Based on observations, interviews and record reviews, the facility failed to identify Urinary Tract Infections (UITs) as a high-risk concern area through their Quality Assurance Program (QAPI) which resulted in actual harm when 4 of 5 residents reviewed for UTIs resulted in immediate jeopardy after acute changes of condition, wherein; Resident B ultimately died of septic shock, Resident G was admitted to the hospital and diagnosed with sepsis secondary to a UTI, Resident F's acute change of condition was not noticed by facility staff so that her family member called 911 and she was also diagnosed with a UTI, and Resident H was not treated promptly to prevent pain and burning when voiding after they began to exhibit signs and symptoms of a UTI. …
F867 citations in Indiana
QAPI improvement activities · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Indiana cites F867 less often than its own record predicts
0.60 times the national share — cited less often here than elsewhere.
Of every deficiency written in Indiana in 2025, this is the portion that was F867.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Indiana surveyors wrote
F867 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 observations, interviews, and record review, the facility failed to implement an effective QAPI plan that identified, investigated, analyzed, and corrected persistent dementia related safety concerns on the secured memory care unit. This deficient practice had the potential to affect all 11 of 11 residents residing on the secured memory care unit.Findings include:In January 2026, the facility received an Immediate Jeopardy (IJ) citation for dementia care involving Resident 10 and Resident 29. …
Based on record review and interview, the facility failed to ensure the formation of a Quality Assurance Assessment committee and conduct Quality Assurance Performance Improvement meetings in order to assess areas of concern within the facility for 5 of 6 months reviewed. This deficient practice had the potential to affect 115 of 115 residents who reside in the facility. Findings include: During an interview on 4/8/19 at 12:16 p.m., the Administrator indicated the facility did not have a QAPI (Quality Assurance Performance Improvement) Plan until January. The first QAPI meeting was held on (MONTH) 24, 2019. She started as Administrator on 09/10/18 and indicated the previous administration did not have any documentation of previous QAPI plans or meetings. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 0.41% | 0.70× |
| 2024 | 0.21% | 0.46× |
| 2025 | 0.20% | 0.60× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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