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Residential Citation Update – Jan. 2024

Posted Feb 26, 20246 min Read

Regulatory & Clinical

The Indiana Department of Health reported the following survey activity for the month of January:  

  • 30 Complaint Investigations  
  • 5 Recertification Surveys  
  • 22 State Residential Licensure Surveys  
  • 2 Post Survey Revisit Surveys 

 There was a total of Ninety (90) Residential tags cited and of those eleven (11) were Offense tags. 

Offense Tags are as follows:  

Tag 052 (6 times) – Residents’ Rights Offense – 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 241 (3 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.  

Tag 245 (2 times) – Health Service Offense – licensed personnel shall only give Injectable medications.  

Top Deficiency tags are as follows:  

Tag 273 (16 times) – Food and Nutritional Services Deficiency – All food preparation and serving areas (excluding areas in resident units) are maintained in accordance with state and local sanitation and safe food handling standards, including 410 IAC 7-24. 

Tag 217 (7 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; 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 shall be reviewed and revised as appropriate and discussed by the resident and facility 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 shall be given to the resident upon request. 4) No identification and documentation of services provided is needed if evaluations after the initial evaluation indicate 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 243 (4 times) – Health Services Deficiency – The individual administering the medication shall document the administration in the individual’s medication and treatment records that indicate the: A) time; B0 name of medication or treatment; C0 dosage (if applicable); and D) name or initials of the person administering the drug or treatment.  

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

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 148 (3 times) – Sanitation and Safety Standards Deficiency – The facility shall 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 as follows: 1) Each facility shall establish and implement a written program for maintenance to ensure the continued upkeep of the facility. 2) The electrical system, including appliances, cords, switches, alternate power sources, fire alarm and detection systems, shall be maintained to guarantee safe functioning and compliance with state electrical codes. 3) All plumbing shall function properly and comply with state plumbing codes. 4) At least yearly, heating, and ventilating systems shall be inspected.  

Tag 118 (3 times) – Personnel Deficiency – Any unlicensed employee providing more than limited assistance with activities of daily living must be either a certified nurse aide or a home health aide. Existing facilities that are not licensed on the date of adoption of this rule and that seek licensure within one (1) year of adoption of this rule have two (2) months in which to ensure that all employees in this category are either a certified nurse aide or a home health aide. 

Tag 117 (3 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.  

For questions or assistance with survey readiness, contact  

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