Residential Citation Update: February 2025

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

• Complaint Survey – 24  

• Recertification Survey – 16  

• State Licensure – 3  

• Post Survey Revisit – 0  

• Deficiency Free – 7  

• Offense Tags – 8  

• Deficiency Tags – 61  

• Residential Tags – 69  

The Offense Tags are as follows:  

Tag 52 (3 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 (4 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 as follows: 1) Medication shall be administered by licensed nursing personnel or qualified medication aides.  

Top Deficiency Tags are as follows:  

Tag 273 (9 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 (8 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 (6 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 090 (6 times) – Administration and Management Deficiency – The administrator is responsible for the overall management of the facility. The responsibilities of the administrator shall include, but are not limited to, the following: 1) Informing 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. 2) Promptly arrange for or assist with the provision of medical, dental, podiatry, or nursing care or other health care services as requested by the resident or resident’s legal representative. 3) Obtaining director approval prior to the admission of an individual under eighteen (18) years of age to an adult facility. 4) Ensuring the facility maintains, on the premises, and accurate record of actual time worked that indicates the: A) Employee’s full name; and B) dates and hours worked during the past twelve (12) months 5) Posting the results of the most recent annual survey of the facility conducted by state surveyors, any plan of correction in effect with respect to the facility, and subsequent surveys. The results must be available for examination in the facility in a place readily accessible to residents and a notice posted about their availability. 6) Maintaining survey reports conducted by the division in each facility for two (2) years and making them available for inspection to any member of the public upon request.  

Tag 036 (5 times) – 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 existing form of treatment due to adverse consequences or to commence a new form of treatment.  

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 reason for the move, in wring, and in a language and manner that the resident understands. Place a copy of the notice in the clinical record and transmit a copy to the following:  

• The resident  

• A family member of the resident (if known)  

• The resident’s legal representative (if known)  

• The local ombudsman program (for involuntary relocations or discharges only)  

• The person or agency responsible for the resident’s placement, maintenance, and care in the facility.  

• In situations where the resident is developmentally disabled, the regional office of the division of disability, aging, and rehabilitative services, who may assist with placement decisions.  

Record the reasons for the discharge, the effective date of the discharge and the location to which the resident is being transferred or discharged.  

Provide a statement in not smaller than 12-point bold type that reads, “You have the right to appeal the health facility’s decision to transfer you.  

More information is available on how to transfer/discharge a resident following the regulations, so please reach out to Lori Davenport at Ldavenport@ihca.org.