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
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel/bladder, and that catheter care and UTI prevention measures were inadequate. These failures resulted in a deficiency related to resident care.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
Surveyors found that staff failed to maintain accurate narcotic drug counts and records on two nursing units. Discrepancies were observed between the count logs and the actual number of controlled substance tablets present, with staff attributing the errors to being hurried or behind in their duties. Facility policy requires real-time documentation and verification of controlled substances, which was not followed.
A resident with a gastrostomy tube did not receive water flushes at the volume ordered by the physician, as the feeding pump was set to deliver 60 mL per hour instead of the prescribed 50 mL per hour. This discrepancy was confirmed by two nurses during separate observations, despite facility policy requiring adherence to physician orders for feeding tube care.
Staff failed to perform hand hygiene after removing gloves and before donning new gloves while assisting a resident with toileting and personal care. After glove removal, a CNA also handled the resident's personal items without hand hygiene, contrary to facility policy and infection prevention standards.
The facility did not notify the physician or NP of significantly elevated blood glucose levels for two residents with diabetes, despite physician orders and facility policy requiring such notification. Blood glucose readings above the specified threshold were not reported, and there was no documentation in the progress notes to indicate that the provider was informed, as confirmed by staff interviews.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to resident care.
A resident with multiple complex diagnoses did not receive diazepam as ordered, despite documentation on the MAR indicating administration. The narcotic count sheet showed the medication was not removed for two scheduled doses, and staff interviews confirmed the required documentation on the controlled medication log was missing, suggesting the medication was not actually given.
The facility did not provide quarterly funds statements to two residents whose personal funds were managed by the facility, as required by policy. Staff acknowledged that statements were not given to residents without a responsible party, resulting in the deficiency.
The facility did not maintain a surety bond sufficient to cover all resident funds it managed, as required by policy. On multiple occasions, the balance of resident funds exceeded the bond amount, and the Business Office Manager confirmed that no reviews were conducted to ensure adequate coverage.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Failure to Provide Safe and Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for this resident, indicating that the required services were not adequately provided as needed.
Inaccurate Narcotic Drug Counts and Recordkeeping
Penalty
Summary
The facility failed to maintain accurate drug records and account for all controlled substances on two nursing units. During observations, discrepancies were found between the narcotic count logs and the actual number of medications present in the drug packs. On the East unit, the narcotic count log for hydrocodone-acetaminophen 5-325 mg tablets indicated 23 available, but only 22 were present, and another log indicated 30 available with only 29 present. The RN responsible stated she may have forgotten to sign out the medications after administration, as she typically signs the narcotic log as she gives them. On another unit, similar discrepancies were observed. The count log for clonazepam 0.5 mg tablets showed 17 available, but only 16 were present, and the log for Ativan 1 mg tablets showed 8 available, but only 7 were present. The QMA responsible indicated she was passing medications on two halls and was behind, but normally signs the medication out as she gives it. The facility's policy requires each dose to be recorded at the time of administration and the drug supply to be confirmed before and after assembling the required dose, including documentation of date, time, dosage, signature, and quantity remaining.
Failure to Follow Physician Orders for Feeding Tube Flushes
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube did not receive water flushes according to the physician's orders. The resident, who had diagnoses including muscle weakness, dysphagia, diabetes mellitus, and gastrostomy status, was dependent on tube feeding and water flushes as documented in their care plan. The physician's order specified tube feeding at 65 mL per hour and water flushes at 50 mL per hour. During observations, it was found that the feeding pump was set to deliver 60 mL per hour of water flushes, which was confirmed by two different nurses at separate times. This setting did not match the physician's order for 50 mL per hour. The facility's policy required staff to follow physician orders for feeding tube care, including the frequency and volume of flushes, but this was not adhered to in this instance.
Failure to Perform Hand Hygiene Between Glove Changes and After Glove Removal
Penalty
Summary
During an observation of care, two CNAs assisted a resident with toileting and perineal care. After providing perineal care, one CNA removed (doffed) used gloves and immediately donned new gloves without performing hand hygiene in between glove changes. Both CNAs then assisted the resident with dressing and transferring to a wheelchair. Subsequently, the CNA removed gloves and, without performing hand hygiene, opened the resident's bedside table drawer and handed the resident a hair comb. The CNA verbally indicated to the resident that she needed to wash her hands, but did not perform hand hygiene herself at the required times. The facility's infection preventionist confirmed during an interview that staff are expected to change gloves when moving from dirty to clean tasks and to perform hand hygiene between glove uses and immediately after removing gloves. Review of the facility's hand hygiene policy also indicated that hand hygiene should be performed after removing gloves and as the final step after removing personal protective equipment. These lapses in infection control practices were directly observed and confirmed through staff interviews and policy review.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician or Nurse Practitioner of significantly elevated blood glucose levels for two residents with diabetes, as required by physician orders. For one resident with type 2 diabetes, blood glucose readings exceeded the ordered notification threshold of 400 mg/dl on multiple occasions, specifically with values of 443 mg/dl, 546 mg/dl, and 436 mg/dl, without documentation that the physician or Nurse Practitioner was notified. Interviews with nursing staff and the Director of Nursing confirmed that the protocol was to notify the provider and document the notification in the progress notes, which was not done in these instances. Another resident with multiple diagnoses, including type 2 diabetes and acute kidney failure, had several blood glucose readings ranging from 319 mg/dl to 397 mg/dl over two days. Despite facility policy and staff statements indicating that elevated blood glucose levels should prompt notification of the physician and documentation in the progress notes, there was no evidence in the resident's record that the physician was notified of these abnormal results. The facility's policy required following physician orders and parameters, but this was not adhered to in these cases.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Failure to Administer Medication According to Physician Order and Documentation Requirements
Penalty
Summary
A deficiency occurred when a resident with diagnoses including spastic quadriplegic cerebral palsy, dysphagia, and scoliosis did not receive medication as ordered. The resident had a physician's order for diazepam 2.5 mg to be administered four times daily. According to the June Medication Administration Record (MAR), four doses of diazepam were documented as given on a specific date. However, the corresponding narcotic count sheet indicated that the medication was not removed for the morning and noon doses on that date. Interviews with facility staff confirmed that the medication was signed off as administered on the MAR but was not signed out on the controlled medication log, as required by facility policy. Review of the records suggested that the medication may not have actually been administered to the resident, despite documentation to the contrary. Facility policy requires that controlled substances be signed out on the narcotic sheet after administration, which was not done in this instance.
Failure to Provide Quarterly Funds Statements to Residents
Penalty
Summary
The facility failed to provide quarterly funds statements to residents for whom it managed personal funds, specifically for two out of three residents reviewed. Record review showed that the facility managed funds for 32 residents, and quarterly statements were requested for three of these residents. However, two residents did not have quarterly statements available for review. During interviews, the Administrator and Business Office Manager acknowledged that quarterly statements had not been given to residents who did not have a responsible party, which was an error, as the residents themselves should have received the statements. Facility policy requires that residents be provided with a confidential quarterly statement of funds on deposit.
Insufficient Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to provide a surety bond in an amount sufficient to safeguard all resident funds managed by the facility. Record review showed that the facility managed funds for 32 residents, and the surety bond in place covered only $30,000.00. However, bank statements for May, June, and July 2025 revealed that on 23 separate days, the daily ledger balance of resident funds exceeded the bond amount, with balances reaching as high as $48,374.65. During an interview, the Business Office Manager confirmed that the facility did not conduct reviews to ensure the surety bond was adequate for the actual balance of resident funds, as this responsibility was handled by the home office. The facility's policy required it to act as a fiduciary and safeguard resident funds, but this was not met due to the insufficient bond coverage.
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
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