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The Indiana State Department of Heath conducted a total of 16 surveys and of those, four (25%) were found to be deficiency-free. There were a total of 4 Offense tags cited, 40 Deficiency tags cited for a total of 44 residential tags for the month of November. The following Offensive tags were cited:
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Tag 0052 (1 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.
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Tag 0241 – (2 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 aides.
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Tag 0406 (1 time) – Infection Control Offense for failure to 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 following deficiency tags were cited:
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Tag 0090 (5 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.
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Tag 0117 (5 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.
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Tag 0148 (4 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.
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Tag 0217 (4 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.
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Tag 0273 (4 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.
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Tag 0027 (2 times) – Residents’ Rights Deficiency for failure to ensure resident right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Residents have the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States.
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Tag 0036 (2 times) — Residents’ Rights Deficiency for failure to immediately consult the resident’s physician and the resident’s legal representative when the facility has noticed: (1) A significant decline in the resident’s physical, mental, or psychosocial status; or (2) a need to alter treatment significantly, that is a need to discontinue an existing form of treatment due to adverse consequences or to commence a new form of treatment.
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Tag 144 (2 times) – Sanitation and Safety Standards Deficiency for failure to ensure the facility is clean, orderly, and in a state of good repair, both inside and out, and shall provide reasonable comfort for all residents.
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Tag 270 (2 times) – Food and Nutritional Services Deficiency for failure to meet: 1) daily dietary requirements and requests, with consideration of food allergies; 2) reasonable religious, ethnic, and personal preference; and 3) the temporary need for meals delivered to the resident’s room.
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Tag 272 (2 times) – Food and Nutritional Services Deficiency for failure to ensure food is served at a safe and appropriate temperature.
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Tag 029 (1 time) – Residents’ Rights Deficiency for failure to ensure residents have the right to be treated with consideration, respect, and recognition of their dignity and individuality.
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Tag 149 (1 time) – Sanitation and Safety Standards Deficiency for failure to ensure a pest control program is operational and in compliance with 410 IAC 7-24.
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Tag 154 (1 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.
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Tag 187 (1 time) – Physical Plant Standards Deficiency for failure to ensure hot water temperature for all bathing and hand washing facilities shall be controlled by an automatic control valve. Water temperature at point of use must be maintained between one hundred (100) degrees Fahrenheit and one hundred twenty (12)) degrees Fahrenheit.
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Tag 214 (1 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.
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Tag 240 (1 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.
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Tag 247 (1 time) – Health Services Deficiency for failure to ensure any error in medication administration shall be noted in the resident’s record. The physician shall be notified of any error in medication administration when there are any actual or potential detrimental effects to the resident.
If you would like assistance with preparing for your annual survey, contact ldavenport@ihca.org.