Hillside Manor Nursing Home

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

over closer to the wall outside, resident showing exit-seeking behaviors at this time. Staff was monitoring

the resident closely. 8/30/25 at 6:45 P.M. - The nurse was alerted by another resident that Resident C had climbed the gazebo in the outside courtyard, jumped over the wall, and run towards the East. At the time of

the incident, the nurse was in another resident's room helping the Emergency Medical Service (EMS) transfer another resident. Police were dispatched to locate resident C. A police report, dated 8/30/25, indicated an initial call was received at 6:59 P.M. that Resident C had run away from the facility. At 7:14 P.M., Resident C was seen by a vape store near Highway 57. At 7:25 P.M., Resident C was located by law enforcement behind an air conditioning unit at the vape store. The police report included, I located the male subject hiding behind an AC unit. He was behind the vape store between buildings. The male subject ran, and I gave chase. He was apprehended prior to running into traffic on National (Highway).During an

observation on 9/3/25 at 11:30 A.M., two unlocked double doors near a common area and nurses' station led to a walled-off courtyard. A gazebo inside the courtyard was observed being approximately two feet away from a concrete wall. The outside concrete wall was approximately 66 inches tall. During an interview

on 9/3/25 at 11:45 A.M., QMA 5 indicated that Resident C had climbed the gazebo and jumped the courtyard wall on 7/23/25 when EMTs arrived at the facility to transport him to a hospital. The resident did

the same on 8/30/25 when the EMS arrived for another resident. QMA 5 indicated the resident was frightened by the EMTs. During an interview on 9/3/25 at 11:50 A.M., the Director of Nursing (DON) indicated Resident C had jumped the courtyard wall on 8/30/25 and left the facility property. Resident C had also jumped the courtyard wall on 7/23/25 after being frightened by the EMTS when they arrived at the facility for transport. On 8/30/25, Resident C was away from the facility for approximately one hour. Local law enforcement returned the resident to the facility. Resident C had also left the facility by himself to walk to a fast-food restaurant in June 2025; however, staff were aware of the resident's whereabouts and felt the resident was capable of walking to the restaurant by himself at that time. The resident was at risk for elopement after an isolated incident when the resident attempted to leave the facility property in April 2024.

During an interview on 9/4/25 at 12:55 P.M., the DON indicated if a resident at risk for elopement began to show increased exit-seeking behaviors or attempted elopement, their care plan should be updated with new interventions to prevent elopement. During an interview on 9/5/25 at 10:45 A.M., the DON indicated an at-risk for elopement assessment should be completed quarterly and any time a resident exhibits an increase in exit-seeking behavior. On 9/4/25 at 11:45 A.M., the DON supplied a facility policy titled, Wandering and Elopements, dated 03/2019. The policy included, If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. Immediate Jeopardy was removed on 9/5/2025 at 11:20 A.M. The deficient practice remained at isolated, no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. The facility implemented a systemic plan that included the following actions: the facility completed audits of clinical records for all residents for all residents at risk for exit-seeking behavior or elopement. Removed the Gazebo from the courtyard, removed a tree in the courtyard, and secured patio furniture. All exit doors were equipped with Wander-guard key pad. In-service training was provided to all staff on the elopement exit seeking policy and on-going daily monitoring of changes in residents' behavior.

This citation relates to intakes 2604869 and 2606469. 3.1-45(a)(2)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hillside Manor Nursing Home

1109 E National Highway Washington, IN 47501

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on interview and record review, the facility failed to ensure adequate pharmaceutical services were available to provide physician prescribed routine medications to 1 of 3 residents reviewed for pharmacy services. Following a change in a resident's routine medications, the facility failed to obtain an ordered routine medication which resulted in multiple missed doses of the medication. (Resident C) Finding includes:During record review on 9/3/25 at 11:00 A.M., Resident C's diagnoses included, but were not limited to, anxiety, depression, unspecified psychosis, schizophrenia, and pedophilia. Resident C's most recent annual MDS (Minimum Data Set) assessment, dated 6/20/25, indicated the resident was rarely to never understood. The resident had moderately impaired cognitive skills related to daily function. The resident received antipsychotic medication routinely. Resident B's physician orders included, but were not limited to, Geodon oral capsule 40 milligrams (MG), give 40 mg by mouth two times a day related to schizophrenia and anxiety (continued 8/13/25). Resident B's Medication Administration Record (MAR) for August 2025 indicated the resident did not receive the prescribed medications Geodon oral capsule 40 MG

on 8/22/25 (two doses), 8/26/25 (two doses), 8/27/25 (afternoon dose), 8/28/25 (two doses), and 8/29/25 (afternoon dose).Resident B's nurse's progress notes included but were not limited to:8/22/25 at 9:36 A.M. Medication unavailable.8/22/25 at 12:50 A.M. - Medication unavailable.8/26/25 at 9:26 A.M. - (Medication) not in stock. 8/26/25 at 1:26 P.M. - (Medication) not in stock.8/27/25 at 2:16 P.M. - (Medication) not available.8/28/25 at 9:07 A.M. - (Medication) not available. 8/28/25 at 12:11 P.M. - (Medication) not available. 8/29/25 at 12:55 P.M. - Medication not available. During an interview on 9/8/25 at 10:05 A.M., LPN 8 indicated that the facility had trouble receiving routine medications from a particular pharmacy due to residents' payor source. LPN 8 indicated if a resident's routine medication is not available, nursing staff should check the facility's emergency drug kit for the medication. If the resident does not receive a routine medication, staff should document the missed dose and notify the physician. During an interview on 9/8/25 at 10:15 A.M., the Director of Nursing (DON), indicated the facility had difficulty obtaining Resident C's ordered Geodon medication from the pharmacy. On 9/8/25 at 11:00 A.M., the DON supplied a facility policy titled, Medication Ordering and Receiving from Pharmacy, dated 05/2014. The policy included, .4. If the medication is not available, calls/faxes (sic) the pharmacy, using the after-hours emergency number(s) if necessary . D. Medications are not borrowed from other residents. The ordered medications is obtained either from the emergency box or from the provider pharmacy .This citation relates to intake 2606469.3.1-25(a)

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Hillside Manor Nursing Home

1109 E National Highway Washington, IN 47501

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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public.

Based on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment in 1 of 2 resident shower rooms, 1 of 2 dining rooms, and 1 of 2 halls observed and clean linens were not covered during transport in resident halls. Overhead air vents contained a build up of dust in and around the vent, a dining room floor was uneven and flooring was raised or warped, and a shared shower room contained multiple broken floor tiles, appeared unclean, and contained a small swarm of gnats and flies near the commode. (North Unit, South Unit, North Unit dining room, and Middle-hall shower room, Resident D)Findings include:1. During an observation on 9/3/25 at 3:25 P.M., the North Unit dining room had a towel draped on the floor under an in-wall air conditioning unit. The flooring between the air conditioning unit and the entrance to the dining room was uneven, warped, and cracked. During an

observation on 9/8/25 at 10:10 A.M., the North Unit dining room flooring between the air conditioning unit and the entrance to the dining room was uneven, warped, and cracked. 2. During an observation on 9/3/25 at 3:35 P.M., clean linens were being transported through the South Unit to a linen closet near an exit door.

The linens were transported in an open laundry basket on top of a cart on wheels.3. During an interview on 9/4/25 at 3:26 P.M., Resident D indicated the shared shower room in the middle hall that connected the North and South Units required maintenance and the maintenance staff could not keep up with tasks in the facility. During an observation on 9/4/25 at 3:35 P.M., the shared shower room in the middle hall contained three broken tiles near the base of the commode. The base of the commode appeared unclean and there were approximately seven gnats and one fly swarming around the commode. An overhead vent appeared to be rusted and contained a build-up of dust in and around the vent. During an observation on 9/8/25 at 10:08 A.M., the shared shower room in the middle hall contained three broken tiles near the base of the commode. The base of the commode appeared unclean and there were approximately seven gnats and one fly swarming around the commode. An overhead vent appeared to be rusted and contained a build-up of dust in and around the vent. 4. During an observation on 9/8/25 at 10:15 A.M., an overhead vent on the North Unit Hall near an exit door to a facility courtyard contained a build-up of dust in and around the vent.

On 9/8/25 at 11:00 A.M., the Director of Nursing (DON) supplied a facility policy titled, Environment and Physical Standards, dated 6/25/25. The policy included, (a) The facility must be: .(4) maintained; to protect

the health and safety of residents, personnel, and the public . (f) The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public . (g) Personnel shall handle, store, process, and transport linen in a manner that prevents the spread of infection as follows: .(2) Clean linen from a commercial laundry shall be delivered to a designated clean area in a manner that prevents contamination .This citation relates to intake 2606469.3.1-19(a)(4)3.1-19(f)(5)3.1-19(g)(2)

Event ID:

Facility ID:

If continuation sheet