Based on record review and interview, the facility failed to ensure a notice of discharge was provided in writing, discharge planning was completed, and a resident's discharge was safe with continuity of care ensured for 1 of 3 residents reviewed for discharge. (Resident E) This deficient practice resulted in an unsafe discharge when the resident was transferred to a hospital waiting area without admission arrangements and no way to obtain nutrition through enteral feedings. The resident voiced feeling of hopelessness and felt others wanted him to die. The immediate jeopardy began on 12/24/24 when the facility discharged Resident E to a hospital waiting area. The Administrator and Regional Administrator were notified of the immediate jeopardy at 3:58 P.M. on 1/6/25. …
F622 citations in Indiana
Transfer and discharge · Resident Rights Deficiencies
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Indiana cites F622 more often than its own record predicts
2.17 times the share F622 takes of citations nationally.
Of every deficiency written in Indiana in 2025, this is the portion that was F622.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Indiana surveyors wrote
F622 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 record review and interviews, the facility failed to establish a discharge plan and to ensure documentation was accurate and allowed at least 30 days prior to the transfer for a facility initiated transfer and failed to allow a resident to remain the building when the resident verbalized opposition to the transfer for 1 of 3 discharged records reviewed. (Resident B) This deficient practice resulted in the resident inflicting self harm due to the impending transfer. Finding includes: The record for Resident B was reviewed on 10/13/2023 at 9:45 A.M. …
Based on interview and record review, the facility failed to ensure documentation of a resident's transfer included a progress note with pertinent information that the resident was being transferred to the hospital and the facility failed to ensure report was called to the emergency room for 1 of 1 resident reviewed for hospitalization (Resident 7). Findings include: During an interview, on 4/22/25 at 8:52 a.m., Resident 7 indicated she had been transferred to the hospital a couple of times in the last few months. Resident 7's record was reviewed on 4/23/25 at 8:59 a.m. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 0.56% | 2.22× |
| 2024 | 0.47% | 1.46× |
| 2025 | 0.25% | 2.17× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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