F641 in Indiana. Pick another state for the same tag.
Against expectation — 2025
Indiana cites F641 less often than its own record predicts
Versus expected share0.99×
0.99 times the national share — cited less often here than elsewhere.
Share of Indiana citations1.82%
Of every deficiency written in Indiana in 2025, this is the portion that was F641.
Indiana1.82%
National1.84%
Share of all citations that were F641.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Indiana surveyors wrote
F641 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.
G · Actual harm, isolatedNovember 1, 2022
Based on record review and interview, the facility failed to accurately document a medication error in detail and the full assessment for a medication error in the resident's clinical record for 1 of 3 residents reviewed for accuracy of assessment. (Resident B)
Findings include:
The clinical record for Resident B was reviewed on 10/31/22 at 10:11 A.M. An Admission MDS (Minimum Data Set) assessment, dated 08/22/22, indicated the resident was cognitively intact. The diagnoses included, but were not limited to, sepsis, cancer, anemia, hypertension, anxiety, depression, and respiratory failure. The resident required the extensive assistance of two physical staff for bed mobility. …
D · No harm, potential for more than minimal, isolatedJune 18, 2026
Based on interview and record review, the facility failed to ensure accuracy of MDS Minimum Data Set (MDS) assessments for 2 of 5 residents reviewed for unnecessary medications. A resident received an opioid that was not marked on the MDS, and a resident's use of injections and insulin was not marked on the MDS. (Resident 9, Resident 35)Findings include:1. On 6/15/26 at 10:12 A.M., Resident 9's clinical record was reviewed. Diagnosis included, but was not limited to, diabetes mellitus.The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/15/26, indicated Resident 9 had a severe cognitive impairment and did not receive insulin or injections during the assessment period.Physicians Orders during the assessment period included, but were not limited to:Humalog U-100 Insulin… …
B · No harm, potential for minimal, patternOctober 8, 2024
Based on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 4 of 7 residents reviewed for MDS accuracy (Resident 1, 12, 22, and 42).
Findings include:
1. The clinical record for Resident 1 was reviewed on 10/7/24 at 12:31 p.m. The diagnoses included, but were not limited to, paraplegia.
The Admission MDS assessment, dated 8/18/24, indicated Resident 1 had bed rails used as a restraint daily.
2. The clinical record for Resident 12 was reviewed on 10/7/24 at 12:40 p.m. The diagnoses included, but were not limited to, dementia.
The Quarterly MDS assessment, dated 9/13/24, indicated Resident 12 had bed rails used as a restraint daily.
3. The clinical record for Resident 22 was reviewed on 10/7/24 at 12:48 p.m. …
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