Signature Healthcare Of Terre Haute

F-F744.

This citation relates to Complaint IN00458972.

3XXX,d+[DATE REDACTED](a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 11 155426 Department of Health & Human Services Printed: 08/27/2025 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 155426 B. Wing 05/09/2025

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

Signature Healthcare of Terre Haute 3500 Maple Ave Terre Haute, IN 47804

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 - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38767

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure resident specific interventions were implemented for a dementia resident who was known to have behaviors upon admitting to the facility and intrusive wandering for 1 of 6 residents reviewed for dementia care (Resident J). This deficient practice resulted in harm when Resident J wandered into Resident F's room unsupervised and then exited with three circular bruises on the right lower arm and scratches with fresh blood on them. Resident F was found on the ground of her room with skin tears, and was diagnosed at the hospital with a non-displaced acute distal right clavicle fracture, and a subdural hematoma with mild midline shift.

Findings include:

A confidential interview during the survey indicated that local police responded to a nearby hospital to speak with Resident F who was being treated for injuries that occurred at the nursing home. The resident died on [DATE REDACTED]. There was concern that the deceased resident had been beaten by Resident J.

Resident J's record was reviewed on [DATE REDACTED] at 2:30 p.m. Diagnoses on Resident J's profile included, early onset Alzheimer's disease (a progressive disease that destroys memory and other mental functions), and anxiety disorder (stress that was out of proportion to the impact of the event, inability to set aside a worry, and restlessness).

On [DATE REDACTED] at 9:35 a.m., Resident J was observed in an activity/dining room on the secured memory care unit, at a table with a peer, and their seating was spaced apart. The resident was calm and looking around.

On [DATE REDACTED] at 9:35 a.m., an observation of the secured memory care unit with the Nurse Consultant was completed. Resident J's room was at the end of a hallway near the outside exit doors, four resident rooms down from the nurse's desk. Resident F's room was observed to be directly next door on the same side of

the hallway. The nurse's desk was located in the middle where the 3 separate hallways intersected on the 900 hallway. The Nurse Consultant indicated that a couch had previously been in an alcove in front of the nurse's desk on the hallway leading towards the exit into the main part of the facility, where QMA 5 who was

in charge of the 900 hallways on [DATE REDACTED] had been sitting while she charted and would not have been able to view Residents J and F's rooms at the end of the hallway.

During a continuous observation of the 900 hallways, on [DATE REDACTED] from 11:05 a.m. to 11:25 a.m., Resident J was observed walking swiftly towards the exit door upon entry of a visitor to the unit. The resident was observed to turn and follow the visitor to the nurse's desk, where she watched but did not engage the four unidentified staff members standing and sitting around the desk. At 11:17 a.m., Resident J was persuaded to enter the dining/activity room and sit at the end of a long table where peers were sitting during an activity, the resident actively watched activity around her, but maintained a flat affect and did not engage with those around her.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 11 155426 Department of Health & Human Services Printed: 08/27/2025 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 155426 B. Wing 05/09/2025

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

Signature Healthcare of Terre Haute 3500 Maple Ave Terre Haute, IN 47804

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 Review of documentation from the skilled nursing home Resident J had transferred from on [DATE REDACTED], indicated Resident J had initiated two prior resident-to-resident altercations by hitting other residents in the Level of Harm - Actual harm four months prior to admission to the current skilled nursing home. The most recent incident occurred on [DATE REDACTED]. Residents Affected - Few Physician's orders dated [DATE REDACTED], included:

a. Admit to a gated community due to Alzheimer's dementia.

b. Resident may see psychiatrist as needed.

The resident record lacked a physician's order to monitor target behaviors of wandering, cursing, yelling, until [DATE REDACTED].

A progress note, dated [DATE REDACTED] at 12:16 a.m., indicated Resident J had been admitted on the day shift of [DATE REDACTED]. On the evening shift the resident had been exit seeking and walked fast in the halls. The resident attempted to exit with someone else's family member, but staff assisted, and Resident J was returned from outside the door area to the hall. The resident came back willingly but at times when staff talked to the resident, she got verbally aggressive and called staff curse words. Resident J spit at staff and attempted to throw things at them several times. She targeted resident rooms with stop signs on them and ripped the signs down and threw them on the floor. This behavior caused an issue with another resident (Resident F). Resident J was verbally aggressive toward others, and the administration was notified of the resident to be

on 15-minute checks. Staff were educated that one staff member was to be up alternating to have eyes on Resident J to detour her from other residents' rooms and to decrease the risk of resident to resident incident.

A 48-Hour Baseline Care Plan, dated [DATE REDACTED], indicated a history of impaired daily decision making, dementia, Alzheimer's disease, short or long-term memory loss were not triggered. Interventions related to Alzheimer's or dementia were not added to the baseline care plan.

A care plan for Resident J, dated [DATE REDACTED], indicated the resident was placed in the locked unit as a least restrictive approach to protect the resident and assure her health and safety.

Approaches included encouraging the family to place familiar objects, and pictures in the resident room for cueing, encouraging the resident to participate in activities, and to provide access and visitation by family, resident representative, and/or other individuals. Staff were to be alert to psychosocial needs and conduct ongoing periodic review for the continued need for placement on the unit. The care plan lacked documentation of individualized interventions for Resident J and did not mention the history of altercations with staff or another resident.

A care plan for Resident J, dated [DATE REDACTED], indicated the resident was at risk for injury or adverse outcomes related to wandering behaviors. Approaches included encouraging the resident's representative / family to visit as needed, encourage the resident to participate in activities of interest / choice, observe the resident's wandering patterns and escort her away from other residents or other resident rooms as needed, and observe for signs of increasing fatigue and offer rest periods. The care plan lacked documentation of individualized interventions for Resident J and did not mention the history of altercations with staff or another resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 11 155426 Department of Health & Human Services Printed: 08/27/2025 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 155426 B. Wing 05/09/2025

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

Signature Healthcare of Terre Haute 3500 Maple Ave Terre Haute, IN 47804

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 The resident record lacked documentation of the care plans having been updated with behaviors to include exit seeking, physical and verbally combative behaviors, or the resident having been placed on 15-minute Level of Harm - Actual harm checks

Residents Affected - Few An admission MDS assessment, completed on [DATE REDACTED], assessed Resident J as usually having the ability to make herself understood and to usually understand others. A BIMS score ,d+[DATE REDACTED] indicated moderately impaired cognition. The resident had no signs or symptoms of delirium, behaviors, or rejection of care, but did displayed wandering behaviors daily. The resident was independent with bed mobility and required supervision with transfers and ambulation. The resident had no skin conditions to include pressure wounds, skin tears, or bruises. The MDS lacked documentation of behaviors.

An event entered into the electronic medical record (EMR) by Licensed Practical Nurse (LPN) 6, on [DATE REDACTED] at 3:40 a.m., indicated Resident J had new or worsening behaviors including wandering into other residents' rooms, not able to sleep, and hitting staff at times. LPN 6 indicated the resident wandered frequently and aimlessly, and at times when redirected she hit at staff. Psychiatric services had seen the resident. Interventions to alleviate behaviors included 15-minute checks, and a SBAR (situation, background, assessment and recommendation) had been sent to the physician requesting an order for psychiatric medication and medication to help the resident sleep.

An event entered by LPN 6 on [DATE REDACTED] at 4:19 a.m., indicated the resident had 3 circular dark purple bruises

on the right arm, each measuring 1-centimeter (cm) by (x) 1 cm x 0 cm with scratches. At the time of the bruises occurrence the resident was wandering into another resident's (Resident F's) room. A possible contributing factor was combative/resistive behavior.

A progress note, dated [DATE REDACTED] at 4:13 a.m., indicated Resident J was observed leaving Resident F's room. Resident J had new bruises, three approximate 1 cm x 1 cm circular bruises on the right lower arm, and scratches as well that had fresh blood on them. Administration was notified, and the resident was placed on 15-minute checks.

A progress note, dated [DATE REDACTED] at 2:25 p.m., indicated Resident J was sent by ambulance to an in-house Geri-psychiatric (Geri-psych) hospital for admission.

A progress note, dated [DATE REDACTED] at 5:36 p.m., indicated Resident J returned from Geri-psych for readmission to the facility.

A progress note, dated [DATE REDACTED] at 4:45 p.m., indicated Resident J was seen by a visiting psychiatric group for

a routine psychiatric follow up with no new concerns or orders.

On [DATE REDACTED] at 1:15 p.m., the Nurse Consultant indicated psychiatric services had seen Resident J in the facility on [DATE REDACTED] for an initial visit, the facility had not yet received documentation of the visit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 11 155426 Department of Health & Human Services Printed: 08/27/2025 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 155426 B. Wing 05/09/2025

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

Signature Healthcare of Terre Haute 3500 Maple Ave Terre Haute, IN 47804

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 confidential interview during the survey process indicated Resident F's family member had come through

the locked memory care unit doors for a visit, and when she would not let Resident J out, Resident J became Level of Harm - Actual harm violent with her and staff had to intervene. Resident F's family member had reported Resident J having been found in Resident F's room at least 6 different times prior to the incident on [DATE REDACTED]. On [DATE REDACTED], CNA 8 had Residents Affected - Few reported having seen Resident J walk out of Resident F's room holding her arm, with fresh scratches on her arm. When police arrived at the facility on [DATE REDACTED], QMA 5 indicated staff thought there had been a resident to resident altercation between Residents F and J, causing Resident F to fall.

During an interview on [DATE REDACTED] at 2:03 p.m. Certified Nursing Assistant (CNA) 7 indicated, on the night of [DATE REDACTED] she had been at the nurse's station and had seen Resident J walking around/pacing. Five minutes later CNA 8 had jumped up and said she had heard Resident F say ouch. As both CNAs walked into Resident F's room, Resident J walked out. Resident F was observed sitting on the floor in the doorway of the bathroom next to a footboard of a bed.

During an interview on [DATE REDACTED] at 11:26 a.m., the Nurse Consultant indicated, on [DATE REDACTED] staff had been doing rounds and Resident J was pacing, they were on opposite ends of the hallway. The CNAs had their eyes off Resident J for approximately 3 minutes while they changed another resident. The CNAs then sat down to chart at the nurse's station and heard someone say ouch. Resident J was witnessed exiting Resident F's room, who was witnessed on the floor in her room. The CNAs denied hearing any indication of

a fall.

During an interview on [DATE REDACTED] at 2:10 p.m., CNA 8 indicated, on [DATE REDACTED], she had been doing bed checks with CNA 7, when she heard Resident F say ouch. She observed Resident J exit Resident F's room frowning and holding her right arm, and Resident F was observed sitting on the floor in front of the bathroom door. Resident J was to be watched and staff were to keep eyes on her, but the CNAs had been providing care in another resident room for about 1 minute and then went to the nurse's station to chart.

During an interview on [DATE REDACTED] at 12:51 p.m. the Administrator (ADM) and Nurse Consultant indicated after Resident F left the faciity on [DATE REDACTED] an investigation was initiated, Resident J was placed on one on one (1:1), interviews were conducted with staff, and a policeman came in response to the family member's call. A facility State Reportable Incident report was sent on [DATE REDACTED] in response to the fall with injury for Resident F. Resident J had been on 1:1, and after the fall became aggressive, more than her routine pacing, and was sent to Geri-psych. Resident J had not been viewed by staff as being escalated the night of the incident, but

after being put on 1:1 her behaviors escalated. On the night shift of the incident on [DATE REDACTED], two staff CNAs had been caring for another resident at the end of the hallway, and QMA 5 was sitting at the nurse's desk. Staff thought they heard a help, saw Resident J leave Resident F's room, and staff entered the resident's room to find Resident F on the floor. The Nurse Consultant indicated staff found a smear of blood on the foot board of the roommate's bed and 2 small drops of blood on the floor at the end of the bed to indicate where Resident F had fallen, and the policeman had requested to view the crime scene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 11 155426 Department of Health & Human Services Printed: 08/27/2025 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 155426 B. Wing 05/09/2025

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

Signature Healthcare of Terre Haute 3500 Maple Ave Terre Haute, IN 47804

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 [DATE REDACTED] at 3:10 p.m., LPN 6 indicated on [DATE REDACTED] she had been working on the 700 and 800 hallways, and covering the 2 secured hallways, each of which had a Qualified Medication Aide Level of Harm - Actual harm (QMA). LPN 6 indicated she had been summoned to the 900 hallways by QMA 5 who reported a fall. LPN 6 had observed Resident F on the floor in the doorway to the hallway, sitting on her buttocks with her legs Residents Affected - Few outstretched, which was within ,d+[DATE REDACTED] feet of the bathroom. Resident F had skin tears on both lower shins, her leg looked abnormal, she had skin tears and scratches on the right forearm, there was slight penny sized bleeding on the floor, and she complained of pain in her right shoulder, so they did not move it. 911 was called and Resident F was transported to the hospital for evaluation and treatment. CNA 7 indicated, she had seen Resident J come out of Resident F's room. Resident J had been assessed and found with purple/blue bruising and fresh scratches with blood on the forearm. When asked what had happened Resident F indicated her and pointed to Resident J. The Administrator (ADM) was notified, and

she told LPN 6 to put Resident J on 15-minute checks. LPN 6 instructed the CNAs to keep an eye on Resident J and assure she was not wandering in other residents' rooms. LPN 6 indicated, in the past Resident J had been monitored related to wandering, taking down other residents' stop signs, and hitting at staff, but she thought that might have ended.

During an interview on [DATE REDACTED] at 7:48 a.m., QMA 5 indicated, on [DATE REDACTED], she had worked the night shift passing medications from 6:00 p.m. to 6:00 a.m. QMA 5 had given Resident F her evening medications on [DATE REDACTED] at 7:30 p.m. and had not seen the resident after she was helped to bed by the CNAs. QMA 5 had been sitting on a couch charting, where she did not have a view of Residents F and J's rooms. CNA 7 had come and told her someone was on the floor, and she went and found LPN 6 before going to Resident F's room. Upon entering Resident F's room, the resident was observed on the floor near the end of the roommate's bed, sitting up, facing the doorway. Resident J had been seen exiting Resident F's room. Resident J had a history of aggression, would smack, kick, etc. toward staff, and her behavior got worse at night. QMA 5 indicated staff had been made aware that Resident J could be violent to staff with care, redirection, and did not like to be told what to do. QMA 5 indicated the Director of Nursing was aware of Resident J's behaviors, but to her knowledge she was not aware of Resident J having been placed on 1:1 monitoring related to her known behaviors. Resident J was known to enter other residents' rooms and take their stuff, and she frequently wandered into all other residents' rooms on the unit. QMA 5 indicated the CNAs had been able to see all 3 of the 900 hallways from the nurse's station. CNA 8 had heard Resident F say ouch, and being as her room was approximately 100 feet from the nurse's station it had to have been at

a high volume. QMA 5 indicated she had not seen Resident J in bed asleep, but had seen the CNA's take her to her room, and they said she had been asleep. Staff did not see Resident J go into Resident F's room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 11 155426 Department of Health & Human Services Printed: 08/27/2025 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 155426 B. Wing 05/09/2025

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

Signature Healthcare of Terre Haute 3500 Maple Ave Terre Haute, IN 47804

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 [DATE REDACTED] at 8:19 a.m., CNA 7 indicated, she had worked [DATE REDACTED] from 6:00 p.m. to 6:00 a.m. and made resident rounds every 30 minutes to 1 hour. Resident J had been observed around 12:00 a. Level of Harm - Actual harm m. and 12:30 a.m., walking in the hallways. Resident J was known to wander, and did not sit or lay in bed for long. Resident J used to be a housekeeper and would wander in and out of other residents' rooms, made Residents Affected - Few other residents' beds, would take their bedding to the laundry room, and would pick up cups. CNA 7 indicated Resident J was violent towards staff, was unpredictable going from pleasant to violent, and staff were still learning her behaviors. CNA 7 indicated recently upon redirection from getting into another resident's bed, Resident J tried to backhand her. On [DATE REDACTED], she saw Resident J come out of Resident F's room. Resident J seemed calm, walked to the nurse's station and sat down, and showed the CNA that she had scratches on her left arm. Resident J denied knowing what had happened to Resident F. CNA 7 indicated, her bosses knew Resident J was being violent towards staff, and staff had been told that if an incident was resident to staff, the staff were on their own. CNA 7 indicated she had reported the backhand incident to the DON a few days before [DATE REDACTED], and was told the facility would send the resident for psychiatric help. Staff initially thought Resident J might have been involved in Resident F's fall because she could be mean but later thought due to Resident J's calm demeanor at the time, she was most likely not involved. CNA 7 indicated she had not known Resident J had been put onto 15-minute checks prior to [DATE REDACTED]. If a resident was on 15-minute checks, staff would document seeing the resident every 15 minutes.

Increased Monitoring - 15 minute check reports for Resident J, dated [DATE REDACTED] - [DATE REDACTED], were unavailable at

the time of the survey exit. Handwritten copies of the reports were received via e-mail from the Nurse Consultant on [DATE REDACTED] at 12:10 a.m.

During the exit conference on [DATE REDACTED] at 4:43 p.m., the Nurse Consultant indicated it was the right of all residents on the memory care unit to wander where they wanted, any time they wanted, and that included allowing Resident J to wander into other residents' rooms during the night on the unit. That was the purpose of a secured memory care wing.

A behavior management policy was requested but not provided during the survey process.

This citation relates to Complaint IN00458972.

3XXX,d+[DATE REDACTED](a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 11 155426