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Residential Citation Update

Posted Feb 4, 20194 min Read

Regulatory & Clinical

The Indiana State Department of Heath conducted a total of 15 surveys and of those, three (20%) were found to be deficiency-free. There were a total of 11 Offense tags cited, 55 Deficiency tags cited for a total of 66 residential tags for the month of November. The following Offensive tags were cited:

Tag 0241 – (6 times) – Health Services Offense for failure to ensure the administration of medications and provision of residential nursing care shall be as ordered by the resident’s physician and shall be supervised by a licensed nurse on the premises or on call as follows: 1) Medication shall be administered by licensed nursing personnel or qualified medication

Tag 0052 (4 time) – Residents’ Rights Offense for failure to ensure the right of residents to be free from 1) Sexual abuse; 2) physical abuse; 3) mental abuse; 4) corporal punishment; 5) neglect, and 6) involuntary seclusion.

Tag 0002 – (1 time) – Scope of Residential Care Offense for failure to ensure the facility did not provide comprehensive nursing care except to the extent allowed.

The following deficiency tags were cited:
Tag 0117 (7 times) — Personnel Deficiency for failure to ensure staff are enough in number, qualifications, and training in accordance with applicable state laws and rules to meet the twenty-four (24) hour scheduled and unscheduled needs of the residents and services provided.

Tag 0273 (7 times) — Food and Nutritional Services Noncompliance for failure to ensure an organized food service department directed by a supervisor competent in food service management and knowledge in sanitation standards, food handling, food preparation and meal service.

Tag 0217 (5 times) — Evaluation Deficiency for failure to ensure following completion of an evaluation, the facility, using appropriately trained staff members, identified and documented the services to be provided by the facility as follows:  1) The services offered to the individual resident are appropriate to scope, frequency, need and preference of the resident.

Tag 154 (3 time) – Sanitation and Safety Standards Deficiency for failure to keep all kitchens, kitchen areas, common dining areas, equipment, and utensils clean, free from litter and rubbish, and maintained in good repair in accordance with 410 IAC 7-24.

Tag 155 (3 times) – Sanitation and Safety Standards Deficiency for failure to ensure an effective garbage and waste disposal program in accordance with 410 IAC 7-24.  Provision shall be made for the safe and sanitary disposal of solid waste, including dressings, needles, syringes, and similar items.

Tag 214 (3 time) — Evaluation Deficiency for failure to ensure an evaluation of the individual needs of each resident is initiated prior to admission and updated at least semiannually and upon a known substantial change in a resident condition, or more often at the request of the resident or facility. A licensed nurse will evaluate the nursing needs of the resident.

Tag 414 (3 times) – Infection Control Deficiency for failure to ensure staff wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.

Tag 0045 (two times) – Residents’ Right Deficiency for failure to ensure before an interfacility transfer or discharge occurs. For more information related to Tag 0045, please click here.

Tag 0090 (2 times) — Administration and Management Deficiency for failure to inform the division within twenty-four (24) hours of becoming aware of an unusual occurrence that directly threatens the welfare, safety, or health of a resident.

Tag 0148 (2 times) — Sanitation and Safety Standards Deficiency for failure to maintain buildings, grounds, and equipment in a clean condition, in good repair, and free of hazards that may adversely affect the health and welfare of the residents or the public

Tag 240 (2 time) – Health Services Deficiency for failure to ensure personal care, and assistance with activities of daily living, shall be provided based upon individual needs and preferences.

Tag 246 (2 times) – Health Services Deficiency for failure to ensure PRN medications are administered by a qualified medication aid (QMA) only upon authorization by a licensed nurse or physician.  The QMA must receive appropriate authorization for each administration of a PRN medication.  All contacts with a nurse or physician not on the premises for authorization shall be documented in the nursing notes indicating the time and date of the contact.

Single tag was cited in the following tags:
0300, and

Forward questions to
To schedule assistance with survey readiness, Lori Davenport at the email provided above.