Harbour Manor Health & Living Community

F-F600.

This citation relates to Complaint IN00448256.

3.1-28(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 155381 Department of Health & Human Services Printed: 09/11/2025 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 155381 B. Wing 01/02/2025

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

Harbour Manor Health & Living Community 1667 Sheridan Rd Noblesville, IN 46060

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm 32663

Residents Affected - Few Based on interview and record review, the facility failed to follow a care plan intervention of providing care with staff pairs to protect the resident from anxiety related to allegations of inappropriate care for 1 of 3 residents reviewed for abuse. (Resident C)

Findings include:

During an interview on 1/2/25 at 9:35 a.m., Resident C indicated, on 12/26/24 during the night shift, CNA 3 touched him inappropriately during incontinence care. The resident reported the incident to other facility staff.

Resident C's clinical record was reviewed on 1/2/25 at 9:39 a.m. Diagnoses included multiple sclerosis, pain, abdominal aortic aneurysm-without rupture, type 2 diabetes mellitus with diabetic polyneuropathy and hyperosmolarity, depressive disorder, and dysphagia following cerebral infarction.

Review of the most current quarterly Minimum Data Set (MDS) assessment, dated 11/5/24, indicated the resident was cognitively intact.

A current CNA Assignment Sheet, care plan dated 4/28/23, indicated an intervention for care in pairs, initiated 11/7/23 due to resident behaviors as evidenced by making false accusations against staff members.

During an interview on 1/2/25 at 10:52 a.m., CNA 4 indicated staff provided care to Resident C in pairs due to his behaviors.

During an interview on 1/2/25 at 11:02 a.m., CNA 5 indicated Resident C required two staff members when care was provided. This intervention was listed on the CNA Assignment Sheet.

During an interview on 1/2/25 at 2:26 p.m., the DON indicated Resident C came to her to report being physically assaulted by CNA 3. The facility initiated an investigation and sent the resident to the hospital for evaluation. The DON indicated CNA 3 had provided care alone while another CNA was in the hallway. The DON indicated CNA 3 did not follow the intervention to provide care in pairs.

Review of a written statement, dated 12/27/24, CNA 3 indicated they did provide care to Resident C on 12/26/24. CNA 3 did not indicate if there had been another staff member present while care had been provided.

CNA 3 was not available for interview during the survey on January 2, 2025.

This citation relates to Complaint IN00449955 and IN00450213.

3.1-35(b)(1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 155381