Waters Of Muncie, The

F-F602.

This citation relates to complaint IN00455668.

3.1-28(c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 42685 potential for actual harm Based on observation, interview, and record review, the facility failed to provide oxygen and humidity as Residents Affected - Few ordered for 1 of 1 resident reviewed for oxygen. (Resident F)

Finding includes:

During an observation on 3/25/25 at 11:27 a.m., Resident F was in her bed asleep with oxygen on via nasal cannula at 5 liters per minute (lpm). The humidity bottle attached to the oxygen concentrator was empty and dated 3/21/25.

During an observation on 3/25/25 at 3:10 p.m., the resident was seated in a wheelchair with her oxygen on via nasal cannula and attached to an oxygen concentrator. The oxygen was on at 5 lpm and the humidification bottle was empty.

During an observation on 3/26/25 at 11:18 a.m., the resident was in bed asleep with the oxygen on at 5 lpm via nasal cannula. The humidification bottle was empty and dated 3/21/25.

Resident F's clinical record was reviewed on 3/26/25 at 3:56 p.m. Diagnoses included chronic obstructive pulmonary disease, solitary pulmonary nodule, and weakness.

A current physician order, dated 7/22/24, included oxygen at three liters per minute via nasal cannula.

A current physician order, dated 7/22/24, included a humidification bottle change once weekly and as needed for humidity.

A quarterly Minimum Data Set (MDS) assessment, dated 3/1/25, indicated the resident had moderate cognitive impairment. The resident had a chronic condition that may result in a life expectancy of less than six months. Special services included oxygen therapy.

A current care plan, dated 8/11/24, indicated the resident was at risk for respiratory distress related to a left lung pulmonary nodule/lung cancer. Interventions included monitoring respiratory status frequently (8/11/24) and oxygen as ordered per the physician (9/11/24).

During an interview on 3/26/25 at 4:56 p.m., LPN 7 indicated the resident's oxygen was on via nasal cannula at 5 lpm. The humidity canister was empty. She indicated the resident typically required 2-3 lpm. LPN 7 had not been informed of any changes nor had hospice left any notes.

During an interview on 3/26/25 at 5:00 p.m., LPN 7 indicated the resident's hospice binder did not have any notes regarding a change in the orders for oxygen. The resident's oxygen was ordered at 3 lpm. The physician orders should have been followed and the humidity should not have been empty.

During an interview on 3/28/25 at 11:46 a.m., the CNA 5 indicated the resident was very cooperative with care. She had never known the resident to change her own oxygen settings, as her vision was impaired. She required staff assistance with her oxygen needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During an interview on 3/28/25 at 1:10 p.m., the DON indicated she had contacted hospice on 3/26/25 and confirmed no changes had been made to the resident's oxygen orders. The resident's oxygen flow rate and Level of Harm - Minimal harm or humidity should have been provided for the resident as it was ordered. potential for actual harm

A current facility policy, undated, titled OXYGEN ADMINISTRATION, provided by the DON on 3/28/25 at Residents Affected - Few 1:17 p.m., indicated the following: Policy . It is the policy of this facility to provide oxygen to maintain levels of saturation to residents as needed and as ordered by the attending physician . 1. Check orders for accurate oxygen liter flow . 4. Tubing, humidifier bottles and filters will be changed, cleaned, and maintained no less than weekly and PRN [as needed]

3.1-47(a)(6)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed Level of Harm - Minimal harm or consent; and (4) Correctly install and maintain the bed rail. potential for actual harm 48146 Residents Affected - Few Based on record review and interview, the facility failed to accurately complete assessments to prevent a cognitively impaired resident from entrapment between a mattress and a side rail/grab bar. (Resident B)

Finding includes:

Resident B's record was reviewed on 03/31/25 at 12:52 p.m. Diagnosis included unspecified dementia in other diseases classified elsewhere, delusional disorders, muscle wasting and atrophy, and other frontotemporal neurocognitive disorder.

An admission mobility assessment, dated 1/22/25, indicated Resident B did not require side rails/enablers.

A side rails assessment, dated 1/22/25, indicated Resident B did not require side rails.

A physician's order, dated 1/24/24, indicated an enabler bar to help patient transfer, reposition, and turn.

A bed mobility care plan, initiated 1/24/25, indicated Resident B utilized enabler bars for bed mobility. Interventions included the following: enabler on bed per resident request, resident quality of life to be maintained and side rails/enabler assessment quarterly and as needed (PRN).

A quarterly Minimum Data Set (MDS) assessment, dated 2/13/25, indicated Resident B was severely impaired and required supervision from staff for transfer, bed mobility, and walking. Resident B did not utilize any mobility devices.

A nursing progress note, dated 3/11/25 at 9:15 a.m., indicated Resident B was found on their knees beside

the bed with their head between the mattress and the side rail. The side rail was in the up position. Staff assisted Resident B from the floor back into the bed. Resident B was assessed for injuries and pain. The left side of Resident B's face had some redness. Resident B voiced no pain. The side rail was lowered. The resident family and doctor were notified.

A physician's order, dated 3/11/25, indicated to discontinue enabler bars.

An Interdisciplinary team (IDT) note, dated 3/12/25 at 3:48 p.m., indicated Resident B was found on the floor beside the bed on their knees. The resident's head was noted to be between the mattress and the enabler bar. The resident was immediately assessed by licensed nurse who noted redness to the left side of his face which quickly dissipated. The root cause of the fall was the resident attempted to self-transfer from bed. The immediate intervention was to remove the enabler bars from bed. The care plan to be reviewed and updated.

A side rails assessment, dated 3/14/25, indicated Resident B did not require side rails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 During an interview, on 3/31/25 at 1:46 p.m., LPN 6 indicated a resident would need to be assessed by physical therapy for enabler bars and nursing would get a physician's order before the bars were put into Level of Harm - Minimal harm or place. If a resident had a fall and was found to have their head stuck between the mattress and the enabler potential for actual harm bars, there would be a full assessment completed, and the enabler bars would likely be removed.

Residents Affected - Few During an interview, on 3/31/25 at 1:51 p.m., the DON indicated a resident would be assessed for mobility issues prior to enabler bars being utilized. If a resident was found caught between the mattress and the enabler bars, the staff would immediately assess the resident for injury and completed any assessments necessary. The resident's family and physician would be notified. The IDT would discuss the incident, review care plans, and orders.

An undated, current facility policy, titled, Side Rails/Enabler Bars, provided by the DON on 3/31/25 at 3:45 p. m., indicated the following: It is the intent of the facility to provide the licensed medical staff with a process for

the evaluation, documentation needs and necessary interventions relating to side rails/enabler bars evaluation and utilization Enabler bars attach to the bed, so they are to be considered side rails . 1. The IDT will discuss the predisposing factors that resulted in the conclusion that a side rail(s) or enabler bar(s) evaluation and utilization may be needed. 2. The side rail/enabler bar screen will be completed . 3. If upon completion of the evaluation, the IDT reaches the conclusion that a side rail(s) or enabler bar(s) is needed,

the least restrictive side rail(s) or enabler bar(s) that is appropriate for the resident's specific situation will be implemented . If it is determined that an enabler is to be used strictly for enabling more independence in bed mobility and not as a restraint this will be indicated on the assessment screen as well as the care plan . 4.

The medical symptoms and related diagnosis that supports the use of the side rail(s) or enabler bar(s) will be documented on the side rails/enabler bar evaluation screen . 10. Residents who have side rail(s) or enabler bar(s) will be re-evaluated at least quarterly or in the event of a change of condition .

3.1-45(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or 48146 potential for actual harm Based on observation, interview, and record review, the facility failed to post complete nurse staffing Residents Affected - Few information daily for residents and visitors. This deficiency had the potential to affect 46 of 46 residents in the facility.

Finding includes:

During an observation, on 3/25/25 at 9:30 a.m., the Daily Report of Nursing Staff was posted on the wall by

the receptionist desk. The posting was dated 3/21/25.

During an observation on 3/26/25 at 9:37 a.m., the Daily Report of Nursing Staff remained unchanged, showing 3/25/24.

During an observation on 3/26/25 at 2:37 p.m., the Daily Report of Nursing Staff remained unchanged, showing 3/25/24.

During an observation on 3/27/25 at 9:48 a.m., the Daily Report of Nursing Staff was posted on the wall by

the receptionist desk. The posting was dated 3/26/25.

During an observation on 3/27/25 at 1:42 p.m., the Daily Report of Nursing Staff remained unchanged showing 3/26/25.

During an observation on 3/27/25 at 3:41 p.m., the Daily Report of Nursing Staff remained unchanged showing 3/26/25.

During an observation on 3/28/25 at 9:21 a.m., the Daily Report of Nursing Staff remained unchanged showing 3/26/25.

During an interview, on 3/31/25 at 9:00 a.m., the Administrator indicated the scheduler was responsible for updating the staff posting. This posting was supposed to be completed every morning.

During an interview, on 3/31/25 at 11:48 a.m., QMA 8 indicated he was responsible for ensuring the staffing posted was updated daily at the beginning of each day. However, he was often needed to cover shifts and would work as a QMA providing resident care and updated the staff posting as quickly as possible.

A current facility policy, dated 4/24/23, titled Guidelines for BIPA Staffing Posting Requirement, provided by

the Administrator on 3/31/25 at 9:00 a.m., indicated the following: . 1.) SNF's and NF's must post daily, at the beginning of each shift, the facility specific shift schedule for the 24 hour period, the number and category of nursing staff employed or contracted by the facility for each 24 hour period, as well as the total number of hours worked by licensed and unlicensed nursing staff who are directly responsible for resident care

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Level of Harm - Minimal harm or 48146 potential for actual harm Based on record review and interview, the facility failed to provide individualized interventions to prevent Residents Affected - Few resident to resident physical altercations for cogntively impaired residents with dementia for 1 of 4 residents reviewed for physical altercations. (Resident B)

Finding includes:

Review of an Indiana State Department of Health facility reported incident, dated 1/22/25 at 8:30 p.m., indicated the facility initiated an investigation of a resident to resident altercation. The incident was identified

on 1/22/25 at 8:30 p.m. The brief description indicated Resident B had entered another residents room and refused to leave. The other resident made contact with his hand to Resident B's chest. The nurse removed Resident B from the room. The immediate actions taken were separation of the residents and Resident B was given a one to one staff supervision. Resident B was assessed for injury and/or pain. The police were notified. A follow-up on 1/31/25 indicated the investigation was complete without any findings. No further behaviors noted and care plans updated as needed.

Resident B's clinical record was reviewed on 3/27/25 at 3:45 p.m. Diagnosis included dementia in other diseases classified elsewhere with moderate behavioral disturbances, mood disorder due to know physiological condition with mixed features, delusional disorder, and unspecified dementia with agitation.

A current care plan, initiated on 1/23/25, indicated the resident had been noted to have altercations with other residents. Interventions included the following: establish if resident has any needs (1/23/25), provide resident with one on one as needed (1/23/25), redirect resident as needed (1/23/25), and remove resident from areas of other residents immediately (1/23/25).

A current care plan, initiated on 1/27/25, indicated the resident had been noted to wander and will go in and out of other resident rooms due to confusion related to dementia and requires a secure unit. Interventions included the following: assessments as necessary (1/27/25), one on one as needed (1/27/25), and redirect resident as needed (1/27/25).

A 1/22/25 nursing progress note indicated Resident B wandered into another residents room and was hit in

the chest. The incident was unwitnessed. Resident B was taken back to his room and a small red area was noted to his chest. The resident's family and physician was notified. The police were notified.

A 1/23/25 nursing progress note indicated Resident B had one to one staff supervision. The resident had not rested on this shift, was exit seeking, and difficult to re-direct. The resident wandered into other resident rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 A 1/23/25 social service note indicated Resident B was given one to one staff supervision after an incident

the previous day. Staff continued to walk with the resident and tried to redirect. The interventions lasted for a Level of Harm - Minimal harm or short time and the resident was on the move again. The resident was moved to a new room, since the potential for actual harm previous room shared a bathroom with another resident. The resident was confused upon seeing another person from the bathroom and believed someone was in his home. Residents Affected - Few

A 1/24/25 behavior charting note indicated Resident B was ambulating in the lounge and became agitated with a Certified Nursing Assistant (CNA) when redirection to the bathroom was attempted. Resident B drew back his fist as if to strike the CNA. Resident B urinated on the lounge floor.

A 1/26/25 nursing progress note indicated the resident continued with one to one staff supervision. The resident was ambulating in the hallways and attempting to enter other residents rooms. Staff continued to redirect and offer snacks and beverages.

A 1/27/25 social service note indicated the Interdepartmental team (IDT) met and discussed the one on one staff supervision for Resident B. The resident was easily redirected and had no further incidents with other residents. The one to one staff supervision was discontinued at this time.

A 1/29/25 behavior charting note indicated Resident B was participating in an activity and became angry; he started hitting staff. The resident was pushing chairs and the treatment cart around. Redirection was ineffective. Staff reached out to family for assistance.

A 1/29/25 nursing progress note indicated the resident picked up a chair and was carrying it towards the exit doors. Staff was able to redirect and remove the chair from the resident. Resident became tearful. The physician was notified and staff was given a new order. The physician indicated the resident might require an outside provider for a psychiatric evaluation and treatment.

A 1/30/25 behavior charting note indicated the resident was angry and agitated. He was ambulating in the hallways, pushing the treatment cart, and removing items from the medication cart. Staff attempts at redirection were ineffective.

A 1/31/25 daily skilled nursing note indicated the resident was awake and walked nude to the nurse station. Staff needed multiple attempts to get the resident dressed. He remained at the nurse station for roughly 20 minutes attempting to open the door. He was seen ambulating the hallways.

A 1/31/25 nurses note indicated Resident B attempted to urinate on the hallway wall. He became combative when staff make attempts to redirect. Staff was able to direct Resident B to the bathroom, but he returned to

the hallway and urinated in the hall.

A 1/31/25 nurses note indicated the resident attempted to pull down his own pants. Staff attempts to redirect were difficult. The resident hung onto the side rail in the hallway to resist being redirected to the bathroom.

The resident allowed staff to assist him into a wheelchair.

A 2/1/25 behavior charting note indicated Resident B was wandering the halls and into other residents' rooms. The resident was agitated with staff and redirection attempts were ineffective. The resident pushed a staff member out of the way in an attempt to enter a room on the female hallway. Resident B was witnessed mocking another resident and sticking his tongue out toward that resident while in the common areas. Resident was resistant to care and was grabbing or striking out at staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 A 2/2/25 behavior charting note indicated Resident B was wandering in and out of his room pulling his pants and brief down. The resident become agitated and resistive to redirections and interventions were ineffective. Level of Harm - Minimal harm or potential for actual harm A 2/3/25 behavior charting note indicated the resident was ambulating the hallway and began to disrobe in

the dining room. Resident became agitated and struck out at staff when redirection was attempted. The staff Residents Affected - Few attempts at redirection were ineffective.

A 2/4/25 nursing progress note indicated Resident B entered into another resident's room. Resident B was struck across the left cheek. Staff immediately separated the residents. Resident B was placed on one to one staff supervision. The resident was sent to the emergency room for evaluation and treatment.

Review of an Indiana State Department of Health facility reported incident, dated 2/4/25 at 7:44 p.m., indicated the facility initiated an investigation of a resident to resident altercation. The incident was identified

on 2/4/25 at 7:44 p.m. The brief description indicated Resident B had entered another residents room uninvited. The other resident made contact with his hand to Resident B's left cheek. The nurse removed Resident B from the room. The immediate actions taken were separation of the residents and Resident B was given one to one staff supervision. The family and physician were notified. The physician ordered Resident B sent to the emergency room for evaluation. The care plan was reviewed and updated as deemed appropriate. The police were notified. A follow-up was not provided.

A current physician order, dated 1/22/25, indicated to take one risperidone (an anti-psychotic medication) 1 milligram (mg) tablet by mouth 3 times a day with a .50 mg tablet to equal 1.5 mg total.

A current physicians order, dated 1/22/25 indicated to take one risperidone (an anti-psychotic medication) 0. 5 mg tablet by mouth 3 times a day with a 1 mg tablet to equal 1.5 mg total.

A current physicians order, dated 2/24/25, indicated to take one Wellbutrin XL (an anti-depressant medication) extended release 150 mg tablet by mouth in the morning for depression.

A current physicians order, dated 3/5/25, indicated to take two amitriptyline HCI (an anti-depressant medication) 25 mg tablet by mouth in the evening for mood disorders.

A quarterly Minimum Data Set (MDS) assessment, dated 2/13/25, indicated Resident B was not cognitively intact, had difficulty focusing, and had disorganized or incoherent thoughts. He displayed physical and verbal behaviors towards others and wandering. He required supervision from staff for transfer, bed mobility, and walking.

During an interview, on 3/31/25 at 12:02 p.m., SSD 11 indicated Resident B was wandering on the locked unit and was difficult to re-direct. He was to meet with the psychiatric provider tomorrow. The SSD was part of the IDT meeting where it was decided to discontinue Resident B's one to one staff supervision. The documentation indicated he had not had any other resident to resident incidents. This resident was new to

the facility at the time of the first incident and he went through a difficult adjustment period. The staff had taken all the appropriate actions to prevent another resident to resident altercation. She indicated one on one staff supervision was not a long term option for the facility

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744 During an interview, on 3/31/25 at 1:02 p.m., the ADON indicated she was part of the IDT meeting on 1/27/25. The resident was new to the facility when the first incident happened. The one on one staff Level of Harm - Minimal harm or supervision was removed when he had no further behaviors. The ADON indicated if the resident had potential for actual harm remained on one to one staff supervision while adjusting to the facility, the second incident could have been avoided. Residents Affected - Few

During an interview, on 3/31/25 at 1:08 p.m. CNA 13 indicated Resident B wandered the hallways and stood outside other residents' rooms, looking inside. The resident had slapped at staff and some redirection did not work. The facility staff utilized the resident's family and hospice staff for assistance with his continued behaviors.

During an interview, on 3/31/25 at 1:16 p.m., LPN 6 indicated Resident B continued to wander the hallways, but he wasn't going into other residents rooms as much. The facility staff attempted to redirect the resident but he could get agitated. They utilized his family and hospice staff for assistance with his behaviors.

A current facility policy, dated 10/22/22, titled, Abuse Prevention Program, provided by the Administrator on 3/25/25 at time of entrance, indicated the following: It is the policy of this facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property .The facility will take steps to prevent mistreatment while the investigation is underway .Prevention: . As part of the social history assessment and MDS assessments, staff will identify resident with increased vulnerability for abuse, neglect, mistreatment or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches which would reduce the chances of mistreatment for these residents. Staff will continue to monitor the goals and approaches on a regular basis .

3.1-37(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 42685

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure the shift-to-shift narcotic count sheets were completed and signed for 2 of 3 medication carts reviewed. (300 Unit and 400 Unit medication carts). This deficiency had the potential to affect 11 of 46 residents who received controlled medications from the 200 Unit and 300 Unit medication carts.

Findings include:

1. During a medication storage observation with the ADON on 3/28/25 at 12:43 p.m., the 400 Unit medication cart shift-to-shift narcotic count log lacked signatures or a count from the in-coming nurse and off-going staff members during shift change at the beginning of day shift on 3/28/25. It also lacked a shift-to-shift narcotic count or signature from the in-coming and off-going staff members when the cart was exchanged around approximately 12:30 p.m. on 3/28/25.

During an interview on 3/28/25 at 12:43 p.m. the ADON indicated the 400 Unit medication cart shift-to shift narcotic log had not been completed by QMA 8 on 3/28/25 at the beginning of the day shift. The ADON had recently taken over the 400 Unit medication cart from QMA 8 to administer the insulin and they had not completed the shift-to shift narcotic count. The shift-to shift narcotic count should have been completed with each exchange of the medication cart. This was an opportunity for misappropriation of medications.

During an interview on 3/28/25 at 12:47 p.m., QMA 8 indicated he had not signed the shift-to-shift narcotic count when he took over the 400 Unit Medication cart at 6:00 a.m. on 3/28/24. The medication reconciliation should have been completed with each exchange of the medication cart.

Review of the 400 Unit Shift-to-Shift Narcotic Count Sheets from 3/1/25 to 3/28/25 lacked the following information:

a. 3/4/25: 7:00 p.m. - 11:00 p.m. - Count completion

b. 3/5/25: 7:00 a.m. - 11:00 p.m. - Count completion

c. 3/5/25: 11:00 p.m. - 7:00 a.m. - Count completion

d. 3/6/25: 3:00 p.m. - 11:00 p.m. - Count completion

e. 3/6/25: 11:00 p.m. - 7:00 a.m. - In-coming signature

f. 3/6/25: 7:00 a.m. - 5:00 p.m. - Count completion and off-going signature

g. 3/6/25: 5:00 p.m. - 11:00 p.m. - Count completion

h. 3/8/25: 3:00 p.m. - 7:00 p.m. - Count completion

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 i. 3/9/25: 7:00 p.m. - 7:00 a.m. - Count discrepancy (scored through without explanation)

Level of Harm - Minimal harm or j. 3/15/25: 7:00 p.m. - 7:00 a.m. - Count discrepancy (scored through without explanation and illegible) potential for actual harm k. 3/20/25: 11:00 p.m. - 7:00 a.m. - Count completion and discrepancy Residents Affected - Some l. 3/27/25: 11:00 p.m. - 7:00 a.m. - In-coming signature

m. 3/28/25: 7:00 a.m. - 12:30 p.m.- Count completion, in-coming signature, and off-going signature

2. During an interview on 3/28/24 at 12:44 p.m., QMA 8 indicated the 300 Unit medication cart shift-to-shift narcotic count log had not been completed for his shift. The form for 3/27/25 from 11:00 p.m. - 7:00 a.m. lacked the in-coming nurse signature. Prior to providing a copy, he signed the form and filled in the blanks for his shift dated 3/28/25 from 7:00 a.m. to 3:00 p.m. The form should have been completed at the beginning of his shift.

Review of the 300 Unit Shift-to-Shift Narcotic Count Sheets from 3/1/25 to 3/28/25 lacked the following information:

a. 3/1/25: No shift marked

b. 3/3/25: 7:00 a.m. - 7:00 p.m. - Count completion and in-coming signature

c. 3/4/25: 7:00 a.m. - 10:00 a.m. shift- Count completion

d. 3/4/2: 10:00 a.m. - Count completion and in-coming signature

e. 3/8/25: 7:00 a.m. - 7:00 p.m. - Count completion

f. 3/8/25: 11:00 p.m. - 7:00 a.m. - Count discrepancy (marked error without explanation)

g. 3/13/25: 3:00 p.m. - 7:00 p.m. - Count discrepancy (scored through without explanation)

h. 3/14/25: 3:00 p.m. - 11:00 p.m. - Count completion, in-coming signature, and off-going signature

i. 3/15/25: 7:00 a.m. - 11:00 p.m. - Count completion

j. 3/15/25: 11:00 p.m. - 7:00 a.m. - Count discrepancy (scored through without explanation)

k. 3/18/25: 7:00 a.m. - 3:00 p.m. - Count completion

l. 3/18/25: 3:00 p.m. - 7:00 a.m. - Count completion

m. 3/23/25: 7:00 a.m. - 11:00 p.m. - Count completion

n. 3/26/25: 7:00 a.m. - 7:00 p.m. - Count completion

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 o. 3/28/25: 7:00 a.m. - 3:00 p.m. - Count completion, in-coming signature, and off- going signature

Level of Harm - Minimal harm or During an interview on 3/28/25 at 12:56 p.m., the DON indicated she was aware the facility was deficient for potential for actual harm shift-to-shift narcotic counts because she identified the problem in March 2025 when she audited for misappropriation of medications. Staff had been in-serviced regarding shift-to-shift narcotic counts. She had Residents Affected - Some not yet completed her audit on 3/28/25.

A current facility policy, dated 7/22/23, titled GUIDELINES for Controlled Substance Medications - an Overview, provided by the DON on 3/31/25 at 12:39 p.m., indicated the following: .Shift-to Shift Controlled Substance/Medication Counting: At each shift change, a physical inventory of controlled substances/medications as well as any other medications selected by the facility to closely track will be conducted by 2 licensed nurses. This will be documented on the Shift Change Accountability Record For Controlled Substances Form. This will include a count cards/bottles & corresponding sheets to be documented on the Narcotic Counts Sheets - shift to shift. Additionally, whenever there is an exchange of keys, there will be a count completed

This citation relates to Complaint IN00455668.

3.1-25(e)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 48146 potential for actual harm Based on record review and interview, the facility failed to develop and implement approaches to maintain a Residents Affected - Some Quality Assurance and Performance Improvement (QAPI) program to prevent repeat deficiencies.

Finding includes:

Review of the Summary Statement of Deficiencies, for the facility's last annual Recertification and State Licensure Survey completed on 5/17/24, indicated the facility failed to ensure controlled medication counts were completed and acknowledgements signed to account for controlled medications. The plan of correction indicated, During the monthly QAPI meeting, monitoring will be reviewed, and any concerns will have been corrected as found. Any patterns will be identified. If necessary, an Action Plan will be written by the committee. Any written Action Plan will be monitored by the Administrator weekly until resolution.

During an interview, on 3/31/25 at 3:53 p.m., the Social Services Director indicated the QAA committee meets monthly to review facility concerns. The committee utilized an online program to assist with streamlining the process, assessing trends, and documentation of these meetings.

During a follow- up interview, on 3/31/25 at 4:00 p.m. the Regional Director of Operations indicated if the facility was found to have a concern that was previously cited, they would ensure the previous plan of correction had been completed. A previous plan of correction would be completed within six months and then discontinued. If issues remained, the problem would be put into the QAPI program, and a Performance Improvement Plan (PIP) would be developed. The current shift to shift narcotic count concern was found just days before the March QAPI meeting. The concern was discussed in the QAPI meeting on 3/18/25, but a PIP was not put into place immediately at the meeting. The facility's annual survey started on 3/25/25 and

the QAA committee was unable to get one in place.

Repeat concerns regarding lack of shift-to-shift narcotic counts and signatures were cited during the March 31, 2025, survey as follows: Based on observation, interview, and record review, the facility failed to ensure

the Shift-to-Shift Narcotic Count Sheets were completed and signed for 2 of 3 medication carts reviewed. (300 Unit and 400 Unit medication carts). This deficiency had the potential to affect 11 of 46 residents who received controlled medications from the 200 Unit and 300 Unit medication carts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 24 155443 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 155443 B. Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Waters of Muncie, The 2400 Chateau Dr Muncie, IN 47303

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0865 A current facility policy, revised 3/9/22, titled, Quality Assurance/Performance Improvement Program(QAPI), provided by the Administrator at entrance, indicated the following: . It is the intent of this facility to conduct an Level of Harm - Minimal harm or on-going Quality Assurance/Performance Improvement (QAPI) program designed to systematically monitor, potential for actual harm evaluate, and improve the quality and appropriateness of resident care . 6. The facility will identify areas for QAPI monitoring and tools/resources to be utilized. These monitoring activities should focus on those Residents Affected - Some processes that significantly affect resident outcomes. 7. The QAPI committee will review, and coordinate audits and assessments based on the QAPI process. Completion of additional audits and assessments will be determined by concerns identified through the QAPI committee. Criteria for selecting additional aspects of care for performance improvement are based on the following: . d. Problem areas- the aspect of care has tended in the past to produce problems for staff or residents .12. Based on audit findings, plan will be developed, and tasks assigned to appropriate employees to include required completion dates.

Cross reference

F-F755.

3.1-52(b)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 24 155443