Countryside Meadows

F-F578. Residents Affected - Few

This citation relates to Complaint IN00438111.

3.1-37(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38768 Residents Affected - Few Based on interview and record review, the facility failed to ensure lab specimens were obtained immediately with symptoms of urinary tract infection and laboratory results were reviewed in a timely manner for a resident with an indwelling urinary catheter to prevent urinary tract infection for 1 of 3 residents reviewed for quality of care (Resident F). This deficient practice resulted in a delay of treatment and the resident developed urosepsis with acute kidney failure with a systemic inflammatory response syndrome (SIRS) and died .

Findings include:

During a confidential interview, it was indicated Resident F's family member received a phone call on [DATE REDACTED]. The facility wanted to confirm Resident F's Do-Not-Resuscitate (DNR) orders because he had an infection and experienced a change in condition. The family member wanted Resident F to be sent out to the hospital, had been unaware that Resident F was being treated for an infection, and that his condition had worsened so severely. Resident F had a history of infections. When the family member arrived to the facility, there was an ambulance at the front door. EMS and the facility nurse said there was nothing more they could do for Resident F, and the resident took his last breaths moments after the family walked into the room.

On [DATE REDACTED] at 10:55 a.m., Resident F's medical record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, history of a cerebral infarction (stroke, bleeding in the brain) which resulted in left side hemiplegia and hemiparesis, (similar conditions that cause weakness on one side of the body), Alzheimer's disease (a degenerative brain disease with affects memory and cognition) and he required the use of a suprapubic catheter (a surgically created connection between the urinary bladder and the skin through the abdominal cavity used to drain urine from the bladder in individuals with obstruction of normal urinary flow) related to neuromuscular dysfunction of the bladder.

Resident F had a Physician's Scope of Treatment (POST) form dated [DATE REDACTED]. The POST form gave instruction for Resident F to be a DNR if the patient had no pulse AND was not breathing, and also specified his wishes for main treatment goals were to give, full interventions including life support measures in the intensive care unit. In addition to care described in Comfort Measures and Limited Additional Interventions above, use intubation, advance airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated to meet medical needs.

Resident F had a care plan, initiated [DATE REDACTED], which indicated he required the use of a suprapubic catheter related to his diagnosis of neurogenic bladder. Interventions for this plan of care included, but were not limited to, report complications/UTI: acute confusion, bladder spasms, low back/flank pain, malaise, nausea, emesis, chills, fever, foul odor, concentrated urine, blood in urine .staff to record urinary output in milliliters

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0690 Resident F had a care plan, initiated [DATE REDACTED], which indicated he had the potential for pain related to his diagnoses which included, but was not limited to, back pain. Interventions for this plan of care included, but Level of Harm - Actual harm were not limited to, Notify MD [Medical Doctor] if pain is unrelieved and/or worsening.

Residents Affected - Few On [DATE REDACTED] at 11:04 a.m., Resident F's Medication Administration Record (MAR) indicated he complained of back pain on a scale of 7 out of 10. An as needed (PRN) physician order for 500 milligrams (mg) of extra-strength Tylenol was administered and effective until 4:39 p.m., when he complained of increased pain at a level 9 out of 10. A second dose of his PRN Tylenol was administered. There was no documentation on

the MAR, progress notes, or within the resident's electronic record that the physician was notified of resident's worsening pain.

On [DATE REDACTED] at 3:12 p.m., Resident F's MAR indicated he complained of pain at a level 9 out of 10 and his PRN Tylenol was administered. There was no documentation on the MAR, progress notes, or within the resident's electronic record that the physician was notified of resident's continued back pain.

A Nurse Practitioner (NP) progress note, dated [DATE REDACTED] at 4:09 p.m., indicated nursing staff requested the NP visit due to increased confusion. seen today for confusion. He has a history of dementia with acute worsening of confusion. He is seen today, sitting up in his wheelchair. Nursing noted increased confusion over night. He asked what time dinner was after he just finished dinner. They also noted purulent drainage around SP cath [suprapubic catheter]. On exam, he is awake but drowsy in his wheelchair. He has a low grade temp of 99.3. Other VSS [vital signs stable]. He denies SP [suprapubic] pain but does endorse CVA tenderness [Costovertebral angle- CVA tenderness often indicates kidney pathology]. His SP cath has purulent sediment noted in the tubing . The NP ordered STAT (an task that is to be completed immediately.

The standard time for STAT lab results is 90 minutes, or one hour or less from specimen receipt) for a CBC (Complete metabolic panel), BMP (Basic Metabolic Panel), and urinalysis.

A Lab requisition form, dated [DATE REDACTED], with a timestamp that was not visible, indicated Resident F's urine sample had been collected at 4:00 p.m. The requisition did not indicate or specify STAT status. At the bottom of the requisition, Lab Use Only indicated the urine sample was not collected by the lab until [DATE REDACTED] at 7:33 a.m.

A nursing progress note, dated [DATE REDACTED] at 4:00 p.m., indicated, collected urine specimen for STAT UA C&S [urinalysis with culture and sensitivity] stored in lab refrigerator for pick up.

During an interview on [DATE REDACTED] at 2:00 p.m., the Director of Nursing (DON) indicated the facility did not have

a policy or procedure related to lab services/STAT lab services.

On [DATE REDACTED] at 1:33 p.m., the Senior [NAME] President (SVP) of Customer Service for the contracted Lab Service company provided a copy of the Lab's timeline of events for the Resident F's STAT lab order as follows:

a. Order for STAT labs was received on [DATE REDACTED] at 2:54 p.m.

b. On [DATE REDACTED] at 7:03 p.m., a Lab Associate called the facility to notify them, a Lab Technician would not be available until the next morning and made a note, nurse didn't answer page.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0690 c. On [DATE REDACTED] results of the CBC were faxed at 10:41 a.m., the BMP results were faxed at 11:42 a.m., and

the UA results were faxed at 10:49 a.m. Level of Harm - Actual harm

On [DATE REDACTED] at 9:00 a.m., the DON provided a copy of Resident F's urinalysis lab results. The results were Residents Affected - Few dated [DATE REDACTED] at 8:27 a.m. and were positive for signs of infection as the urine was cloudy and orange with white blood cell (WBC) clumps, many bacteria and a large amount of Leukocytes were present. The results were initialed by the NP as reviewed on ,d+[DATE REDACTED].

On [DATE REDACTED] at 9:00 a.m., the DON provided a copy of Resident F's C&S results. The results were reported [DATE REDACTED] at 10:39 a.m. and indicated the presence of Proteus mirabilis (a gram-negative bacterium that is a common cause of catheter-associated urinary tract infections).

During an interview on [DATE REDACTED] at 10:24 a.m., the NP indicated she received the urinalysis results at home over the holiday weekend and decided to wait for the C&S before she ordered a treatment because he had a history of frequent infections. The NP indicated she did not remember what time she received the urinalysis or the C&S results.

Resident F's electronic record including, but not limited to, vital signs, and progress notes, lacked documentation of a set of vital signs or resident assessment over the weekend on [DATE REDACTED] or [DATE REDACTED].

Resident F's electronic record including, but not limited to, events, documents, and progress notes, lacked documentation of assessment/monitoring of his suprapubic catheter (SP cath) insertion cite and/or tubing/drainage system after signs of an infection had been noted on [DATE REDACTED].

A nursing progress note, dated [DATE REDACTED] at 11:26 p.m., indicated at 4:00 p.m., Resident called for help in a very faint voice, resident panting, cyanotic [bluish-purplish discoloration] lips and legs, cold clammy all extremities, bloody urine noted in urine bag. Temperature: 101.5, unable to get BP [blood pressure] and O2 [oxygen] saturation. Placed on 2 L [liters] O2 via nasal cannula Eventually obtained BP of ,d+[DATE REDACTED], pulse of 124, O2 sat of 99% at 2L O2 via nasal cannula. DON and on call NP notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0690 On [DATE REDACTED] at 12:47 p.m., the DON provided a copy of the On-Call Provider correspondence which indicated

the following: On [DATE REDACTED] at 4:25 p.m., the facility nurse messaged the On-Call Provider to report Resident Level of Harm - Actual harm F's change in condition and indicated, .last week he started to have confusion and back pain. Pus and redness noted on SP cath insertion site, cloudy urine, now it's bloody, redness on SP region . The NP Residents Affected - Few responded (with no timestamp noted) and indicated to administer Rocephin (antibiotic) 1 gram (gm) IM (intramuscular) now and place a peripherally inserted central catheter (PICC) to administer Vancomycin (antibiotic) 1 gm now then to have the pharmacy determine the dose time for additional Vancomycin over the next 7 days. The provider ordered STAT labs for diagnosis of sepsis. Nursing was to administer Tylenol 650 milligrams (mg) every 4 hours and as needed (PRN) ibuprofen 400 mg every 6 hours for fever. Once temps trended down vital signs were to be obtained every 4 hours for 24 hours. Additional orders included a chest x-ray after PICC placement. The facility nurse responded (with no timestamp notes), phlebotomist was not able to put PICC but she was able to put a midline [a long, flexible tube inserted into a vein in the upper arm to administer medication or fluids into the bloodstream], I will give Vancomycin IV now. At 7:49 p.m., the facility nurse responded, .we ran out [Vancomycin] in the EDK [Emergency Drug Kit], I called pharmacy to expedite vancomycin one time 1 gram IV. At 8:01 p.m., the facility nurse notified the On-Call Provider, Vancomycin came, he is now much better after Rocephin .

A nursing progress note, dated [DATE REDACTED] at 1:15 p.m., indicated the results of the chest x-ray concluded no abnormalities, infiltrate or effusion.

An NP Progress note, dated [DATE REDACTED] at 3:38 p.m., indicated Resident F was, .seen today for AKI [Acute Kidney Injury] and SIRS [Systemic Inflammatory Response Syndrome]. He was seen Friday for AMS [altered mental status] at which time, labs were ordered. Labs reviewed . Yesterday, on call provider was called after nurse noted hematuria, increased weakness, low grade temp and tachycardia. On call provider ordered Rocephin IM x 1 and Vancomycin. After discussion with pharmacy, vanc [vancomycin] had to be discontinued because of elevated creatinine and dosing being every 72 hours. He is seen today, resting in his bed. He is awake, confused and agitated. He does report that he has not been feeling well. He remains tachycardic but is afebrile on exam. His SP cath is draining dark, brown urine with purulent drainage at SP site. He is 97% [02 saturation] on room air with no reported hypoxia, cough or dyspnea. He has a RUE [right upper extremity] midline in place. He meets SIRS criteria with fever and tachycardia. Likely urinary source, however culture is <100,000. He has a history of Proteus UTI as well as EColi with ESBL. Will start rocephin and if no improvement will transition to Merrem . The NP ordered to start IV fluids and a renal ultrasound.

On [DATE REDACTED] at 5:20 a.m., Resident F had bloodwork drawn for a CMP and the results were reported on [DATE REDACTED] at 1:46 p.m. His Creatine level rose from 4.6 to 6.7 and his BUN level was elevated at 94.

A nursing progress note, dated [DATE REDACTED] at 10:45 a.m., indicated Resident F, .continues on second liter of IVFs [intravenous fluids] per MD order .

On [DATE REDACTED] at 5:10 a.m., Resident F had bloodwork drawn for a BMP and the results were reported on [DATE REDACTED] at 1:57 p.m. His BUN level rose and was now critically high at 102.

A nursing progress note, dated [DATE REDACTED] at 2:50 p.m., indicated, .Received call from lab regarding critical high urea nitrogen 102. On call NP notified, NP ordered additional 1L NaCl 0.9% 100ml/hr, and repeat BMP in AM. Lab request placed, resident completed 2 L NaCl 0.9%. Hooked additional 1 L NaCl 0.9% 100 ml/hr

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0690 A nursing progress note, dated [DATE REDACTED] at 2:07 p.m., indicated, an ultrasound technician had been unable to complete a renal ultrasound due to unable to obtain clear imaging and the NP was notified. Level of Harm - Actual harm

A late nursing progress note, created, [DATE REDACTED] at 3:54 p.m., and set as effective for [DATE REDACTED] at 8:30 p.m. Residents Affected - Few indicated, Resident's SP cath was changed per order and a 22 French catheter was inserted. Resident tolerated the change well and urine output flowing with ease.

On [DATE REDACTED] at 8:26 a.m., Resident F had bloodwork drawn for a CMP and the results were reported on [DATE REDACTED] at 1:12 p.m. His BUN and Creatine levels remained elevated. His BUN was still critically high at 101.

A nursing progress note, dated, [DATE REDACTED] at 6:14 a.m., indicated during morning care the Certified Nursing Aide (CNA) called the nurse into room to show the discoloration to Resident F's left side of abdominal area.

The area was hard to touch. The resident did not complain of pain when touched. Resident's name was put

in the doctor's binder to be reviewed.

During an interview on [DATE REDACTED] at 9:00 a.m., the DON provided the Doctor's Binder for review. She indicated

the binder was an internal tool used by the nurses to put notes and concerns related to resident conditions, so that when the MD or NP came in, they would look through the Doctor's Binder to review and see residents as needed. The DON looked for notes related to Resident F from May, 2024, but was unable to locate any. When the DON contacted the NP, the NP indicated she threw the old pages away after the resident's had been seen.

A nursing progress note, dated [DATE REDACTED] at 8:10 a.m., indicated a second nurse was notified by a CNA .that resident had a large hematoma to side of ABD [abdomen], writer assessed area and it was hard to touch, resident did not c/o pain .Vital signs were within normal limits. The NP was informed of findings. NP had seen him during the week, and would see him this morning.

On [DATE REDACTED] at 4:20 a.m., Resident F had bloodwork drawn for a BMP and the results were reported on [DATE REDACTED] at 12:05 p.m. His BUN was even more elevated and critically high at 105.

Resident F's electronic record lacked documentation, and no documentation or evidence was provided by

the DON, NP, or any facility staff before exit, to indicate his increased and critically high BUN level had been reviewed.

During an interview on [DATE REDACTED] at 10:24 a.m., the NP could not recall if there was a note on her Doctor's Binder. The NP had seen Resident F on the morning of [DATE REDACTED] and saw the discolored area. The NP described the discoloration as a large bruise that was tender to touch, but at that time he had been eating breakfast so she told him she would come back later in the day to see him again. The NP indicated the bruising could be a symptom of worsening SIRS, but the NP still felt comfortable treating Resident F in-house. The NP indicated she had been asked to come back around lunch time, to re-assess and check on Resident F as he had another change of condition. The NP indicated when she saw him, he was not well.

They called Resident F's family member and reviewed his code status as a DNR, but also asked if the family would like him sent to the ER. The Family member did want him sent out. By the time EMS got to the facility,

they determined due to Resident F's DNR status, he was too far gone and there was nothing more they could do except let him pass away.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0690 On [DATE REDACTED] at 9:00 a.m., the DON provided a copy of the lab contract. The document was titled, American Senior Communities, L.L.C. Service Agreement, Service Agreement: Clinical Laboratory Services which was Level of Harm - Actual harm dated [DATE REDACTED]. The contract indicated, .Vendor will provide Lab Services to ASC Locations in accordance with each ASC Location's policies .Vendor provides STAT (life threatening situation) services 24 hours per Residents Affected - Few day, 365 days per year. Laboratory STAT testing will be reported within four (4) hours . Vendor shall respond to an ASC Location's request for STAT Services within 30 minutes and notify ASC Location of the time that Vendor will arrive . Critical and STAT results will be phoned to the ASC Location as soon as they are available The contract did not indicate/specify a timeframe and/or a minimum number of attempts to contact

the facility for Critical/STAT labs. According to the Lab Contract specifications, Resident F's urine specimen should have been picked up, processed and reported by [DATE REDACTED] at 8:00 p.m. but was not picked up until more than 11 hours later.

The facility did not have a policy for the Lab Service to indicate/specify a timeframe and/or a minimum number of attempts should be required to report Critical/STAT labs, and/or have facility nursing staff follow up on Critical/STAT labs.

On [DATE REDACTED] at 9:00 a.m., the DON provided a copy of current facility policy titled, Resident Change of Condition, revised ,d+[DATE REDACTED]. The policy indicated, It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .1. Life Threatening Change: the licensed nurse will notify the family/representative party of resident change of condition and document in the medical record .2. Acute Medical Change: any acute or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician . the responsible party will be notified that there has been a change in the resident's condition and what steps are being taken . Non-Urgent Medical Change: . the nurse in charge is responsible for notification of physician and family/representative party prior to end of assigned shift when a significant change in the resident's condition is noted. If unable to reach the physician or family/representative party, all calls to physician's or exchanges and family/representative party requesting callbacks will be documented in the medical record . the licensed nurse responsible for the resident will continue assessment and documentation in the medical record every shift until the resident's condition has stabilized

This citation relates to Complaint IN00438092.

3XXX,d+[DATE REDACTED](a)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm 46414

Residents Affected - Few Based on observations, record review, and interviews, the facility failed to document the results of glucometer (blood sugar) results for 1 of 3 residents reviewed for quality of care (Resident D).

Findings include:

On 7/31/24 at 12:13 p.m., a record review was conducted for Resident D. He had the following diagnoses which included but were not limited to cerebral infarction (stroke), Parkinson's disease, and diabetes mellitus.

He had a physician order, updated on 7/23/24, to obtain blood sugar every 6 hours and to notify the physician if results are below 70 or greater than 400.

His Medication Administration Record (MAR) for June and July 2024 had missing documentation of the results for the following dates/times:

a.) 7/14/24 at 8:00 a.m.

b.) 7/30/24 at 6:00 a.m.

c.) 6/20/24 at 8:00 a.m.

d.) 6/19/24 at 8:00 a.m.

e.) 6/17/24 at 8:00 a.m.

During an interview with the Director of Nursing Services (DNS), she indicated they had gotten away from running reports to see what was omitted from the day before.

A policy titled;, Blood Glucose Monitoring, dated 2/2015, was provided by the Minimum Data Set (MDS) Coordinator on 8/1/24 at 3:27 p.m. It indicated, .Blood glucose results will be documented on the capillary blood glucose monitoring tool or on the medication administration record (MAR)

This citation relates to Complaint IN00438994.

3.1-3(o)

3.1-3(r)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 155792

F-F684.

This citation relates to Complaint IN00438111.

3.1-4(l)(4)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Level of Harm - Minimal harm or potential for actual harm 38768

Residents Affected - Few Based on interview and record review, the facility failed to ensure the family/representative for a resident, (Resident F) was notified of a change in condition related to an acute urinary tract infection (UTI) which resulted in urosepsis-associated acute kidney injury/failure, (SA-AKI) and had a systemic inflammatory response (SIRS) for 1 of 3 residents reviewed for quality of care.

Findings include:

During a confidential interview, it was indicated, Resident F's family member received a phone call on the day he passed away which was 5/31/24. The facility wanted to confirm Resident F's Do-Not-Resuscitate (DNR) orders because he had an infection and experienced a change in condition. The facility asked if the family member wanted Resident F to be sent to the hospital. The family member did want Resident F to be sent out and had been unaware that Resident F was being treated for an infection and that his condition had worsened so severely. Resident F had a history of infections and they could get bad fast. When the family member arrived to the facility, there was an ambulance at the door. When the family member got to Resident F's room, EMS and the facility nurse said there was nothing more they could do, and he took his last breaths moments after the family walked into the room. The family member indicated they were shocked and in denial that this had happened so quickly and did not understand why they had not been made aware of the infection in the first place.

On 7/30/24 at 10:55 a.m., Resident F's medical record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, history of a cerebral infarction (stroke, bleeding in the brain) which resulted in left side hemiplegia and hemiparesis, (similar conditions that cause weakness on one side of the body), Alzheimer's disease (a degenerative brain disease with affects memory and cognition) and he required the use of a suprapubic catheter (a surgically created connection between the urinary bladder and the skin through the abdominal cavity used to drain urine from the bladder in individuals with obstruction of normal urinary flow) related to neuromuscular dysfunction of the bladder.

Resident F had a Physician's Scope of Treatment (POST) form dated 4/16/2020. The POST form gave instruction for Resident F to be a DNR if the patient had no pulse AND was not breathing, and also specified his wishes for main treatment goals were to give, full interventions including life support measures in the intensive care unit. In addition to care described in Comfort Measures and Limited Additional Interventions above, use intubation, advance airway interventions, and mechanical ventilation as indicated. Transfer to hospital and/or intensive care unit if indicated to meet medical needs.

Resident F had a care plan, initiated on 11/1/2012, which indicated he was in the facility for long term placement. Interventions for this plan of care included, but were not limited to, encourage family/friends to stay involved in resident care.

A STAT (immediate) New Order Documentation/Temporary Care plan was initiated on 5/24/24 at 3:13 p.m. Notification to the family/representative was not noted as completed until 5/31/24 at 12:22 p.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0580 Resident F's condition continued to decline over the weekend of May 25th-26th with critical lab results and acute SIRS related bruising. Level of Harm - Minimal harm or potential for actual harm Cross Reference

F-F690.

Residents Affected - Few The record lacked documentation, and documentation and/or evidence was not provided before the time of exit, to indicated Resident F's family had been notified of his acute change of condition.

On 7/31/24 at 9:00 a.m., the DON provided a copy of current facility policy titled, Resident Change of Condition, revised, 11/2018. The policy indicated, It is the policy of this facility that all changes in resident condition will be communicated to the physician and family/responsible party, and that appropriate, timely, and effective intervention takes place .1. Life Threatening Change: the licensed nurse will notify the family/representative party of resident change of condition and document in the medical record .2. Acute Medical Change: any acute or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician . the responsible party will be notified that there has been a change in the resident's condition and what steps are being taken . Non-Urgent Medical Change: . the nurse in charge is responsible for notification of physician and family/representative party prior to end of assigned shift when a significant change in the resident's condition is noted. If unable to reach the physician or family/representative party, all calls to physician's or exchanges and family/representative party requesting callbacks will be documented in the medical record

This citation relates to Complaint IN00438092.

3.1-5(a)(2)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Level of Harm - Minimal harm or potential for actual harm 46414

Residents Affected - Few Based on record review and interview, the facility failed to update a skin care plan for a resident with skin breakdown for 1 of 3 residents reviewed for care plans (Resident D).

Findings include:

On 7/31/24 at 12:13 p.m., a record review was conducted for Resident D. He had the following diagnoses which included, but were not limited to, cerebral infarction (stroke), Parkinson's disease, and diabetes mellitus.

Resident D had a skin event, dated 7/17/24, indicating he had skin breakdown to his coccyx measuring 1.0 centimeters (cm) by (x) 1.0 cm x 1.0 cm.

Resident D's care plan, dated 6/14/24, indicated resident was at risk for skin breakdown related to decreased mobility, incontinence, friction/shearing, and related to diagnoses of CVA (Cerebral Vascular Accident) with left sided hemiplegia (paralysis), adult failure to thrive, aphasia (loss of ability to understand or express speech, caused by brain damage), and HLD (hyperlipidemia).

On 8/1/24 3:20 p.m., during an interview with the Director of Nursing Services (DNS), she indicated an event was a care plan that was good for at least seven days, after that the care plan should be updated.

A policy titled, IDT (Interdisciplinary Team) Comprehensive Care Plan Policy, dated 8/2023, was provided by

the MDS (Minimum Data Set) Coordinator on 8/1/24 at 3:27 p.m. It indicated, .Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each MDS assessment

This citation relates to Complaint IN00438994.

3.1-35(c)(1)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 38768 potential for actual harm Based on interview and record review, the facility failed to ensure a resident's legal guardian participated and Residents Affected - Few agreed to the changes in the resident's plan of care and treatment for 1 of 3 residents reviewed for quality of care (Resident E).

Findings include:

During an interview on 8/1/24 at 12:11 p.m., Resident E's guardian indicated, she had received a call from Nurse Practitioner, (NP) on 6/14/24 who indicated Resident E had not eaten or drank anything and had been sleeping more than usual. The NP told the guardian, she did believe the decline was related to his dementia.

The NP asked the family about changing his code status from a Full Code, too a Do-Not Resuscitate (DNR).

The guardian lived out of state and told the NP she wanted her brother to go visit Resident E before the guardian made a decision about changing the resident's code status. The guardian indicated her brother went to visit Resident E on June 16th. Resident E had been awake, alert, and took food and drink when assisted by the family. The guardian indicated the family requested staff to sit with Resident E to assist him with meals due to his dementia. The guardian indicated she did not hear anything back after that and assumed everything was going well or back to baseline. On June 26th, the guardian received a call back from the NP who told her Resident E's right big toe had turned black and had an odor, which meant the toe was dead. The NP informed the guardian she had placed a referral for a vascular surgeon and ordered a doppler ultrasound. The NP indicated it would be approximately 2 weeks to a month before the vascular doctor could see Resident E. The guardian indicated, that was unacceptable. On June 27th, the guardian indicated she called the facility back and told them to have a doctor's appointment and a care plan meeting scheduled so they could discuss and review Resident E's condition. A care plan meeting was scheduled for that afternoon, and a vascular doctor's appointment was set for June 28th. During the care plan meeting, the guardian was informed, her brother had been asked and signed a DNR form and Resident E's overall treatment plan and goals had been changed to palliative care without her knowledge or consent. The guardian indicated no one was authorized to sign off, and/or make treatment changes or decisions about Resident E's care.

During an interview on 8/1/24 at 12:58 p.m., Resident E's son indicated his sister was Resident E's guardian, but she lived out of state. So he was often asked to visit Resident E on her behalf to check on his condition.

He indicated there was some confusion on the part of the facility and Resident E's DNR was presented to him under the assumption that his dementia had gotten worse and that he was at the end of his life, basically, he was getting ready to pass. Resident E's son indicated the NP brought him a DNR form and said

it was OK for him to sign it. Resident E's son indicated the form was presented to him as already approved by the guardian.

On 7/31/24 at 10:00 a.m., Resident E's medical record was reviewed. He was a long-term care resident who resided on the secured memory care unit with diagnoses which included, but were not limited to, Parkinson's disease (a chronic, progressive brain disorder that affects the body's motor and non-motor systems), Alzheimer's disease (a degenerative brain disease which affects memory and cognition), peripheral vascular disease (a progressive disorder that occurs when blood vessels outside of the heart or brain narrow, block, or spasm), and atherosclerosis (the thickening or hardening of the arteries caused by a buildup of plaque in

the inner lining of an artery).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0684 A document titled, Permanent Guardianship, dated 12/3/2020, indicated, .granted [name of Resident E's guardian] the authority to administer the permanent guardianship of the Person and Estate of [Resident E's Level of Harm - Minimal harm or name]. Said guardian shall have all of the authority of permanent guardianship under I.C. 29-3-7-3 potential for actual harm Resident E had a physician's order to be a full code had been initiated 3/28/24 and was discontinued on Residents Affected - Few 6/19/24.

A Social Service care plan meeting and documentation progress note, dated 6/17/24 at 10:29 a.m., indicated Resident E had a legal guardian who requested the resident remain a full code.

A nursing progress note, dated 6/18/24 at 2:31 p.m., indicated Resident E was started on the D5W fluid via a subcutaneous (SQ) button, (a site where a healthcare provider inserts a small needle under the skin to administer fluids). Resident E tolerated the fluids well.

A NP progress note, dated 6/18/24 at 3:20 p.m., indicated, Resident E was seen for, .hypernatremia [a condition where the sodium concentration in the blood is too high]. Labs reviewed on Friday and Na [sodium] was elevated at 155. New orders were given for midline and D5W [a type of intravenous (IV) fluid]. He pulled out his midline and did not receive the fluids . his R [right] great toenail is bleeding and likely bumped on something . The NP gave new orders to discontinue (DC) his Lasix (a diuretic medication) and re-insert a midline for fluids.

An interdisciplinary team (IDT) progress note, dated 6/18/24, indicated a new skin injury had been noted to Resident E's right great toe. The root-cause determination was Resident E, .is in weakened state and while ambulating stubbed toe. Currently resting in bed since injury. New interventions initiated: Lab tests ordered and IV fluids ordered to determine reason for weakness and support hydration

A NP progress note, dated 6/18/24 at NP 1:43 p.m., indicated, Resident E was .seen today in f/u [follow up] for hypernatremia. Labs reviewed and sodium remains elevated at 155 and creatinine up to 2.0. He is resting

in bed with SQ button in place. He previously discontinued his Midline. Daughter called to discuss resident declining condition with poor PO [by mouth] intakes and labs. Daughter states that her father was previously

a DNR with comfort care. Son in building. Reviewed POST form and signed DNR comfort measures. Discussed declining condition with poor PO intakes. He has the same wishes as his sister. Both agree on palliative care with comfort focused care. The NP gave new orders at that time to DC the SQ button and added morphine (a narcotic pain medication) and lorazepam (an anti-anxiety medication) as needed.

A Physician's Order for Scope of Treatment (POST) form, dated 6/18/24, changed his code status from a full code to a DNR with comfort measures. The POST was signed by Resident E's son and the NP.

A new order for a doppler ultrasound was conducted on 6/18/24 and results were available the same day at 4:22 p.m. The doppler indicated, .Right common femoral artery and infrapopliteal arterial stenosis. The doppler results also recommended, .further examination recommended such as additional imaging modalities

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 15 155792 Department of Health & Human Services Printed: 09/17/2025 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 155792 B. Wing 08/01/2024

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

Countryside Meadows 762 N Dan Jones Rd Avon, IN 46123

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 0684 A nursing progress note dated 6/18/24 at 9:49 p.m., indicated, Resident E's son (and not his guardian) had been notified of the new orders to DC all labs, doppler, and was placed on palliative care with morphine and Level of Harm - Minimal harm or lorazepam as needed. potential for actual harm Cross reference