Grey Stone Health & Rehabilitation Center

F-F609.

2. On 2/25/25 at 3:12 P.M., Resident F's record was reviewed. Diagnoses included chronic pain syndrome and weakness. Prior to admission, she'd been hospitalized for acute respiratory issues and was receiving rehabilitation services with plans to go back home.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 5 155809 Department of Health & Human Services Printed: 09/08/2025 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 155809 B. Wing 02/25/2025

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

Grey Stone Health & Rehabilitation Center 10445 Dupont Oaks Blvd Fort Wayne, IN 46845

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 Neither Resident F's progress notes nor admission assessments indicated home medications had been brought to the facility. Level of Harm - Minimal harm or potential for actual harm An MAR, dated January 2025, listed medications prescribed and administered by staff. The MAR did not indicate any medications were from Resident F's home supply. Residents Affected - Few Progress notes, dated 1/17/25 through 2/4/25, did not indicate home supplied medications had been returned to the resident. Resident F's record did not indicate Resident F's home medications had been erroneously given to another resident discharged home.

A discharge assessment, dated 2/4/25, did not indicate home supplied medications had been returned to the resident. Resident F's record did not indicate her home medications had been erroneously given to another resident discharged home.

On 2/25/25 at 12:05 P.M., the Administrator and Assistant Directors of Nursing (ADON 8 and ADON 9) were interviewed. The Administrator indicated staff didn't know what happened to Resident B's 2 bottles of missing medications and she wasn't aware 3 bags of medications had been left unsecured on the nurse's station desk. Both ADON's indicated neither Resident B's nor Resident F's medications should've been left unsecured at the nurses station. Medications brought in from home by residents were to be documented in

the resident record when received, when returned to the resident, and kept securely stored. ADON 8 indicated there had been no documentation in the record of the number of medications placed in a bag to be returned to Resident F's family. The Administrator indicated she had been notified of the missing medications reported to the sheriff's office. Prior to being notified of the police report, she indicated, on 1/28/25, the Director of Nursing (DON) had picked up Resident F's medications from Resident B's home and the facility offered to pay for the missing medications but had received no response from the resident.

Current facility pharmacy policies, provided by the Administrator on 2/25/25 at 10:45 A.M., indicated the following:

-Medication Brought into the Facility policy stated: Procedure: Facility staff should not administer medications .brought to facility by a resident .without physician/prescriber's order .Facility staff should return any unused medications brought into the facility by the resident .to the resident's family .A facility nurse should store unused non-controlled substance medications securely

-Loss or Theft of Medications policy stated: Where facility staff suspect theft or loss of medications, staff should take such actions as required by applicable law and facility policy. Appropriate actions may include, without limitation: 1. Immediately reporting suspected theft of loss of drugs to supervisor/manager or Director of Nursing for appropriate investigation and follow up; and 2. Investigating and reconciling discrepancies

This Citation relates to Complaint IN00452515.

3.1-25

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 5 155809