Waters of Greencastle, the

Inspectors wroteBased on observation, record review, and interview, the facility failed to supervise and ensure the safety of a resident with dementia residing on the locked dementia unit when an exit glass door and an outside courtyard gate were left open by a contractor and the resident eloped from the facility and fell into a ditch for 1 of 3 residents reviewed for accidents (Resident B). The immediate jeopardy began on 6/2/26 at 1:58 p.m., when Resident B was observed via video footage exiting the gate from the locked unit courtyard. She continued across the parking lot into a grassy field. She walked at a rapid pace, carrying a blanket in front of her. She walked approximately 100 yards and veered towards the road and was observed falling on her face in a ditch. She was observed trying to get up and falling again. [...]

Inspectors wroteBased on observation, record review, and interview, the facility Administrator and Director of Nursing (DON) failed to communicate accurate information, complete accurate documentation, and pressured facility staff to provide false statements for an elopement from the memory care unit for 1 of 5 residents reviewed for accidents (Resident B). This deficiency had the potential to affect 68 of 68 residents residing at the facility who were overseen by the Administrator and DON.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure beard restraints were worn appropriately and hand hygiene was performed after staff touched their face during 5 of 5 kitchen observations. This deficient practice had the potential to affect 68 of 68 residents who ate meals from the kitchen.

Inspectors wroteBased on record review and interview, the facility failed to obtain consent for treatment of psychotropic medications for 4 of 5 residents reviewed for unnecessary medications. (Residents 7, 8, 27, and 22).

Inspectors wroteBased on interview and record review, the facility failed to ensure the grievances expressed by the residents were addressed and resolutions were explained to the residents for 6 of 24 residents reviewed for food concerns (Residents 6, 71, 38, 24, 68, and 65).

Inspectors wroteBased on record review and interview, the facility failed to ensure Abnormal Involuntary Movement Scale (AIMS) (a clinical tool to detect and monitor tardive dyskinesia (TD) in patients taking (antipsychotic) medications, rating involuntary facial, limb, and trunk movements) assessments were completed timely for 2 of 5 residents reviewed for unnecessary medications (Residents 7 and 22).

Inspectors wroteBased on record review and interview, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessment for 2 of 17 reviewed (Residents 22 and 65).

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan was developed related to weight loss (Resident 7), failed to ensure a care plan was developed related skin concerns (Resident 71), and failed to ensure documentation of care plan meeting being held (Resident 19) for 3 of 24 residents reviewed for care plans.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it was free of a medication error rate of greater than 5 percent for 1 of 4 residents (Resident 19) observed during the medication pass. There were 32 opportunities for error observed with 4 medication errors, resulting in a medication error rate of 12.5 percent.

Inspectors wroteBased on record review and interview, the facility failed to document resident refusal or justification for holding insulin, and failed to document notification to the physician for 1of 1 resident reviewed for unnecessary medications (Resident 8).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure hand hygiene was performed during the medication pass for 3 of 4 residents reviewed on the medication pass (Residents 19, 26, and 67).

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's preference regarding meal service for 1 of 3 records reviewed for quality of care (Resident C).

Inspectors wroteBased on record review and interview, the facility failed to ensure a reweight was completed for a resident with a significant weight change for 1 of 3 residents reviewed for nutrition (Resident 47).

Inspectors wroteBased on record review and interview, the facility failed to ensure a pharmacy recommendation had been addressed in a timely manner for 1 of 5 residents reviewed for unnecessary medications (Resident 35).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate sanitation of drinking glasses, pitcher, and kitchen equipment for 2 of 2 kitchen observations, and failed to ensure snacks were served in a sanitary manner for 1 of 1 random snack distribution observation.

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to ensure proper handwashing in the kitchen, and sanitary practices while pureeing foods and measuring the temperature of food to be served from the kitchen, during 4 of 4 kitchen observations. This deficient practice had the potential to effect 11 of 11 residents who received pureed food, and 63 of 63 residents who received food from the kitchen. B. Based on observations, interview, and record review, the facility failed to use proper hand hygiene when 3 certified nursing aides (CNA's) were observed assisting 6 residents to eat during 1 of 2 dining room observations (Residents 34, 36, 14, 30, 9, and 37).

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to ensure proper handling of oral and eye drop medication for 2 of 2 residents observed during the medication administration observation (Residents 63 and 42). B. Based on observation, interview, and record review, the facility failed to ensure hand sanitization was performed in between glucometer blood testing for 3 of 3 residents observed during medication administration (Residents 52, 27, and 41).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rights to privacy and dignity were maintained for 3 of 3 residents when completing blood glucose testing (Residents 27, 41, and 52).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide comfortable water temperatures of more than 105 degrees Fahrenheit (F) and less than 115 degrees F in 8 of the 9 shared resident bathrooms on the secured memory care area observed for unsafe water temperatures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plans were revised for concerns and interventions for 3 of 19 residents' care plans reviewed (Residents 14, 41 and 32).

Inspectors wroteBased on observation, record review, and interview, the facility failed to trim the fingernails of a resident's contracted hand to prevent the nails from pressing into the palm of the hand for 1 of 24 residents reviewed for activities of daily living (Resident 14).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was labeled properly for 2 of 2 medication carts and 1 of 2 medication storage rooms reviewed for medication storage (Resident 8 and 24), and the facility failed to ensure expired medications were disposed of for 1 of 2 medication storage rooms reviewed.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the licensed occupational therapist had the knowledge, competencies to enter a completed physicians order into the medical record of 1 of 24 residents reviewed (Resident 14). Finding Includes: On 8/8/23 at 10:15 a.m., during initial observation Resident 14 did not have a palm pillow (layers of MicroSpring Textile rolled to 1 1/2 think pillow prevents digging fingernails into palms. Adjustable soft band with Velcro) applied to the contracted (a permanent shortening (as of muscle, tendon, or scar tissue) producing deformity or distortion) left hand. The fingernails on the left hand were long and jagged and were pressing into the palm of the hand. On 8/9/23 at 11:30 a.m., observed the resident sitting in a wheelchair in the main dining room. Palm pillow was not applied to the left hand. [...]

Inspectors wroteBased on record review and interview, the facility failed to accurately report weekend staffing hours in the PBJ (payroll-based journal) reporting system for the 1 of 3 staffing quarters in 2023.