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)
Some of the Latest Corrective Actions taken by Facilities in Indiana
- Conducted audits of elopement evaluations and care plans to verify appropriate preventive measures for residents at risk of elopement (J - F0689 - IN)
- Trained staff on elopement procedures and one-to-one supervision requirements to strengthen competency in preventing resident elopement (J - F0689 - IN)
Failure to Provide Required Supervision Resulting in Resident Elopement
Penalty
Summary
A resident with diagnoses including dementia, alcohol abuse, and frontotemporal neurocognitive disorder, who resided on a secured memory care unit, was identified as being at risk for elopement and was placed on one-to-one staff supervision due to exit-seeking behaviors. Despite this intervention, the resident was able to exit the facility through a window in another resident's room. The window led to a secured courtyard, from which the resident used a chair to climb over a six-foot privacy fence and subsequently left the premises. The resident was later found by staff approximately two miles from the facility. On the day of the incident, the staff member assigned to provide one-to-one supervision for the resident was reassigned to perform general duties with other residents due to staffing shortages. As a result, the resident did not receive the required one-to-one supervision during the day shift. Multiple staff interviews confirmed that the resident was not under direct observation at the time of the elopement, and some staff were unaware that the supervision had lapsed. The resident had a documented history of exit-seeking behavior, including a previous incident where he left the facility through a window and walked to a grocery store. Observations and interviews revealed that the resident was able to manipulate the window hardware, remove screws, and exit through the window without staff detection. The facility's elopement prevention policy defined elopement as leaving the premises or a safe area without authorization or necessary supervision. The failure to provide the required supervision allowed the resident to leave the secured unit and the facility, resulting in the deficiency cited by surveyors.
Removal Plan
- audits of elopement evaluations and care plans
- inservicing staff on elopement procedures and one-to-one staff supervision
- ongoing monitoring
Latest Citations in Indiana
Surveyors found that drugs and biologicals in the medication room were not properly labeled or discarded. Two Ozempic injector pens for two residents lacked clear open or expiration dates, and a bottle of liquid Omeprazole for another resident was present past its expiration date and after being discontinued. The DON confirmed that labeling and timely disposal procedures were not followed, and the facility lacked a policy for labeling opened medications.
A resident with multiple medical conditions, including neurogenic bladder, was repeatedly observed with urinary catheter tubing and drainage bag resting on the floor while in bed and recliner. The care plan lacked instructions for catheter placement, and staff acknowledged the tubing was sometimes on the floor, contrary to facility policy requiring catheter bags to be kept off the floor.
A resident with specific dietary needs related to a vegetarian diet did not have her preferences reflected in her care plan or clinical record, despite repeated requests and a physician's order. The dietary department was aware of the preference but lacked access to update the clinical record, and the resident and her family experienced ongoing dissatisfaction with meal options and preparation. Multiple complaints to facility leadership went unresolved for an extended period, contrary to the facility's grievance policy.
A resident with a history of CHF, syncope, and hypomagnesemia experienced multiple acute changes in condition, including unrelieved pain, low BP, dehydration, and respiratory distress, without timely notification to the physician or family. The resident's advance directives for hospital transfer were not promptly followed, and physician orders for medication administration were inconsistently documented and implemented. Staff communication with the family was inconsistent, and required notifications and assessments were not completed as per facility policy.
The facility employed a Dietary Manager who lacked the required certification and had not received any training since being hired. Leadership was aware of the lack of qualifications, and facility policy requiring a qualified Food Service Director was not followed, potentially affecting all residents receiving meals.
Surveyors observed unsanitary conditions in the kitchen, including improper storage of food and chemicals, unclean equipment and surfaces, and staff failing to follow safe food handling practices. These deficiencies had the potential to affect all residents receiving food from the kitchen.
Multiple residents and their representatives reported that meals were frequently cold, lacked flavor, appeared unappetizing, and were served in inconsistent and often insufficient portions. Observations confirmed issues with food temperature, presentation, and portion sizes, while grievances and council minutes documented ongoing dissatisfaction with meal quality and adequacy. Staff interviews and facility records acknowledged these concerns, indicating a systemic failure to meet standards for palatable and properly served meals.
Two residents were observed eating meals while seated in wheelchairs that were too low for the dining tables, causing difficulty in reaching food and drinks and requiring awkward postures. Both residents, who were cognitively intact and required some assistance with eating, experienced undignified dining conditions over multiple meals. Staff did not recognize the issue, and care plans included interventions to ensure proper positioning, but these were not effectively implemented.
The facility did not provide required Skilled Nursing Facility Advance Beneficiary Notices of Non-coverage (SNF ABN) to two residents who remained after their Medicare Part A skilled services ended. The Business Office Manager reported informing residents of private pay amounts but had never issued an ABN form, and clinical records lacked documentation of the required notice.
Two residents were found using wheelchairs that remained visibly soiled with food particles, stains, and unidentified substances over several days, despite a facility policy and cleaning schedule requiring regular deep cleaning. Staff interviews revealed inconsistent understanding of cleaning responsibilities, and the ADON confirmed the wheelchairs should have been cleaned as scheduled.
Failure to Properly Label and Discard Medications in Medication Room
Penalty
Summary
Surveyors observed that drugs and biologicals in the facility's medication room were not properly labeled or discarded according to accepted professional standards. Specifically, two Ozempic injector pens for two residents were found in the medication room refrigerator without clear open or expiration dates. One pen had a date written on the box, but the DON could not confirm if it was the open or expiration date, while the other pen had no date at all. The DON confirmed that all opened medications should be labeled with both an open date and an expiration date, and that Ozempic pens should be discarded 56 days after first use. Additionally, a bottle of liquid Omeprazole for another resident was found with an expiration date that had already passed, and the DON verified that the medication should have been discarded. The medication had also been discontinued prior to the survey but was still present in the medication room. Review of the facility's policy on storage and disposal of medications revealed that while it addressed disposal of outdated medications, it did not specify procedures for labeling medications when opened. The Administrator was unable to provide a policy regarding labeling of opened medications.
Failure to Maintain Proper Catheter Tubing Placement
Penalty
Summary
Surveyors observed that the facility failed to implement proper infection control practices for a resident with an indwelling urinary catheter. Over multiple days, the resident was seen in both bed and recliner with the urinary catheter tubing and drainage bag resting on the floor. These observations were made on several occasions, indicating a repeated failure to maintain catheter tubing and drainage bag placement according to infection control standards. The resident involved had diagnoses including diabetes mellitus, cerebral infarction, and neurogenic bladder, and had a physician's order for monthly catheter changes. The resident's care plan addressed urinary retention but did not include instructions for proper placement of the catheter tubing while in bed or recliner. During an interview, a CNA acknowledged that the catheter tubing was sometimes on the floor and confirmed that it should not be. The facility's catheter management policy specified that collecting bags should always be kept below the level of the bladder and not resting on the floor, but this policy was not followed in practice.
Failure to Promptly Resolve Grievance Regarding Vegetarian Diet
Penalty
Summary
The facility failed to promptly resolve a grievance related to a resident's request for a vegetarian diet. The resident, who had diagnoses including hypothyroidism, gastro-esophageal reflux disease, and hypertension, was admitted with a physician's order for a regular vegetarian diet. Despite this, the clinical record and care plan did not reflect the resident's dietary preference, and the quarterly dietary assessment did not mention the need for a vegetarian diet. The resident and her family repeatedly expressed dissatisfaction with the vegetarian food options and preparation, with the family even providing plant-based protein due to ongoing issues. Interviews revealed that the Dietary Manager was aware of the resident's vegetarian preference within 24 hours of admission and provided available vegetarian items, but this information was not incorporated into the resident's clinical record or a multidisciplinary care plan. The dietary department lacked access to the electronic clinical record, further hindering coordinated care. The resident reported that meals often consisted of repetitive items like eggs, dairy, and peanut butter, and that food brought in by her family was sometimes improperly prepared by staff. Documentation and interviews indicated that the resident's family had communicated their concerns to multiple facility leaders, including the Administrator and DON, without resolution for an extended period. The Ombudsman confirmed that the issue persisted since admission and that the facility, resident, and family were unable to resolve the concern until a care plan meeting was eventually held. The facility's grievance policy required prompt review and resolution of complaints, but this was not achieved in the resident's case.
Failure to Assess, Notify, and Follow Advance Directives and Physician Orders
Penalty
Summary
The facility failed to ensure timely assessment and physician notification following acute changes in a resident's condition, did not follow the resident's advance directives for hospital transfer, and did not consistently follow physician orders for medication administration. The resident, who had a history of congestive heart failure, syncope, hypomagnesemia, and muscle weakness, was admitted for rehabilitation with the goal of returning home. Her POST form indicated she wished for full interventions, including hospital transfer and intensive care, if needed. Despite this, there were multiple instances where significant changes in her condition, such as unrelieved pain, low blood pressure, dehydration, difficulty breathing, anxiety, restlessness, and vomiting, were not promptly communicated to the physician, nurse practitioner, or family. Documentation in the resident's medical record was inconsistent regarding the administration and holding of her magnesium supplement, which was ordered to be held due to diarrhea but continued to be administered on several days. The Medication Administration Record (MAR) did not consistently reflect the reasons for holding or administering the supplement, and there was a lack of documentation supporting the clinical decisions made. Additionally, the resident's family was not promptly notified of her acute decline, and her wishes for hospital transfer were not immediately honored when her condition worsened. Staff communication with the family was inconsistent, and the family reported confusion and distress over the explanations provided and the documentation in the medical record. Interviews with facility staff, the nurse practitioner, and the resident's family revealed that the physician and family were not notified in a timely manner of the resident's significant changes in condition, including unrelieved pain, low blood pressure, dehydration, and acute respiratory distress. The facility's policies required immediate notification of significant changes, but these were not followed. The failure to assess, notify, and act according to the resident's advance directives and physician orders contributed to the deficiency identified by surveyors.
Unqualified Dietary Manager Employed Without Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the required qualifications and completed the necessary education to serve in that role. The Dietary Manager, who was hired in December 2024, reported during an interview that she did not possess certification qualifying her to act as Dietary Manager and had not received any training at the time of hire or since. Both the Administrator and the Regional Director of Operations confirmed their awareness that the Dietary Manager was not certified and had been employed in the position since December 2024. Facility policy requires the employment of a qualified Food Service Director per regulatory requirements, but this standard was not met, potentially impacting all 56 residents who received meals from the facility kitchen.
Unsanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to store and prepare food under safe and sanitary conditions, as evidenced by multiple observations in the kitchen. Surveyors observed an open container of brown sugar with a scoop handle inside the sugar, a microwave with dried food splatters, and upper cabinets with visible food splatters. Discarded kitchen gloves and empty coffee packets were found on the countertop, and the floor beneath was covered with corn flakes. The toaster had crumbs on both the spill tray and countertop, with scissors lying among the crumbs and an uncovered container of melted butter on top. The refrigerator had sticky fingerprints on the exterior and contained a roast beef in a zip lock bag that was past its date. Utensil drawers contained crumbs, a brown substance, and torn paper, and an open bag of panko breadcrumbs was stored improperly under a counter. In the dry storage area, chemicals such as bleach and floor cleaner were stored on the floor beneath electrical panels. Additionally, a kitchen staff member was observed improperly emptying a can of green beans, allowing the lid to repeatedly touch the food, which the Dietary Manager acknowledged was incorrect and attributed to lack of training. The chemicals in the dry storage area remained improperly stored during subsequent observations. Facility policies required clean, sanitary, and safe food storage and preparation, as well as proper cleaning schedules and staff training, but these were not followed, resulting in unsanitary conditions that had the potential to affect all residents receiving food from the kitchen.
Failure to Provide Palatable, Attractive, and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that meals provided to residents were palatable, attractive, and served at a safe and appetizing temperature for 17 of 31 residents reviewed. Multiple residents and their representatives reported that the food was consistently cold, lacked flavor, was unappetizing in appearance, and was sometimes served in insufficient portions. Specific complaints included hard rolls, unidentifiable or flavorless soups, watered-down drinks, and inconsistent portion sizes. Observations confirmed that food items such as meatloaf appeared grayish and unappealing, mashed potatoes and gravy lacked flavor, and pudding portions varied between residents. Residents also reported receiving meals late, with some meals missing items listed on the menu or being substituted with less desirable options due to shortages. Grievances and resident council minutes further documented ongoing dissatisfaction with the quality, temperature, and quantity of food served. Residents described meals as poorly cooked, insufficient to satisfy hunger, and sometimes inedible, with examples such as undercooked French fries, very small portions of pizza, and missing condiments like butter or sour cream. Several residents indicated they relied on snacks or food brought in by family members to supplement their meals due to the inadequacy of the facility's food service. The issues were persistent, with complaints spanning several months and being raised repeatedly in resident council meetings and formal grievances. Staff interviews and facility records acknowledged the residents' dissatisfaction, with staff noting inconsistent food temperatures, portion sizes, and presentation. The facility's own policy required that food be prepared, held, and served in a manner that maintains its nutritive value and palatability, but observations and resident feedback indicated this standard was not consistently met. The deficiency was evident through direct resident interviews, observations of meal service, review of grievances, and resident council minutes, all pointing to a systemic failure to provide meals that met residents' expectations for palatability, temperature, and adequacy.
Failure to Provide Dignified Dining Experience Due to Improper Table and Wheelchair Positioning
Penalty
Summary
Surveyors observed that two residents were not provided with a dignified dining experience during multiple meal services in the main dining room. Both residents were seated in wheelchairs that were significantly lower than the dining tables, resulting in their chins being at or below the tabletop. This positioning made it difficult for them to eat and required them to reach upward for their food and drinks. One resident was seen eating while hunched over and leaning to the right, and both had to lift their cups from below the table to drink. Staff interviews revealed that CNAs did not perceive the table height as a problem and were unsure if the tables could be adjusted. Neither resident had complained about the table height, and the ADON had not previously considered the issue. The clinical records for both residents indicated they were cognitively intact and required setup or clean-up assistance with eating. One resident had diagnoses including dementia, osteoarthritis, and heart failure, while the other had altered mental status, dysphagia, epilepsy, and adult failure to thrive. Care plans for both residents included supervision and assistance during meals, with interventions to ensure they were close enough to the table to reach food and drink properly. Facility policy stated that residents' needs and preferences should be honored as much as possible, considering their health status and safety.
Failure to Provide Medicare Non-Coverage Notification
Penalty
Summary
The facility failed to provide required notification of Medicare non-coverage to two residents who remained in the facility after their Medicare Part A skilled services ended. For both residents, the clinical records did not contain a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) after their last covered day under Medicare Part A. During an interview, the Business Office Manager stated that she informed residents or their representatives of private pay amounts but had never provided an ABN form to any resident. The facility's current policy referenced providing a detailed explanation of non-coverage, but there was no evidence that the required SNF ABN was issued to the affected residents.
Failure to Maintain Clean Wheelchairs for Two Residents
Penalty
Summary
The facility failed to provide clean and sanitary wheelchairs for two residents, as evidenced by multiple observations over several days. One resident's wheelchair was repeatedly found with smeared dark and reddish-brown substances, as well as honey-colored streaks on the outer panels. Despite a cleaning schedule indicating that deep cleaning should occur every Wednesday night, the wheelchair remained visibly soiled during several observations. Staff interviews revealed inconsistent understanding of cleaning responsibilities, with some indicating that third shift CNAs were responsible for deep cleaning, while others stated it was the responsibility of all staff members. Another resident's wheelchair was observed to have a nickel-sized dark brown substance on the right arm pad, a buildup of food particles and stains on the left side of the seat, and additional unidentifiable streaks and crumbs on various parts of the wheelchair. These conditions persisted over several days, despite the facility's policy requiring durable medical equipment to be clean and in good repair. The Assistant Director of Nursing confirmed that the wheelchairs should have been cleaned according to the schedule, but the deficiencies remained unaddressed at the time of the observations.