Based on record review, observation, and interview; the facility failed to ensure an effective process was in place to prevent recurrent medication storage concerns for 1 of 3 carts reviewed.Findings include: During an observation, on 01/04/2026 at 11:08 AM, a bottle of liquid medication was observed with the liquid level approximately 1.5 inches from the top if the bottle. The medication label had NOT OPEN in capital letters with black marker. There was no open date on the bottle. Licensed Practical Nurse (LPN) 2 opened the lid. A puncture to the inner seal was observed with red liquid on the puncture and around inner part of lid. The multiple dose bottle was opened and used. Resident 47's record was reviewed on 1/4/26 at 11:22AM. …
F865 citations in Indiana
QAPI program · Administration Deficiencies
Have a plan that describes the process for conducting QAPI and QAA activities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Indiana cites F865 less often than its own record predicts
0.35 times the national share — cited less often here than elsewhere.
Of every deficiency written in Indiana in 2025, this is the portion that was F865.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Indiana surveyors wrote
F865 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.
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 0.04% | 0.22× |
| 2024 | 0.05% | 0.28× |
| 2025 | 0.08% | 0.35× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction