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
A resident with restless leg syndrome, chronic pain, anxiety, and post-stroke hemiplegia had ropinirole increased from 1 mg daily to 1.5 mg at bedtime after increased symptoms were noted. The resident had moderate cognitive impairment, and the POST and DPOA identified a family member as the legal representative. The DON stated the representative was not notified at the time of the med change and was only notified several days later, despite facility policy requiring notification when meds are altered and attempts within 24 hours.
Failure to Notify Physician of Critical Lab Results and Change in Condition: A resident with CKD, AFib, and anticoagulant therapy had critical low platelet counts, repeated low BP readings, and increasing confusion with hallucinations, but the record lacked documentation that the physician was notified of the STAT lab results or the abnormal vital signs. Family members reported the resident was not acting like himself, and the resident was later sent to the hospital with altered mental status, hypotension, hypothermia, thrombocytopenia, acute metabolic encephalopathy, and sepsis.
A resident with CHF, diabetes, COPD, and morbid obesity had a physician order for daily weights, but the record showed weights were documented only sporadically and most missed weights had no refusal documentation or provider notification. Staff interviews showed confusion about whether the order was active, and the DON stated the resident had a history of noncompliance with weights, fluid restrictions, medications, and treatments.
Failure to notify physician of new skin impairment. A resident with HTN, morbid obesity, edema, hemiplegia/hemiparesis, PVD, DM2, and CHF had intact cognition and a care plan calling for weekly skin checks and notification of the MD/family for any new skin breakdown. Weekly skin documentation did not reflect the bilateral buttock and coccyx impairment later measured by the DON, including a red area with an open area on one buttock and red areas on the other buttock and coccyx. Staff stated new open areas are measured and the DON, doctor, and family are notified, but the physician was not notified of the new skin condition.
Incomplete Weekly Skin Assessment Documentation: A resident with multiple chronic conditions, including DM, PVD, obesity, and hemiplegia, had orders and care plan interventions for weekly skin checks and wound treatment to the buttocks. Review of the chart showed weekly skin assessment forms that did not document the resident’s bilateral buttocks and coccyx skin impairment noted on the day of survey, even though staff and the DON described the areas and the facility policy required weekly wound documentation in PCC.
Unsafe and Unclean Unit Environment: The 200 unit had marred walls, chipped door trim, a large hole in a resident room wall, missing drywall near the offices, and dirt buildup on baseboards, floors, and around the elevator. The dining room and elevator area also had debris buildup, and the elevator door frame wrap was hanging off on both sides. An HSKP staff member stated the facility was down a housekeeper and floors should be cleaned daily.
Failure to Timely Notify Representative of Medication Change
Penalty
Summary
The facility failed to notify a resident's representative of a medication change for Resident E, who had diagnoses including restless leg syndrome, chronic pain, anxiety, and hemiplegia following a stroke. Resident E's quarterly assessment indicated moderate cognitive impairment, and the resident's POST and Durable Power of Attorney forms identified Family Member A as the legal representative and power of attorney. Physician orders showed ropinirole was changed from 1 mg daily to 1.5 mg at bedtime for restless legs syndrome, with the increase starting on 6/4/26. A physician note documented that the resident had increased difficulty with restless legs and that the ropinirole dose was increased to better control symptoms. A nursing progress note later stated that the representative had been notified of the medication change, but the DON stated in interview that the responsible party should have been notified at the time of the change and was not notified until 6/11/26. The facility policy required the nurse to notify the representative when medications or treatment were altered and indicated notifications would be attempted within 24 hours.
Failure to Notify Physician of Critical Lab Results and Change in Condition
Penalty
Summary
The facility failed to ensure that the physician was notified of STAT lab results and of a resident’s change in condition related to low platelet counts and increased confusion. The resident involved had diagnoses including urinary tract infection, hypothermia, toxic encephalopathy, chronic kidney disease stage 4, hypertension, atrial fibrillation, and anticoagulant therapy. A care plan directed staff to monitor blood pressure, report abnormal lab results to the doctor, and notify the doctor of sudden changes in mental status and significant or sudden changes in vital signs. The resident was seen by the NP for decreased blood pressures and not feeling well, and routine labs were ordered. A lab report showed a critical platelet count of 34, along with other abnormal values, but the record lacked documentation of when the lab called the facility with the critical result. The Medical Director was later notified of the low platelet level and ordered a STAT CBC, copies of labs to the nephrologist, and a referral to hematology; however, the record lacked documentation that the labs were sent to the nephrologist or that the hematology referral was completed. An LPN stated she could not find documentation that the lab copies were sent and could not recall whether she faxed them. Vital signs showed low blood pressures on multiple occasions, including 91/61, 102/53, and 96/40, but the record lacked documentation of physician notification for those abnormal readings. A STAT lab later showed a platelet count of 32 and other abnormal values, and the record again lacked documentation that the physician was notified of the STAT results. Family members reported the resident was hallucinating, talking out of his head, and not acting like himself, and staff noted increased confusion. The resident was ultimately sent to the hospital by ambulance after family raised concerns, and hospital records showed altered mental status and hallucinations for 3 days, hypotension, hypothermia, thrombocytopenia, acute metabolic encephalopathy, and sepsis.
Failure to Document Ordered Daily Weights
Penalty
Summary
The facility failed to routinely document physician-ordered daily weights for Resident B, who had diagnoses including CHF, diabetes, COPD, and morbid obesity. His MDS assessment indicated he was cognitively intact, non-ambulatory, and used a wheelchair for mobility. The current order summary showed an order placed for daily weights, but the order did not include parameters for notifying the physician for weight gain or loss within a defined time period. Weights were documented only on a few dates in the clinical record, and the majority of dates without weights had no documentation showing that the resident refused the weight or that the attending physician or NP was notified that the weight was not obtained. During interview, Resident B denied that daily weights had ever been obtained at the facility. An LPN stated she was unaware of any current residents who were to have daily weights, while another LPN identified Resident B as the resident with that order. The DON stated Resident B had a history of noncompliance with care, including refusing daily weights, and said the doctor and NPs were aware of his noncompliance with fluid restrictions, weights, medications, and treatments. The RD stated she believed the daily weight order had been discontinued after the resident signed a waiver for fluid restrictions and noted he was noncompliant with many aspects of care, including refusing weights at times. The facility later provided policies on weight assessment and provider notification, which stated that resident weights were to be monitored and recorded and that the physician or practitioner was to be informed of diagnostic results or changes in condition in a timely manner. The DON also stated the facility did not have a specific policy or procedure regarding implementation of physician orders and that the expectation was that all physician orders were followed.
Failure to Notify Physician of New Skin Impairment
Penalty
Summary
The facility failed to notify the physician of a change in health condition for 1 of 3 residents reviewed. Resident D had diagnoses including hypertension, morbid obesity, localized edema, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, peripheral vascular disease, type 2 diabetes, and chronic diastolic heart failure. The resident’s quarterly MDS indicated cognition was intact, and the care plan included interventions to perform weekly skin checks, document findings, and inform the resident, MD, family, and caregivers of any new area of skin breakdown. The clinical record showed weekly skin assessment forms from 3/12/26 through 7/1/26, but the form did not document the skin impairment observed to the bilateral buttocks and coccyx on 7/1/26 at 1:20 p.m. Earlier skin documentation reflected prior buttock and sacral issues that were described as pre-existing or healed, including a wound NP note on 3/10/26 stating the right buttock MASD had completely epithelialized and was fully closed. On 7/1/26, the DON measured new or current skin areas and identified a left buttock red area 4 cm by 4 cm, a right buttock red area with a 1 cm by 0.5 cm open area in the center, a circular red coccyx area 4 cm by 3 cm, and a reddened area above the coccyx measuring 3 cm by 4.5 cm. The DON stated that if a new skin area is found, it is measured and reported to the wound NP and regular NP, and that the DON should have been told by staff of any open areas to Resident D’s skin. RN 2 stated that if a new open area is found, measurements are taken and the DON, doctor, and family are notified. The administrator provided the facility policy requiring prompt notification of the resident, physician, and resident’s representative when there is a change requiring notification, including new treatment or alteration of treatment. The report indicates the physician was not notified of the new skin impairment.
Incomplete Weekly Skin Assessment Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple diagnoses including hypertension, morbid obesity, localized edema, hemiplegia and hemiparesis following cerebral infarction, peripheral vascular disease, type 2 diabetes, and chronic diastolic heart failure. The resident’s quarterly MDS indicated cognition was intact, and the care plan directed weekly skin checks and documentation for skin integrity concerns. Orders were in place for weekly skin assessments and for Triad hydrophilic wound dressings to the bilateral buttocks for MASD and soilage. Review of the weekly skin assessment forms from 3/12/26 through 7/1/26 showed entries documenting various skin findings, including open areas, redness, and a left thumb infection, but the form for 7/1/26 did not document the skin impairment observed to the bilateral buttocks and coccyx at 1:20 p.m. The record also showed that the only weekly skin assessment forms present were those reviewed in the chart, while the TAR was initialed for weekly skin assessments completed. A wound NP note dated 3/10/26 documented that the right buttock MASD had completely epithelialized and was fully closed. On 7/1/26, the DON stated the wound NP came weekly and that if a new skin area was found, staff were to report it to the DON, measure it, and notify the wound NP and regular NP. The DON later measured the resident’s buttocks and coccyx and found a left buttock red area, a right buttock red area with an open area in the center, a circular red coccyx area, and a reddened area above the coccyx. RN 2 stated weekly skin assessments were supposed to be documented on a PCC form and that new open areas required measurements and notification to the DON, doctor, and family. The facility policy required weekly wound assessments and documentation of wound characteristics and notifications related to wound changes.
Unsafe and Unclean Unit Environment
Penalty
Summary
The facility failed to ensure a safe, sanitary, and homelike environment on the 200 unit. During observation, the unit hallways had marred walls, a resident room had a large hole in the wall by the foot of the bed, and the wall by the offices had a large chunk of drywall missing. Baseboards had dirt buildup, door trim around resident rooms was marred or had chipped paint, and the hallways had dirt buildup in corners and around the double doors. The dining room floor had debris buildup around the baseboards and in corners, the elevator floor had dirt buildup around the edges of the walls, and the wrap around the elevator door frame outside the elevator doors was hanging or coming off on both sides. Housekeeper 3 stated the floor technician had recently been let go, the facility was down a housekeeper, and floors should be cleaned daily. The Administrator provided the facility policy on safe and homelike environment with a copyright date of 2025, which stated the facility will provide a safe, clean, comfortable, and homelike environment.
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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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