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Residential Citation Update

Posted Apr 23, 20246 min Read

Regulatory & Clinical

The Indiana Department of Health reported the following residential survey activities during the month of March 2024:  

  • 27 Complaint Investigations  
  • 9 Recertification Surveys  
  • 31 State Residential Surveys  
  • 2 Post Survey Revisit Surveys  

There was a total of eighty-seven (87) Residential tag and of those, eight (8) were Offense tags.  

Offense tags are as follows:  

Tag 052 (4 times) – Residents’ Rights Offense  

Residents have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident’s medical symptoms.  

Tag 241 (2 times) – Health Services Offense  

The administration of medications and the 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 aides.  

Tag 406 (2 times) – Infection Control Offense 

The facility must establish and maintain an infection control practice designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of transmission of diseased and infection. 

The top Residential tags are as follows:  

Tag 273 (17 times) – Food and Nutritional Services Deficiency  

All food preparation and serving areas (excluding areas in residents’ units) are maintained in accordance with state and local sanitation and safe food handling standards, including 410 IAC 7-24.  

Tag 217 (8 times) – Evaluation Deficiency  

Following completion of an evaluation, the facility, using appropriately trained staff members, shall identify and document the services to be provided by the facility, as follows:  

Tag 117 (6 times) – Personnel Deficiency 

Staff shall be sufficient in number, qualifications, and training in accordance with applicable state laws and rules to meet the twenty-four (24) hours scheduled and unscheduled needs of the residents and services provided. The number, qualifications, and training of staff shall depend on skills required to provide for the specific needs of the residents. A minimum of one (1) awake staff person, with current CPR and first aid certificates, shall always be on site. If fifty (50) or more residents of the facility regularly receive residential nursing services or administration of medication, or both, at least one (1) nursing staff person shall always be on site. Residential facilities with over one hundred (100) residents regularly receiving residential nursing services or administration of medication, or both, shall have at least one (1) additional nursing staff person always awake and on duty for every additional fifty (50) residents. Personnel shall be assigned only those duties for which they are trained to perform. Employee duties shall conform with written job descriptions.  

Tag 246 (4 times) – Health Services Deficiency  

PRN medications may be administered by a qualified medication aide (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 to administer PRNs shall be documented in the nursing notes indicating the time and date of the contact.  

Tag 240 (3 times) – Health Services Deficiency  

Personal care, and assistance with activities of daily living, shall be provided based upon individual needs and preferences.   

Tag 301 (3 times) – Pharmaceutical Services Deficiency  

Labeling of prescription drugs shall include the following: A) Resident’s full name. B) Physician’s name. C) Prescription number. D) Name and strength of the drug. E) Directions for use F) Date of issue and expiration date (when applicable). G) Name and address of the pharmacy that filled the prescription. If medication is packaged in a unit dose, reasonable variations that comply with the acceptable pharmaceutical procedures are permitted.  

Tag 300 (3 times) – Pharmaceutical Services Deficiency  

Over-the-counter medications must be identified with the following: A) Resident name. B) Physician name. C) Expiration date. D) Name of drug. E) Strength.  

Tag 214 (3 times) – Evaluation Deficiency  

An evaluation of the individual needs of each resident shall be initiated prior to admission and shall be updated at least semiannually and upon a known substantial change in the resident’s condition, or more often at the resident’s or facility’s request. A licensed nurse shall evaluate the nursing needs of the resident.  

Email Lori Davenport at with questions. 

About the Author

Lori Davenport

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