Based on interview and record review, the facility failed to ensure agency staff who worked in the facility as Certified Nursing Assistants and a Licensed Practical Nurse were certified and/or licensed according to Federal and State law from 9/29/21 to 1/15/22. The facility had 18 individuals working as Certified Nursing Assistants who were not certified. The facility also had 1 individual who worked as an LPN who was not licensed. These individuals performed the functions as if they were licensed. License and certifications were not verified by the facility. This deficient practice had the potential to affect all residents who resided in the facility from [DATE] to 1/15/22. The immediate jeopardy began on 9/29/21 when the first uncertified nursing assistant began working with residents. …
F839 citations in Indiana
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Indiana cites F839 less often than its own record predicts
1.00 times the national share — cited less often here than elsewhere.
Of every deficiency written in Indiana in 2025, this is the portion that was F839.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Indiana surveyors wrote
F839 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 interview and record review, the facility failed to ensure a nurse, who was employed to work in the facility in the nursing department, had a valid Indiana nursing license (LPN 3). This deficient practice had the potential to impact 56 of 56 residents who resided in the facility. Finding include: Employee records were reviewed on 5/22/25. Licensed Practical Nurse (LPN) 3 was listed on the Employee Records form, which was completed by the facility. The form indicated the employee's job title as LPN. The form indicated the nurse had been employed by the facility since 6/20/24. The facility's provided a binder containing nursing licenses verification, for facility employees. …
Based on observation, interview, and record review, the facility failed to ensure an LPN employed to work in the facility in the nursing department had a valid Indiana nursing license or an active out of state license valid through an interstate compact agreement (LPN 3). This deficient practice had the potential to impact 164 of 164 residents who resided in the facility. Finding include: Employee records, completed by the facility, were reviewed on 4/29/24. LPN 3 was listed on the form as an LPN Supervisor. The form indicated the nurse had been employed by the facility since 2/27/23. A facility-provided binder containing nursing licenses verification for facility employees, indicated LPN 3 held a Texas Board of Nursing, License Type-LPN, Compact Status-Single State. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 0.11% | 2.84× |
| 2024 | 0.08% | 1.37× |
| 2025 | 0.06% | 1.00× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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