents, staff, and the public.
Failure to Complete Ordered Follow-Up Visit and Weekly Wound Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to provider orders and facility policy for a resident with multiple comorbidities. Resident C had diagnoses including COPD, heart failure, and kidney failure, and a quarterly MDS indicated cognitive impairment, need for staff assistance with hygiene, and no pressure areas at that time. A behavioral care plan revised in late September directed staff to make referrals as needed. A provider visit note in mid-November documented that the resident was having behavioral issues, with a plan that included medication changes and a follow-up visit in two to three weeks or sooner if indicated. However, during an interview, the NP reported that the resident was not seen again after that mid-November visit, and the record contained no evidence that the ordered follow-up visit occurred. The facility also failed to complete and document weekly wound assessments as required by its Skin Management policy. The resident’s skin care plan, revised in late September, identified skin impairments and directed staff to inspect the skin every shift and report changes. A weekly wound assessment in mid-November showed a blister on the resident’s left leg, but there were no weekly wound assessments documented from the following day through late November. A subsequent weekly assessment in late November documented two venous ulcers on the left leg, followed by another gap with no weekly wound assessments from late November through early December. A weekly assessment in early December then documented two venous ulcers on the left leg and one venous ulcer on the right leg. The facility’s Skin Management policy required immediate treatment for any open area and weekly assessments with ongoing wound documentation, which were not consistently completed for this resident.
Some of the Latest Corrective Actions taken by Facilities in Indiana
- Implemented a systemic plan that included assessments, audits, and updated care plans to prevent recurrence of missed monitoring and treatment related to changes in condition (J - F0684 - IN)
Failure to Monitor and Treat Resident’s Acute GI and Mental Status Changes, Including Missed STAT Labs and Assessments
Penalty
Summary
The deficiency involves the facility’s failure to monitor, assess, and treat a cognitively intact resident with new onset altered mental status and gastrointestinal symptoms in a timely and thorough manner, in accordance with physician orders, care paths, and facility policies. The resident had significant medical diagnoses including prostate cancer, lung cancer, insulin‑dependent diabetes, GERD, and COPD, and a care plan identifying risk for rehospitalization with interventions such as completing labs as ordered and timely communication with the physician regarding changes in condition. Despite this, when the resident developed new symptoms of coughing, coffee‑ground emesis, feeling "drunk," and staggering while ambulating, nursing staff documented the initial episode and a physician order for a CBC and medication changes, but the CBC was never obtained and there was no further documentation of the resident’s condition that day. On subsequent days, the resident continued to experience nausea, vomiting, confusion, dizziness, and abdominal pain, with a documented pulse of 128. The physician ordered STAT chest and abdominal x‑rays and a STAT CBC for cough, nausea, vomiting, abdominal pain, altered mental status, weakness, and dizziness. The x‑rays later showed a mild to moderate colonic stool burden contributing to a colonic ileus and a small right pleural effusion, and the physician ordered stool softeners, MiraLAX, and doxycycline. However, the STAT CBC was again not obtained prior to the resident’s death, and the laboratory request log showed the CBC was entered without being marked as STAT. The clinical record lacked documentation that the laboratory was called when the STAT lab was not completed, and there was no evidence that the facility followed its GI Symptoms and Acute Mental Status Change care paths, which called for vital signs and assessments every 4–8 hours, abdominal exams, neuro checks, and monitoring of intake/output. Throughout this period, the record lacked documentation of ongoing assessments, follow‑up vital signs, neurological checks, abdominal assessments, or nursing interventions on multiple days when the resident was symptomatic. Although there were active PRN orders for Zofran 8 mg and Meclizine 12.5 mg for nausea, vomiting, and dizziness, there was no documentation that these were administered on the days in question; only a later order for Zofran 4 mg was documented as given once in the evening, with no subsequent nursing assessment recorded after that administration. The resident’s emergency contact was not notified by nursing staff of the change in condition, and there was no documentation that the resident or his representative was consulted regarding transfer to the hospital, despite the POST form allowing hospital transfer for stabilization and comfort. Confidential interviews indicated staff believed upper management could block hospital transfers and that the DON was aware of the resident’s deteriorating symptoms but instructed staff to wait for physician orders before sending him out. The physician reported he was not informed that vomiting and symptoms persisted for multiple days and had not ordered a hospital transfer based on the limited information provided. The resident was later found with bile‑like emesis, became unresponsive, and died in the facility, with no nursing documentation between the last evening medication administration and the time of the code. Additional record review and interviews confirmed that there were no faxed or scanned urgent communications to the physician beyond what was already in the electronic record, and the physician’s office had no additional documentation from the facility for the days surrounding the change in condition. The facility’s own policies on nursing documentation and changes in resident condition required documentation of condition changes, vital signs, system reviews, and timely notification of the physician and resident representative when there was a significant change in physical or mental status, as well as use of INTERACT tools such as Stop and Watch and SBAR. The resident’s record lacked evidence that these tools were used or that the required notifications and assessments were consistently performed. Surveyors also noted that the facility’s laboratory services policy did not define expectations for STAT lab timelines, and the DON later acknowledged that audits had identified other missed changes in condition in additional residents during the same period.
Removal Plan
- Implemented a systemic plan that included assessments, audits, and updated care plans.
- In-serviced staff on resident assessment, change in condition, physician and resident representative notification, and laboratory policy and procedures.
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