Based on interview and record review, the facility failed to ensure the physician was notified immediately and on-call services were utilized when a resident had a change of condition for 1 of 3 discharged residents reviewed for notification of change. (Resident 67) Resident 67 was admitted to the hospital with a bowel obstruction, perforated bowel, and necrosis. The resident required surgical intervention and subsequently died.The immediate jeopardy began, on [DATE] around 9:40 p.m., when Resident 67 had a change of condition which included, a complaint of constipation with ongoing diarrhea, increased pain, shortness of breath, loss of bowel sounds, and excessive belching. RN 2 faxed the physician's office at this time. …
F580 citations in Indiana
Notifying of changes · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Indiana cites F580 more often than its own record predicts
1.36 times the share F580 takes of citations nationally.
Of every deficiency written in Indiana in 2025, this is the portion that was F580.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Indiana surveyors wrote
F580 findings written in Indiana, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview and record review, the facility failed to ensure an orthopedic surgeon was notified when the frequency of a resident's narcotic pain medication was changed, when the resident's condition failed to improve, and when the resident had continued complaints of pain following a right hip surgery for 1 of 3 residents reviewed for notification. (Resident B) This deficient practice resulted in Resident B experiencing continued pain for two weeks related to a dislocated hip after a hemiarthroplasty (a surgical procedure which replaces only one half of a joint-the ball while leaving the socket) of the right hip. …
Based on record review and interview, the facility failed to ensure the resident's responsible party was notified timely after a fall occurred for 1 of 3 residents reviewed for accidents. (Resident C) Finding includes: Resident C's record was reviewed on 8/25/26 at 10:40 a.m. The diagnoses included, but were not limited to, COPD, heart disease, heart failure, diabetes, anemia, and anxiety. A Functional Abilities admission assessment, dated 8/12/26, indicated the resident's cognition, self-care, indoor mobility, and all other activities of daily living required dependent care. The resident was independent with eating. The resident was admitted on [DATE] and discharged home on 8/15/26. A Care Plan, dated 8/12/26, indicated the resident was admitted for respite stay on hospice support. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 2.35% | 1.64× |
| 2024 | 2.07% | 1.36× |
| 2025 | 2.02% | 1.36× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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