Based on observation, interview, and record review, the facility failed to ensure a resident on dual antiplatelet therapy who had a fall from bed, landed on her face, and sustained a visible head injury was assessed for a change in condition and promptly sent to the hospital for 1 of 3 residents reviewed for accidents (Resident B). The immediate Jeapardy began on [DATE], at approximately 8:00 p.m., when Resident B with previous history of cerebrovascular accident (CVA, commonly called a stroke is a condition where blood flow to a part of the brain is blocked or a blood vessel bursts, causing brain cells to die from a lack of oxygen), subdural hemorrhage in December of 2025, and was taking two antiplatelets (drugs that stop blood cells from sticking together), rolled off her bed during… …
F684 citations in Indiana
Quality of care · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Indiana cites F684 more often than its own record predicts
1.67 times the share F684 takes of citations nationally.
Of every deficiency written in Indiana in 2025, this is the portion that was F684.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Indiana surveyors wrote
F684 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 wound treatments were implemented and consistently completed to promote healing for 2 of 4 residents reviewed for wound care. (Resident B and Resident E) This deficient practice resulted in delayed treatment for a chronic wound to Resident B's toe that was later surgically amputated. Findings include:1.Resident B's clinical record was reviewed on 7/13/26 at 9:24 a.m. Diagnoses included type 2 diabetes mellitus with foot ulcer, other osteomyelitis, unspecified sites, skin graft (allograft) (autograft) infection, non-pressure chronic ulcer of other part of left foot with unspecified severity, peripheral vascular disease, local infection of the skin and subcutaneous tissue, and acquired absence of other toe(s),… …
Based on record review, and interview, the facility failed to accurately assess a resident admitted for respite care and failed to implement medication and procedures applicable to their stay for 1 of 3 residents reviewed for pharmecutical services. (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 residents 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. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 5.82% | 1.61× |
| 2024 | 6.25% | 1.57× |
| 2025 | 7.19% | 1.67× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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