Residential Citation Update: April 2025

The Indiana Department of Health reported the following surveyor activity and/or outcomes for the month of April 2025: 

• Complaint Investigations – 31  

• Recertification – 29  

• State Licensure – 5  

• Post survey visit – 0   

• Deficiency Free – 1  

• Offense Tags – 15  

• Deficiency Tags – 96  

• Total Residential Tags – 111 

Offense Tags are as follows:  

• Tag 0051 (1 time) – Residents’ Rights Offense – 410 IAC 16.2-5-1.2(u) – 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 0052 (4 times) — Residents’ Rights Offense – 410 IAC 16.2-5-1.2(v) (1-6) – Residents have the right to be free from: 1) sexual abuse; 2) physical abuse; 3) mental abuse; 4) corporal punishment; 5) neglect; and 6) involuntary seclusion. 

• Tag 0241 (5 times) — Health Services Offense – 410 IAC 16.2-5-4(e)(1) – 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 0242 (2 times) – Health Services Offense – 410 IAC 16.2-5-4(e)(2) – The resident shall be observed for effects of medications. Documentation of any undesirable effects shall be contained in the clinical record. The physician shall be notified immediately if undesirable effects occur, and such notification shall be documented in the clinical record.  

• Tag 0245 (1 time) – Health Services Offense – 410 IAC 16.2-5-4(e)(5) – Injectable medications shall be given only by licensed personnel.  

• Tag 0406 (2 times) – Infection Control Offense – 410 IAC 16.2-5-12(a) – 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 and transmission of diseases and infection.  

The Top Residential Tags are as follows:  

• Tag 273 (15 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 (11 times) — Evaluation Deficiency – Following completion of an evaluation, the facility using appropriately trained staff, shall identify and document the services to be provided by the facility as follows: 1) The services offered to the individual resident shall be appropriate to the: A) scope; B) frequency; C) need; and D) preference; of the resident. 2) The services offered should be reviewed and revised as appropriate and discussed by the residents and facilities as needs or desires change. Either the facility or the resident may request a service plan review. 3) The agreed upon service plan shall be signed and dated by the resident, and a copy of the service plan given to the resident upon request. 4) No identification and documentation of services provided is needed if evaluations after the initial evaluation indicated no need for a change in services. 5) If administration of medications or the provision of residential nursing services or both is needed, a licensed nurse shall be involved in identification and documentation of the services to be provided.  

• Tag 117 (7 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 the skills required to provide for the residents’ specific needs. 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 receive 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 (5 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 PRN medication. All contacts with a nurse or physician not on premises for authorization to administer PRN medications shall be documented in the nursing notes indicating the time and date of the contact.  

• Tag 414 (5 times) – Infection Control Deficiency – The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice.  

• Tag 144 (4 times) – Sanitation and Safety Standards Deficiency – The facility shall be clean, orderly, and in a state of good repair, both inside and out, and shall provide reasonable comfort for all residents.  

• Tag 214 (4 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 pr facility request. A licensed nurse shall evaluate the nursing needs of the resident.  

• Tag 243 (4 times) – Health Services Deficiency – The individual administering the medications shall document the administration in the individual’s medication and treatment records that indicate the: A) time; B) Name of the medication C) Dosage (if applicable); and D) name or initials of the person administering the drug or treatment.  

• Tag 302 (4 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 the drug. E) Strength.  

There will be more details shared related to each of the top tags in the upcoming Top Tags in Assisted Living webinar on June 19 from noon to 1 p.m.