Oak Grove Christian Retirement Village

F-F689.

A Nurse's Progress Note, dated 3/10/25 at 10:29 p.m., indicated the resident returned to the facility per ambulance. She was assisted to bed by two staff. There was an immobilizer on the right lower leg. She complained of pain to the area.

A Nurse's Progress Note, dated 3/11/25 at 1:37 a.m., indicated the immobilizer on the right leg was in place. There was no assessment of the right leg or the status of the resident.

There were no assessments completed by the nurses on 3/12/25.

A Nurse Practitioner (NP) Progress Note, dated 3/12/25 at 9:51, indicated an immobilizer had been placed

on the right lower leg due to a tibia fracture. Tylenol was not effective for the pain and an order for Norco (narcotic pain medication) was given and effective. She appears to be in distress and pain. She was grimacing anytime the leg was moved. Pain medication was increased to twice a day.

A Nurse's Progress Note, dated 3/13/25 at 10:52 a.m., indicated there was edema of the bilateral lower extremities. No further assessment of the status of the leg or fractured ribs were documented.

There were no further assessments completed on the right leg status and fractured ribs.

During an interview on 5/7/25 at 9:46 a.m., the Director of Nursing indicated the nurses' were to complete follow up assessments. She indicated there were no further assessments found.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 7 155667 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 155667 B. Wing 05/07/2025

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

Oak Grove Christian Retirement Village 221 W Division St Demotte, IN 46310

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 An acute condition change policy, dated 1/23/24 and received from the Director of Nursing as current, indicated the staff were to monitor and document the resident's progress and responses to treatment. Level of Harm - Minimal harm or potential for actual harm This citation relates to Complaint IN00455274.

Residents Affected - Few 3.1-37

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 155667 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 155667 B. Wing 05/07/2025

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

Oak Grove Christian Retirement Village 221 W Division St Demotte, IN 46310

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm 20580 Residents Affected - Few Based on observation, record review, and interview, the facility failed to ensure a resident received proper assistance to prevent accidents, related to a CNA (Agency CNA 1) transferring a dependent resident (Resident B) from the bed to a chair without following the plan of care, causing pain and fractures to the resident's right leg and left ribs. The facility also failed to ensure Resident D, who was a high risk for falls and had a history of falls, was adequately supervised to prevent a fall which resulted in a head laceration requiring staples for healing for 2 of 3 residents reviewed for accidents/supervision.

Findings include:

1. During an observation on 5/6/25 at 9:25 a.m., Resident B was sitting in a high back reclining chair. A mechanical lift pad was underneath the resident. She indicated the staff used a mechanical lift to transfer her. There was an immobilizer on her right lower leg.

Resident B's record was reviewed on 5/6/25 at 10:26 a.m. The diagnoses included, but were not limited to, a spiral fracture of the right tibia, peripheral vascular disease, history of traumatic brain injury, and cognitive deficit.

A Care Plan, dated 11/1/23 and reviewed on 1/13/25, indicated assistance was required for activities of daily living. The interventions included a mechanical lift was to be used for all transfers with the assistance of two staff members.

A Quarterly Minimum Data Set (MDS) assessment, dated 2/8/25, indicated the resident had moderate cognitive impairment, had no behaviors, no impairment of movement of the upper and lower extremities, was dependent for all activities of daily living (ADL's) except eating, had no falls, and received an antiplatelet medication.

A Physical Therapy Evaluation and Plan of Treatment, dated 2/28/25, indicated the resident was dependent for bed mobility and transfers, had decreased balance, and a mechanical lift and a high back wheelchair with elevating legs were to be utilized for the resident.

The CNA Care Card, dated 3/7/25, indicated the resident required a mechanical lift for transfers and was dependent for care. The night shift staff were to assist the resident out of bed in the morning.

A Nurse's Progress Note, dated 3/10/25 at 7:20 a.m., indicated the day shift CNA (CNA 3) reported to the nurse that there was bruising to the resident's right shin. The resident denied pain and winced when touched.

The night shift CNA (Agency CNA 1) indicated the resident's legs were hanging out of the bed when he entered the room that morning. Pain medication was administered as ordered and the Nurse Practitioner (NP) was notified. Orders were received for a STAT x-ray of the right shin and the resident's family was notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 155667 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 155667 B. Wing 05/07/2025

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

Oak Grove Christian Retirement Village 221 W Division St Demotte, IN 46310

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 0689 The NP Progress Note, dated 3/10/25, indicated there were complaints of pain and swelling in the right lower extremity. There was localized redness, swelling, and pain to her right tibia a couple inches below her knee. Level of Harm - Actual harm There was pain with palpation. There was no obvious deformity but a large amount of swelling. The resident was grimacing and appeared to be in distress. There was no respiratory distress, and the breath sounds Residents Affected - Few were clear. After the visit the x-ray result was received and indicated a right proximal tibia fracture, she was transferred to the emergency room for further evaluation.

A mobile x-ray report, dated 3/10/25 at 2:36 p.m., indicated there was an acute appearing proximal right tibia fracture.

The emergency room Physician's Progress Note, dated 3/10/25 at at 1:53 p.m., indicated right lower leg injury, normal breath sounds and no respiratory distress. She had intact distal pulses, no edema, tenderness, or major deformities of the extremities. The hospital x-ray of the right tibia and fibula indicated a nondisplaced spiral fracture of the proximal tibia. There was no abnormal soft tissue calcification, and bone mineralization was normal. The chest x-ray indicated there were multiple left lower rib fractures. The family opted for conservative treatment. A knee immobilizer was applied, and the resident was transferred back to

the facility.

A Hospital emergency room Note, dated 3/10/25 at 7:00 p.m., indicated the resident had no acute distress and was transferred back to the facility.

A Nurse's Progress Note, dated 3/10/25 at 10:29 p.m., indicated the resident returned to the facility per ambulance. She was assisted to bed by two people. There was an immobilizer on the right lower leg. She complained of pain to the area.

An NP Progress Note, dated 3/12/25 at 9:51 a.m., indicated an immobilizer had been placed on the right lower leg due to a tibia fracture. Tylenol was not effective for the pain and an order for Norco (narcotic pain medication) was given and effective. She appeared to be in distress and pain. She was grimacing any time

the leg was moved. Pain medication was increased to twice a day.

A Physician's Order, dated 3/12/25, indicated Norco 5 - 325 milligrams, give one tablet twice a day.

An Indiana Department of Health (IDOH) reported incident, dated 3/10/25 with follow up on 3/24/25, indicated on 3/10/25 at 6:30 a.m., a CNA observed a large bruise on the resident's left shin (sic) (right shin) and notified the nurse. An x-ray was obtained and an acute proximal tibia fracture was found on the left (sic) leg. The resident was then transferred to the Hospital emergency room for a further evaluation.

The investigation of the incident included the following:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 155667 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 155667 B. Wing 05/07/2025

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

Oak Grove Christian Retirement Village 221 W Division St Demotte, IN 46310

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 0689 A handwritten statement by LPN 4, dated and signed on 3/10/25 and no time documented, indicated CNA 3 asked her to assess the resident's swollen area on the right leg. There was a 2 centimeter (cm) by 2 cm Level of Harm - Actual harm raised hematoma on the right shin. The resident was asked what happened and she stated she was skipping and fell . She denied pain. She drew her leg back with light palpitation. An as needed Tylenol was Residents Affected - Few administered. Agency CNA 1 was interviewed. He indicated when he entered the room, the resident's legs were hanging out of the bed. LPN 4 clarified the statement and asked if the resident had been falling out of

the bed and Agency CNA 1 stated, no. He indicated he dressed her and transferred her into the wheelchair.

The NP was notified, and an x-ray was ordered. A skin assessment was completed, and no other bruises or injuries were observed.

A handwritten statement by CNA 3, dated and signed on 3/10/25 and no time documented, indicated she came into work at 6:00 a.m. She was receiving a walking rounds report from Agency CNA 1. Resident B was sitting in her room in a wheelchair with the mechanical lift pad positioned under the resident. She checked

the positioning of the resident and made sure her feet were on the foot pedals. When she started to adjust

the right leg, she observed a large swollen bruise under the right knee and the resident called out in pain.

The nurse was immediately notified.

A text message from the Administrator to Agency CNA 1, dated 3/10/25 at 12:27 p.m., asked the CNA for a written statement. Agency CNA 1 responded on 3/10/25 at 9:21 p.m. and indicated a statement would be emailed.

An e-mailed statement from Agency CNA 1, dated 3/11/25 at 1:09 a.m., indicated the resident had been obvert (sic) with her left and right legs hanging off the left side of the bed. The legs were lifted back onto the bed and she was placed in the wheelchair. The day shift CNA came into the room and noticed the resident grimacing with pain when she attempted to place her legs on the leg rests, and she alerted the nurse.

An e-mailed statement from Agency CNA 1, dated 3/11/25 at 11:47 a.m., indicated he had not used the mechanical lift to transfer the resident. He had placed an arm under both her legs and the other arm under her back and lifted her into the wheelchair. He had sent a picture with e-mail that had a man cradling a woman in his arms, with one arm around her back and one arm supporting the knees. The typed statement under the picture was, Like this into her wheelchair.

The Facility Investigation of the incident, dated 3/10/25, indicated several staff who had worked with the resident one to two days prior to the incident had been interviewed and no injury had been observed. The conclusion of the investigation indicated the injury likely occurred when the resident was transferred from the bed to the chair without the use of the mechanical lift.

Agency CNA 1 had signed an orientation acknowledgement for the facility on 11/26/24.

During an interview on 5/7/25 at 8:30 a.m., the Administrator indicated the orientation of the residents and their care for the agency staff was completed by the nursing staff when the Agency Staff were working. They received report from the nurses and the CNAs, and they were given the CNA Care Card. Agency CNA 1 knew the mechanical lift was to be utilized for the resident's transfer, he placed the lift pad on the wheelchair

before he lifted the resident into the wheelchair. She indicated that he had worked at the facility numerous times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 155667 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 155667 B. Wing 05/07/2025

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

Oak Grove Christian Retirement Village 221 W Division St Demotte, IN 46310

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 0689 A facility mechanical lift policy, dated 6/2024 and received from the Administrator as current, indicated the interdisciplinary team evaluated and assessed each resident's individual mobility needs and the mechanical Level of Harm - Actual harm lift would be utilized based on the resident's needs. Staff were expected to maintain compliance with safe handling/transfer practices. Resident transfers were to be performed according to the individual plan of care. Residents Affected - Few 2. During an observation on 5/7/25 at 2:12 p.m., Resident D was sitting outside in a wheelchair during an activity. She was smiling and had no signs or symptoms of pain. There was a bruise and five staples located

on the left front forehead.

Resident D's record was reviewed on 5/7/25 at 2:07 p.m. The diagnoses included, but were not limited to, stroke and osteoporosis.

A Care Plan, dated 3/11/25, indicated there was a risk for falls. The intervention, dated 11/26/24, indicated

the resident would be assisted to the bathroom.

A Fall Assessment, dated 1/11/25, indicated the resident was disoriented to person, place, and time, had a fall in the past three months, was chair bound, was unable to perform the gait balancing assessment, received medications that could cause falls, and was high risk for falls.

A Quarterly MDS assessment, dated 2/28/25, indicated a severely impaired cognition status, no behaviors, no impairment of the upper and lower extremities, required moderate assistance for toilet transfers and hygiene and maximum assistance for transfers. She required a wheelchair for mobility.

An undated CNA Care Card indicated the resident was a one person assist with the gait belt, a wheelchair was used, and in capital red letters it stated the resident was a fall risk.

A Nurse's Progress Note, dated 4/28/25 at 6:28 a.m., indicated the staff had alerted the nurse at approximately 5:10 a.m. that the resident had fallen. The resident was observed lying on the bathroom floor

on her right side. There was blood on the floor and the CNA was holding pressure to the resident's head. There was a laceration on the left side of the resident's head. The Emergency Medical System was notified for the resident to be transferred to the hospital.

A Written Statement, signed and dated by CNA 2 on 4/28/25 at 5:15 a.m., indicated the resident was in the bathroom on the toilet. The CNA, turned her back for a couple of seconds to obtain a pair of socks and heard

the resident fall. The nurse was notified, and pressure was applied to the wound until the medics arrived.

A Nurse's Progress Note, dated 4/28/25 at 11 a.m., indicated the resident returned from the hospital. The forehead laceration measured 3 cm by 0.1 cm and there were five staples placed that closed the wound. The resident was placed on every 15-minute checks.

A Post Fall Assessment, dated 4/28/25 at 1:30 p.m., indicated the fall had not been witnessed. The fall occurred in the bathroom and the resident attempted to self-toilet at the time of the fall. The resident stood up from the toilet and fell .

An Interdisciplinary Team Note, dated 4/28/25, indicated the CNA had left the resident alone in the bathroom while she retrieved her clothing for the day and the resident fell .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 155667 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 155667 B. Wing 05/07/2025

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

Oak Grove Christian Retirement Village 221 W Division St Demotte, IN 46310

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 0689 An IDOH reported incident, dated 4/28/25, indicated on 4/28/25 at 5:10 a.m., CNA 2 had alerted the nurse

the resident had fallen in the bathroom. The resident was found lying on the bathroom floor on her right side. Level of Harm - Actual harm CNA 2 was holding pressure to the left side of the resident's head due to a laceration. CNA 2 had indicated

she turned around to retrieve a pair of socks, and the resident attempted to perform self-toilet hygiene and Residents Affected - Few fell . The resident was immediately transferred to the emergency room . The interventions that were put into place included the resident would not be left unattended while in the bathroom and clothing needed was to be placed in reach while care was provided.

During an interview on 5/7/25 at 2:30 p.m., the Director of Nursing (DON) indicated CNA 2 was not in the bathroom at the time of the fall. Residents who were at high risk for falls were not to be left alone in the bathroom.

During an interview on 5/7/25 at 2:35 p.m., the Administrator indicated CNA 2 was in the bathroom at the time of the fall. Her written statement indicated she had just turned her back to the resident for a few seconds.

During an interview on 5/7/25 at 2:37 p.m., CNA 2 indicated the resident had never tried to stand on her own before. The resident was on the toilet. She had forgotten to get the resident's socks when she assisted her into the bathroom. She went out of the bathroom to the dresser to get the socks. The resident was always in her sight, until she turned for a second to get the socks and then she heard the resident fall.

This citation relates to Complaint IN00455274.

3.1-45(a)(2)

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