The Indiana Department of Health reports the following survey activity and outcomes during the month of October 2024:
- Complaint Investigation – 18
- Recertification Survey – 7
- State Residential Survey – 14
- Post Survey Revisit – 0
- Deficiency Free – 3
- Offense Tags – 8
- Deficiency Tags – 36
- Total Residential Tags – 44
The Offense Tags are as follows:
Tag 051 (1 time) – –
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 (1 time) — Health Services Deficiency – The administration of medications and the provision of residential nursing 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 a licensed nursing personnel or qualified medication aides.
Top Deficiency Tags are as follows:
Tag 273 (7 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 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 (4 times) – Health Services – Personal care, and assistance with activities of daily living shall be provided based upon individual needs and preferences.
Tag 243 (2 times) – Health Services – The individual administering the medication shall document the administration in the individual’s medication and treatment records that indicate the: A) time; B) name of medication or treatment; C) dosage (if applicable); and D) name or initials of the person administering the drug or treatment.
Tag 149 (2 times) – Sanitation and Safety Standards Deficiency – The facility shall have a pest control program in operation in compliance with 410 IAC 7-24.
Tag 117 (2 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 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 (one hundred) residents regularly receiving residential nursing services or administration of medication, or both shall have at least one (1) additional nursing staff 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 036 – Residents’ Rights Deficiency – The facility must 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 exiting form of treatment due to adverse consequences or to commence a new form of treatment.