Arbor Grove Village

During an observation and interview, on 04/21/2026 at 2:54 P.M., the resident's room door was closed. A therapy associate in the hallway indicated Resident 9's roommate liked the room door to stay closed.

If staff members left the door open, the roommate would get up and close it.

During an observation, on 04/22/2026 at 11:02 A.M., the resident was sitting in her recliner in her room.

Her head was tilted back and her eyes were closed.

Her wheelchair was sitting in front of the recliner, and her feet were propped up on the seat of the wheelchair. A push-button call light was laying in the middle of the resident's bed, several feet away from the resident.

During an observation and interview, on 04/24/2026 at 10:46 A.M., the resident was lying in bed in her room.

Her call light was on the floor under the edge of the bed out of the resident's reach.

Certified Nurse Aide (CNA) 10 indicated the call light must have fallen.

During an interview, on 04/23/2026 at 3:29 P.M., the Physical Therapist indicated the resident fell frequently.

The hardest part for her was getting out of bed in the morning, she required a lot of assistance.

When she first stood up and walked, she was unsteady.

Staff usually stood with her when she first would get up and walked with her down to the dining room.

Throughout the day, the resident was more awake and she would get up and ambulate on her own with stand-by assistance.

During an interview, on 04/24/2026 at 10:48 A.M., the Infection Preventionist indicated to ensure call lights were in reach for residents the staff would give the call light to the resident when they laid them down or when they were in their chairs.

The clinical record was reviewed on 04/21/2026 at 2:24 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 02/10/2026, indicated Resident 9 was rarely understood.

The resident's diagnosis included, but was not limited to, dementia (a progressive, irreversible syndrome characterized by a decline in cognitive function, memory, language, and behavior, beyond normal aging, caused by damaged brain cells).

The resident needed assistance with hygiene and was incontinent of bowel and bladder.

The resident had two or more falls with no injury and two or more falls with minor injuries since the last assessment.

The resident's Risk for Falls Care Plan included, but was not limited to, and intervention, with an approach start date of 05/30/2023, to keep the resident's call light in reach.The Interdisciplinary Team (IDT) Comprehensive Care Plan Policy, with a revised date of 10/2025, was provided by the Administrator on 04/23/2026 at 3:41 P.M.

The policy indicated, .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented.The care plan must include measurable goals and resident specific interventions based on resident needs and preferences to promote the resident's highest level of functioning including medical, nursing, mental, and psychosocial well-being .Purpose .Create an organized, resident-centered review on a routine basis .provided to maintain or restore health and well-being .410 IAC (Indiana Administrative Code) 16.2-3.1-3(v)(1)

155625 04/24/2026

Arbor Grove Village 1021 E Central Ave Greensburg, IN 47240

During an interview, on 04/22/2026 at 10:30 A.M., CNA 3 indicated she was unaware that she could open a resident's Care Plan in the computer and review the resident specific interventions.

During an interview, on 04/23/2026 at 9:08 A.M., Registered Nurse (RN) 11 indicated the resident came to the facility with his urinary catheter.

The resident had an inflatable pump in his penis.

The resident always complained of penis pain, but it would fluctuate.

The resident's penis was not flaccid and always stayed a little erect.

The resident had a penile tear that has since healed but would never grow back.

The tear was from his long-term urinary catheter use.

The resident had gone to a urology consult recently and believed he was going to get a suprapubic catheter; he was going to go back for a follow up appointment in a few days.

During an interview, on 04/23/2026 at 2:35 P.M., the Assisted Director of Nursing (ADON) indicated the resident admitted to the facility with a catheter.

There was a weekend when the staff called her and indicated the resident had a laceration to his penis. It was a typical keratosis (a rare, benign [non-cancerous] skin growth appearing as tan, brown, or black waxy, stuck-on papules or plaques), that the resident always had that had become more inflamed.

The resident would frequently adjust his urinary catheter himself.

The staff should be monitoring the resident's skin while providing urinary catheter care that was completed every shift.

The resident had his first urology visit last week.

Historically the resident had a penile pump, but she had never seen it function.

She believed it would have been documented on the admission assessment.

The resident had told them about the implant on admission.

She didn't think the facility had a policy to care plan a resident for a penile pump only for pacemakers and pain pumps.

The clinical record for Resident 56 was reviewed on 04/22/2026 at 1:57 P.M. A Quarterly MDS assessment, dated 02/09/2026, indicated the resident was cognitively intact.

The resident's diagnoses, included but were not limited to, vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, damaging tissue) and obstructive uropathy (a structural or functional blockage of urine flow, leading to urine backflow, potential kidney swelling (hydronephrosis), and kidney damage.

The residents care plan lacked a care plan related to the penile pump.

The current facility policy, titled IDT Comprehensive Care Plan Policy, revised on 10/2025, was provided by the Administrator on 04/23/2026 at 3:41 P.M.

The policy indicated, .It is the policy of this facility that each resident will have an interdisciplinary care plan developed and implemented. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(1)

155625 04/24/2026

Arbor Grove Village 1021 E Central Ave Greensburg, IN 47240

During an interview, on 04/21/2026 at 9:37 A.M., Resident 12's family member indicated they were concerned about how the resident kept injuring her lower legs.

She had experienced bruising and skin tears on her lower legs.The resident's clinical record was reviewed on 04/23/2026 at 9:52 A.M. A Significant Change MDS assessment, dated 12/22/2025, indicated the resident was severely cognitively impaired.

The resident's diagnosis included, but was not limited to, dementia (a decline in mental ability severe enough to interfere with daily life, caused by physical changes in the brain).

The resident had no skin impairments.

The resident used a manual wheelchair and was able to propel herself short distances independently.A Progress Note, dated 02/14/2026 at 12:00 A.M., indicated the resident was found to have bruising on her left lower leg.

The bruising was noted to align with the resident's wheelchair pedal.

Staff were educated to ensure the resident's wheelchair pedals and the resident's legs were in the appropriate place.An Interdisciplinary Team (IDT) Progress Note, dated 02/16/2026, indicated the resident had bruising to her left leg.

The root cause was determined to be that the resident moved her feet off the wheelchair foot pedals at times to propel herself without moving the pedals to the side.

The new intervention was to remove the pedals from the chair.A Wound Review IDT Note, dated 03/23/2026 at 11:02 A.M., indicated the resident had a skin tear to the back of her left leg.

The root cause was determined to be related to the resident hitting her legs on her wheelchair foot pedals.

The new intervention was to remove the wheelchair foot pedals when not in use. A Wound Review IDT Note, dated 04/11/20260 at 4:12 A.M., indicated the resident had a skin tear on the back of her right leg.

The root cause was determined to be related to mechanical trauma from hitting her legs on the wheelchair foot pedals.

The new intervention was to apply support bandages/stockings to the resident's legs to protect her skin.

The resident's Care Plans that were in place on 03/23/2026 and 04/11/2026 were reviewed on 04/23/2026 at 10:04 A.M.

The Care Plans lacked indication they were updated to include the interventions to remove the resident's foot pedals from her wheelchair to help prevent injury to her legs.

During an interview, on 04/24/2026 at 10:17 A.M., the Director of Nursing indicated during that time she thought hospice had provided a smaller wheelchair for the resident and that wheelchair would have come with foot pedals.

Recently, the resident received a new, high-backed wheelchair and no longer propelled herself.

The resident's Care Plan should have been updated to indicate the foot pedals should have been removed from the wheelchair if that was an implemented intervention to prevent injuries to the resident's legs.

The current facility policy, titled IDT Comprehensive Care Plan Policy, revised on 10/2025, was provided by the Administrator on 04/23/2026 at 3:41 P.M.

The policy indicated, .It is the policy of this facility that each resident will have an interdisciplinary care plan developed and implemented.Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically. 410 IAC (Indiana Administrative Code) 16.2-3.1-35(b)(2)410 IAC (Indiana Administrative Code) 16.2-3.1-35(d)(2)(B)

155625 04/24/2026

Arbor Grove Village 1021 E Central Ave Greensburg, IN 47240

During an interview, on 04/23/2026 at 2:35 P.M., the Assistant Director of Nursing (ADON) indicated the resident admitted to the facility with a catheter.

There was a weekend when the staff called her and indicated the resident had a laceration to his penis. It was a typical keratosis (a rare, benign (non-cancerous) skin growth appearing as tan, brown, or black waxy, stuck-on papules or plaques) the resident had for awhile that had become more inflamed.

The resident would frequently adjust his urinary catheter himself.

The staff should be monitoring the resident's skin while providing urinary catheter care completed every shift.

The resident had his first urology visit last week. If the resident's hospital discharge paperwork indicated they needed to follow-up with urology, then they would call them within a week to get that scheduled.

Urology was only for chronic catheter management and when a resident was discharging home from the hospital.

During an interview, on 04/24/2026 at 3:07 P.M., the DON indicated the facility lacked a policy related to urinary catheter bags touching things.

The resident was care planned for his urinary catheter bag to hang on the trash can.

They added the intervention the day she saw the bag hanging on the trash can during the survey.

The current facility policy titled, Infection Prevention and Control Program Policy, with a revision date of 05/2023, was provided by the Regional Director Clinical Services on 04/24/2026 at 10:19 A.M.

The policy indicated, .The facility shall establish and maintain infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections.

The IPCP is a comprehensive system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under contractual arrangement, is based on the facility assessment, and following accepted national standards.

The IPCP includes Antibiotic Stewardship Program. 410 IAC (Indiana Administrative Code) 16.2-3.1-41(a)(2)

155625 04/24/2026

Arbor Grove Village 1021 E Central Ave Greensburg, IN 47240

During an interview, on 04/23/2026 at 10:42 A.M., Licensed Practical Nurse (LPN) 19 indicated Resident 4 went out for dialysis treatments on Monday, Wednesday, and Friday.

The resident received some medications multiple times throughout the day.

The resident could get his medications before he left for dialysis or when he returned, it just depended on the nurse on duty.

During an interview, on 04/24/2026 at 10:52 A.M., LPN 18 indicated for residents who left the facility for dialysis treatments, the staff managed their medications. It depended on how the medication was ordered.

They just followed the physicians' orders on the EMAR.

During an interview, on 04/24/2026 at 1:07 P.M., the Director of Nursing indicated Resident 4 had not received his Amiodarone medication on April 3 and on April 6, the resident was unavailable.

The Amiodarone was prescribed for his Atrial Fibrillation.

The nurse on duty did not give the resident his medications because he was out of the facility at dialysis.

The DON indicated the facility did not have a policy that said when residents were out of the building when they should give a resident their medications.

The current Dialysis Care policy, with a reviewed date of 11/2017, provided by the Regional Director of Clinical Services on 04/24/2026 at 10:19 A.M.

The policy indicated, .to ensure that residents requiring dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care, and the residents' goals and preferences.

The facility will assure that each resident receives care and services for the provision of hemodialysis and/or peritoneal dialysis consistent with professional standards of practice .410 IAC (Indiana Administrative Code) 16.2-3.1-37(a)

155625 04/24/2026

Arbor Grove Village 1021 E Central Ave Greensburg, IN 47240

During an observation, on 04/23/2026 at 9:00 A.M., Registered Nurse (RN) 11 provided a treatment to Resident 82.

After the treatment was complete, there was a medication cup observed on the resident's over the bed table that contained two pink tablets. RN 11 gave the medications to the resident.

During an interview, on 04/23/2026 at 11:42 A.M., RN 11 indicated the tablets she gave the resident in her room were antacids.

There was a nurse in training, Licensed Practical Nurse (LPN) 12, that had prepared the medications and took them to the resident before she went into the resident's room to complete the treatment.

She asked the nurse to wait to give her the medications until after she was done with her treatment.

Usually, the nurse who prepared the medication was the nurse that would administer the medication.

The clinical record for Resident 82 was reviewed on 04/22/2026 at 1:17 P.M.

The resident admitted to the facility on [DATE].

The resident's diagnoses included, but were not limited to, stricture of artery (thick-walled, elastic blood vessel) and peripheral vascular disease (a slow, progressive circulation disorder involving narrowing, blockage, or spasms in blood vessels).

The current facility policy titled, Medication Administration, with a revision date of 4/2025, was provided by the Administrator on 04/23/2026 at 4:16 P.M.

The policy indicated, .Observe resident taking medications.2.

The clinical record for Resident 77 was reviewed on 04/23/2026 at 9:57 A.M. A Significant Change Minimum Data Set (MDS) assessment, dated 03/15/2026, indicated the resident was severely cognitively impaired.

The resident's diagnoses included, but were not limited, Metabolic encephalopathy (a brain dysfunction caused by underlying systemic illnesses-such as liver failure, kidney failure, or diabetes-that disrupt normal metabolism, leading to altered brain chemistry) and adult failure to thrive.

The February and March 2026 Electronic Medication Administration Record indicated the resident had not received the following medications due to them being unavailable:- Megestrol Suspension 400 mg, twice a day for adult failure to thrive.

The resident did not receive the medications on 02/25/2026 from 7:00 P.M. to 11:00 P.M., 02/26/2026 from 7:00 A.M. to 11:00 A.M., and 02/26/2026 from 7:00 P.M. to 11:00 P.M., and - Sodium Chloride 1,000 mg, three times a day.

The resident did not receive the medications on 03/02/2026 at 2:00 P.M., 03/02/2026 at 8:00 P.M., and 03/03/2026 at 8:00 A.M.

The resident's clinical record lack physician notification related to the resident's medications not being available.

During an interview, on 04/24/2026 at 10:34 A.M., RN 11 indicated if a resident's medication wasn't available in the medication cart, then she would check their emergency drug kit. If it was available from there then she would get it and administer it. If the medication was not available in the emergency drug kit, then she would get it STAT (immediately or without delay). If she ordered it STAT, then it would come within two to four hours.

They would get medications delivered daily from 6:00 A.M. to 8:00 A.M. If resident's medications weren't available, then the physician should be notified.

She would document in the EMAR or the progress notes that the medication was unavailable and that the physician was notified.

The current facility policy titled, Medication Shortages/Unavailable Medications, with a revision date of 08/01/2024, was provided by the Regional Director Clinical Services on 04/24/2026.

The policy indicated, .Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy.If the medication shortage is discovered at the time of medication administration, Facility staff should immediately notify the Pharmacy.410 IAC (Indiana Administrative Code) 16.2-3.1-25(a)410 IAC (Indiana Administrative Code) 16.2-3.1-25(b)(4)

residents on the dementia unit with washing their hands, but they did have individual bathrooms in

Resident Rights, with a revision date of 08/2025, was provided by the Regional Director Clinical

right to care in an environment that promotes maintenance or enhancement of each resident's quality of life.

The resident has the right to be safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely.410 IAC (Indiana Administrative Code) 16.2-3.1-19(r)(1)410 IAC (Indiana Administrative Code) 16.2-3.1-19(r)(2)

155625 04/24/2026

Arbor Grove Village 1021 E Central Ave Greensburg, IN 47240