Residential Citation Update: March 2025

The Indiana Department of Health reports the following survey activity and/or outcomes for the month of March 2025:  

• Complaint Investigation – 30 

• Recertification – 23 

• State Licensure – 5 

• Post Survey Revisit – 0 

• Deficiency Free – 4  

• Offense Tags – 9  

• Deficiency Tags – 75  

• Total Residential Tags – 84  

The Offense Tags are as follows:  

Tag 052(3 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 241 (3 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 051 (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 systems.  

Tag 242 (1 time) – 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.  

The Top Residential Tag citations are as follows: 

Tag 273 (16 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 (12 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 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 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 (5 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 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 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 045 (3 times) – Residents’ Rights Deficiency – Before an interfacility transfer or discharge occurs, the facility must, on a form prescribed by the department, do the following: A) Notify the resident of the transfer or discharge and the reasons for the move, in writing, and in a language and manner that the resident understands. Copy of the notice to be in the clinical record and transmit a copy to the following: resident, a family member of the resident if known, the resident legal representative if known, The Ombudsman, The person or agency responsible for the resident’s placement, maintenance, and care in the facility, the resident’s physician.  

Tag 144 (3 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 (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 pr facility request. A licensed nurse shall evaluate the nursing needs of the resident.