Skilled Nursing Facility Update: April 2025

The Indiana Department of Health in April of 2025 conducted thirty-nine recertification surveys, and three were deficiency free. There were six (6) G-Level citations and 5 SSQC/Immediate Jeopardy citations in April 2025.  

G Level Citations are as follows:  

Tag 689 (4 times) – Free of Accident Hazards/Supervision/Devices  

• The facility failed to revise care plans and to follow interventions to reduce the risk of falls for a resident reviewed for falls with major injury. This practice resulted in two falls with fractures requiring hospitalization and a significant decline in the residents’ Activities of Daily Living.  

• The facility failed to ensure adequate safety measures were in place to prevent accidents for 2 of 3 residents reviewed. This practice resulted in Resident C requiring hospitalization, sutures, and a subarachnoid hemorrhage.  

• The facility failed to provide supervision for a resident with known fall risk and failed to ensure the implementation of fall interventions to prevent repeated falls for 2 of 3 residents reviewed for falls. This practice resulted in a resident sustaining a left ankle fracture during a fall.  

• The facility failed to provide supervision to prevent repeated falls for a resident assessed to be elevated risk for falls. This practice resulted in a resident sustaining fracture of the wrist and hand and hospitalization for decreased mobility in lower extremities.  

Tag 760 (1 time) – Residents are free of Significant Medication Errors  

• The facility failed to ensure residents were free from significant medication errors for 1 of 2 residents reviewed for hospitalization. The resident did not receive blood pressure medications and was admitted to the hospital two times for hypertensive emergencies.  

Tag 686 (1 time) – Treatment and Services to Prevent/Heal Pressure Ulcer 

• The facility failed to ensure services were provided to prevent the development of pressure ulcers for a resident reviewed for pressure ulcers. The facility failed to obtain adequate physician orders or instructions after removing a non-removable brace, which resulted in an unstageable pressure ulcer to the left heel (wound2). Following an assessment by a wound care clinic that indicated a newly developed unstageable pressure ulcer to the top of the left foot (wound 3), the facility failed to assess the wound routinely or create a plan of care to address the wound. This practice resulted in the facility failing to prevent and assess developed pressure wounds and failing to update the residents’ plan of care for pressure wounds.  

SSQC/Immediate Jeopardy Tags are as follows:  

Tag 689 SSQC/J — (3 times) – Free of Accident Hazards/Supervision/Devices  

• The facility failed to provide supervision to a resident that resided on the secured memory unit and had a history of exit seeking behaviors, from exiting the facility through a window in his room. The day of elopement the resident was angry, exit seeking, trying to leave, and stated he needed to get out of there.  

The immediate jeopardy began on 4/15/25 at about 6:20 pm, when the facility failed to supervise a cognitively impaired resident, who lived in the secured memory unit, to prevent elopement. The immediate jeopardy was removed, and the deficient practice corrected on 4/16/25 before the survey started and was therefore Past Noncompliance.  

During an interview with the Assistant Director of Nursing indicated that on 4/15 at approximately 7:00 pm, the ADON saw the resident walking alone near a store about 100 yards from the facility. The ADON returned the resident to the secured memory care unit.  

During an interview, the Social Services Director indicated that the resident started searching for an exit as soon as he was admitted to the facility. The resident packed his belongings and set them in the dining room on the secured unit several times before they climbed out of his window. The resident told staff that he believed “they” were trying to send him to a nursing home and would then stand and knock on the back door. The resident was adamant that he was going to go home.  

• The facility failed to provide supervision to prevent a cognitively impaired resident, who had an appointed guardian and history of exit seeking, from exiting the facility without staff knowledge for 1 of 3 residents reviewed for elopements. This practice resulted in the resident being located by local law enforcement 1.8 miles from the facility.  

The immediate jeopardy began on 3/29/25 at around 10:50 pm when the facility failed to prevent a cognitively impaired resident from leaving the facility without staff knowledge. The IJ was removed, and the deficient practice was corrected on 3/30/25, prior to the survey start and was therefore Past Noncompliance.  

• The facility failed to provide supervision to prevent a cognitively impaired resident who resided on the secured memory care unit from exiting the facility’s property without staff knowledge. The resident was found approximately 1.5 miles from the facility. The deficient practice was corrected prior to the start of the survey and therefore was Past Noncompliance.  

• Tag 686 SSQC/J (1 time) – Treatment/Services to Prevent/Heal Pressure Ulcer 

• The facility failed to ensure received assessment, treatment, and individualized interventions to prevent worsening of a pressure injury to the coccyx.  

The Immediate Jeopardy began on 1/16/25 when the facility failed to assess an identified pressure injury and provide appropriate treatment and interventions. The IJ was removed on 4/25/25.  

Tag 684 SSQC/J (1 time) – Quality of Care  

• The facility failed to ensure residents were adequately assessed, and physician orders were followed with a change of condition post-surgery for 1 of 4 residents reviewed. The facility failed to ensure the resident was assessed, and a Doppler study completed timely as ordered when resident leg showed a change in condition. The deficient practice resulted in a resident hospitalization and death. 

The Immediate Jeopardy began on 3/20/25 when the facility failed to assess Residents’ change of condition. The IJ was removed on 4/30/25, but noncompliance remained at the lower scope and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.  

There will be more details shared in the upcoming Top Tags Webinar June 30, noon to 1 p.m.