Waters of Clifty Falls, the

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident (Resident C) received Indwelling catheter care every shift and failed to ensure Indwelling catheter care was in place (Resident D and Resident E) for 3 of 4 residents reviewed for catheter care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's (Resident D) readmission assessment accurately reflected an Indwelling catheter for 1 of 3 residents reviewed for medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound treatments were administered appropriately for 1 of 3 residents reviewed for treatment and services related to wound care. (Resident B)

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure accurate documentation was completed related to residents wound treatments for 1 of 3 residents reviewed for accuracy of records. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to follow physician's orders and change treatment orders in a timely manner related to a resident's wound care for 1 of 3 residents reviewed for quality of care. (Resident C)

Inspectors wroteBased on record review and interview, the facility failed to follow physician's orders related to treatments for 1 of 3 residents reviewed for pressure ulcers. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an accident during a transfer resulting in skin tears requiring sutures for 1 of 3 residents reviewed for accidents. (Resident B)

Inspectors wroteBased on observation and interview, the facility failed to ensure resident care equipment was in safe operating condition for 1 of 2 high back wheelchairs reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff treated a resident with respect and dignity for 1 of 3 residents reviewed for resident rights. (Resident C)

Inspectors wroteBased on interview and record review, the facility failed to ensure an anti-anxiety medication was administered to a resident within the appropriate time frame and failed to ensure behaviors were documented prior to the administration of an anti-anxiety medication for 1 of 3 residents reviewed for significant medication errors. Findings Include:The clinical record for Resident B was reviewed on 7/10/25 at 10:04 a.m. The resident's diagnosis included, but was not limited to, restlessness and agitation. The progress note, dated 6/17/25 at 8:00 p.m., indicated the resident was in the dining room and stated, I want to leave. The resident was observed to be physically aggressive with staff. At approximately 7:30 p.m., the resident kicked the side window in the dining room. He then picked up a chair and attempted to throw it at the window. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a long-acting insulin order was accurately transcribed for 1 of 3 residents reviewed for significant medication errors. Findings Include:The clinical record for Resident B was reviewed on 7/10/25 at 10:04 a.m. The resident's diagnosis included, but was not limited to, type 2 diabetes. The hospital discharge order, dated 6/17/25, indicated the resident was to receive insulin glargine (long-acting insulin) 100 unit/ml (milliliters), 5 units at bedtime. The insulin was not to be mixed with other insulins. If the resident's blood glucose was less than 70, the staff were to follow the hypoglycemia protocol for glycemic control. The facility admission order, dated 6/17/25, indicated the resident was to receive insulin glargine, 70 units subcutaneously at bedtime. [...]

Inspectors wrote3. During a continuous observation, on 05/29/25 from 1:38 P.M. through 1:44 P.M. the following was observed: - At 1:38 P.M., a computer screen was opened on Medication Cart 1 on the 100 Hallway that was sitting between resident rooms [ROOM NUMBERS]. The screen had Resident 66's name and medication list visible. - At 1:39 P.M., a resident in a wheelchair propelled by the cart and looked towards the computer and kept going, - At 1:40 P.M., LPN 8 who had been standing at Medication Cart 2 outside of room [ROOM NUMBER], approximently ten feet from Medication Cart 1, walked into room [ROOM NUMBER] next to Medication Cart 1 out of visible sight of both Medication Carts 1 and 2. The LPN did not close the open computer screen on Medication Cart 1. [...]

Inspectors wroteBased on record review, interview, and observation, the facility failed to follow physician's orders related to cardiac medication hold parameters and follow manufacturer's guidelines related to insulin pen usage for 5 of 20 residents reviewed for Quality of Care. (Residents 2, 93, 7, 78, and 29)

Inspectors wroteBased on observation and interview, the facility failed to store foods appropriately to prevent contamination for 1 of 2 kitchen observations.

Inspectors wrote3. The clinical record for Resident 52 was reviewed on 06/03/25 at 2:08 P.M. A Quarterly MDS assessment, dated 02/24/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, a stroke, depression, obesity, and weakness. An open-ended physician's order, with a start date of 06/02/25 at 2:31 P.M., indicated the resident was in enhanced barrier precautions for a pressure wound. During an observation, on 06/03/25 at 2:09 P.M., the resident's door had a sign on it that indicated staff were to STOP and that the resident was in ENHANCED BARRIER PRECAUTIONS. Staff must wear a gown and gloves for high contact resident care activities, including but not limited to, Wound Care: any skin opening requiring a dressing. Supplies, including gowns and gloves were in a plastic container with drawers outside the resident's room. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to store medications appropriately for 1 of 1 resident reviewed for self-administering medications. (Resident 7)

Inspectors wroteBased on record review and interview, the facility failed to ensure a Minimum Data Set (MDS) assessment was transmitted to the Centers for Medicare and Medicaid Services (CMS) in a timely manner for 1 of 20 resident assessments reviewed. (Resident 85)

Inspectors wroteBased on observation, record review, and interview, the facility failed to revise a resident's care plan related to the resident's leg prosthesis for 1 of 20 residents reviewed for care plans. (Resident 75)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders related to wound treatments for pressure ulcers for 1 of 4 residents reviewed for pressure ulcers. (Resident 78)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure splint devices were in applied as ordered for 1 of 1 resident reviewed for range of motion. (Resident 84)

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy recommendations were addressed timely for 1 of 5 residents reviewed for drug regimen review. (Resident 75)

Inspectors wroteBased on observation and interview, the facility failed to store medications appropriately for 2 of 3 medication carts (Split Cart and Living Well Cart) reviewed and 1 of 2 medication rooms (Dementia Unit) reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that critical laboratory (lab) test results were received and reported to the physician in a timely manner; and a lab test was completed after a fall related to seizure medication for 2 of 6 residents reviewed for lab services. (Residents 11 and 20)

Inspectors wroteBased on record review, interview, and observation, the facility failed to document colostomy care for 1 of 25 residents' records reviewed. (Resident 26)

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary homelike environment for 1 of 20 residents reviewed. (Resident 53) During an observation and interview, on 06/02/25 at 10:26 A.M., Resident 53 was lying in bed and her eyes were closed. She opened her eyes and denied any concerns. On the floor approximately ten inches from the foot of her bed were a stack of linens that included, but were not limited to, a sheet and a pair of disposable underwear that smelled strongly of urine. The resident was lying on clean sheets. During an observation, of Resident 53's room, on 06/02/25 at 10:47 A.M., on the floor approximately ten inches from the foot of bed remained a stack of linens that included, but were not limited to, a sheet and a pair of disposable underwear that smelled strongly of urine. [...]

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing accurately for 2 of 6 staff posting observations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide functioning bathroom call lights for 4 of 6 residents reviewed for resident call system. (Residents D, E, F, and G)

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident was treated with respect and dignity for 1 of 3 residents reviewed. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to ensure misappropriation of a resident medication did not occur for 1 of 3 residents reviewed for misappropriation. (Resident D)

Inspectors wroteBased on record review and interview, the facility failed to store medications in a secure manner related to medications left on top of the medication cart unattended for 1 of 3 medication carts reviewed. (Living Well Long Hall Cart)

Inspectors wroteBased on interview and record review, the facility failed to ensure an alleged violation was reported to the Indiana Department of Health in a timely manner related to an allegation of misappropriation of residents' medications for 1 of 1 allegations of misappropriation of residents' property. (QMA 2)

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of abuse related to a staff member and misappropriation of medications for 1 of 4 staff reviewed. (QMA 2)

Inspectors wroteBased on observation and interview, the facility failed to store medications appropriately for 4 of 4 medication carts observed. (1 cart on the In Motion Hallway and 3 carts on the Living Well Hallways)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control guidelines during meal preparation related to the use of hair nets and failed to provide a clean and sanitary kitchen for 93 of 95 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and follow physician's orders for 3 of 4 residents reviewed for pressure ulcers. (Residents 15, 37, and 38)

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide appropriate urinary catheter care for a resident with recent history of UTIs (Urinary Tract Infections) for 1 of 2 residents reviewed for UTIs. (Resident 88)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order in regard to the amount of water prescribed for flushing the feeding tube and failed to gently/slowly administer the liquid nourishment without a rapid force for 1 of 2 residents reviewed for feeding tubes. (Resident 33)

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately monitor a dialysis access site for 1 of 2 residents that received dialysis treatments. (Resident 20)

Inspectors wroteBased on record review and interview, the facility failed to ensure PRN as needed orders for psychotropic medications were limited to 14 days for 1 of 5 residents reviewed for unnecessary medications. (Resident 20)

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medication administration records accurately reflected the administration of narcotic pain medication for 4 of 4 residents; and failed to account for controlled drug record forms for 3 of 4 residents reviewed for medical records. (Residents C, D, E and F)

Inspectors wroteBased on interview and record review, the facility failed to ensure medication errors did not occur for 1 of 4 residents reviewed for medication administration.

Inspectors wroteBased on record review and interview, the facility failed to notify an emergency contact of a resident's falls for 1 of 3 residents reviewed for falls. (Resident B)

Inspectors wroteBased on record review and interview, the facility failed to follow care planned interventions and implement an appropriate intervention after a fall for 1 of 3 residents reviewed for accidents. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to have adequate staff available to provide Activities of Daily Living related to showers for 4 of 5 residents reviewed for ADL's. (Residents B, D, N, and G)

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify wound development, complete neurological assessments after a fall, and follow physician orders for wound care for 3 of 12 residents reviewed for Quality of Care. (Residents D, L, and G)

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent and identify pressure ulcers that resulted in a resident developing a Stage 3 and an Unstageable pressure ulcer for 3 of 4 residents reviewed for pressure ulcers. (Residents B, C, and G)

Inspectors wroteBased on interview and record review, the facility failed to prevent a female resident with a diagnosis of dementia and a history of wandering from being inappropriately touched by a male resident when she wandered into his room unsupervised for 2 of 4 residents reviewed for dementia care. (Residents E and F)

Inspectors wroteBased on observation and interview, the facility failed to store and prepare foods in a safe and sanitary manner related to open trash containers, hair net usage, and labeling foods for 4 of 5 kitchen and snack refrigerators observations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations to meet the needs and preferences of a resident related to placement in the locked Dementia Unit for 1 of 24 residents reviewed for Residents' Rights. (Resident 50)

Inspectors wroteBased on interview and record review, the facility failed to accurately complete MDS (Minimum Data Set) assessments related to anticoagulant medication and diagnoses for 2 of 18 residents reviewed for accuracy of assessments. (Residents 60 and 50)

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer physician ordered wound treatments and identify pressure ulcers in a timely manner for 2 of 5 residents reviewed for pressure ulcers. (Residents 57 and 36)

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow Fall Care Plan interventions related to identified falls for 1 of 5 residents reviewed for accidents. (Resident 43)

Inspectors wroteBased on record review and interview, the facility failed to monitor residents while taking psychotropic medications for adverse side effects for 2 of 5 residents reviewed for unnecessary medications. (Residents 44 and 50)

Inspectors wroteBased on record review and interview, the facility failed to prevent significant medication errors and monitor side effects related to Coumadin (a blood thinner medication) for 1 of 5 residents reviewed for unnecessary medications. (Resident 44)

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications appropriately for 2 of 3 medication carts reviewed. (100 Hall and 200 Hall medication carts)