Grey Stone Health & Rehabilitation Center

F 0684 Level of Harm - Actual harm Residents Affected - Few

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

assessments or documentation of Resident L's condition completed on 9/29/25. On 9/30/25 at 6:14 p.m.,

the on-call contracted NP was notified of Resident L's abnormal lab of a critical Hgb level of 5.8. Orders were given to call 911 and transfer the resident to the hospital for blood transfusion and evaluation. There was no assessment or documentation completed to indicate Resident L had a change/decline in condition

on 9/30/25. A contracted on-call NP communication, dated 9/30/25 at 9:33 p.m., indicated Resident L was admitted to the hospital with a gastrointestinal bleed, anemia, and acute kidney failure. On 10/23/25 at 1:23 P.M., the Director of Nursing (DON) was interviewed. She indicated she wasn't sure why labs had been drawn on 9/30/25 and wasn't able to find orders for the lab draw. When questioned, she indicated she was unable to locate STAT lab results ordered 9/24/25 at 11:35 p.m. The facility contracted with a lab who were supposed to draw routine labs, run the labs, and report results to the facility. For STAT labs, the contracted lab was to draw the labs but take the blood to the hospital to be processed and reported. On 10/23/25 at 2:25 P.M., the contracted NP was interviewed. She indicated she had been monitoring Resident L's labs for some time, especially his WBC (white blood count) for infection due to his acute illness over the past month. Resident L's hemoglobin level chronically trended between 8-10; below the normal hemoglobin level of 14.0-18.0 g/dL. She indicated labs had been drawn during the day on 9/24/25 due to the residents' continued weakness and respiratory symptoms. She reviewed the lab results reported by the lab at 2:45 p.m. via secured hospital electronic medical records. She hadn't been made aware STAT labs had been re-ordered the evening of 9/24/25 following the resident's passage of black tarry stool and had not reviewed results of those labs. On 10/23/25 at 2:45 P.M., the DON and Licensed Practical Nurse (LPN) 8 provided a copy of the lab results, ordered on 9/24/25 at 11:35 p.m. and drawn on 9/25/25 at 2:32 a.m. by the contracted lab. The DON indicated the contracted lab had not taken the blood to the hospital to be processed and had run the tests at their lab. The facility had not received results of the labs. When questioned, LPN 8 indicated labs were drawn on 9/30/25 due to an order given on 9/29/25 by the contracted NP but hadn't known the reason for the lab draw. The DON indicated it was nurses' responsibility to document assessments and follow up on labs ordered to ensure the ordering provider was aware of the lab results and resident's condition. The DON indicated the facility had no specific policy for notifying providers of abnormal lab results however, abnormal lab results could be a change in resident condition requiring provider notification. On 10/24/25 at 11:00 A.M., the contracted NP indicated she had not been notified nor had she received results of STAT labs ordered the evening of 9/24/25. She had not known the resident's Hgb had decreased to 7.7 g/dL. She indicated she should have been notified of the lab results.A Competency check-off form, titled Lab and Diagnostic Results Reporting, provided by the Administrator on 10/24/25 at 11:33 A.M., indicated nurses were to call the providers, report abnormal lab results, and document in the medical record. Providers were to be notified immediately of critical lab values and notification documented in the record.A current facility policy, titled Resident Change in Condition, was provided on 10/24/25 by the DON which indicated licensed nurses were to recognize and intervene in the event of a change in resident condition. The physician/provider was to be notified as soon as the change in condition was identified. This Citation relates to Intake 2645131. 3.1-37

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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

10/24/2025

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 0686 Level of Harm - Actual harm Residents Affected - Few

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

centimeters (cm) by 2.5 cm. The DTI had irregular borders and was deep purple/red in color. An order for Skin prep, to be applied every shift, was obtained and applied to her left heel.The National Pressure Injury Advisory Panel (NPIAP) website (npiap.com) indicated a deep tissue injury (DTI) was one of the most serious forms of pressure injury. Pressure is exerted where the muscle and bone come together. A DTI is defined by damage to the tissue beneath intact skin. Treatment of DTI's include frequent re-positioning off

the site of injury, good skin care, and proper support surface selection such as mattress and positioning devices to prevent prolonged pressure.Woundsource.com defined Skin prep as a liquid film-forming skin protectant. Skin prep was not recommended for open areas.A Braden Scale Assessment, dated 10/18/25 at 5:04 p.m., indicated the resident had moderate risk for developing pressure ulcers. The assessment didn't indicate new interventions were put in place to prevent worsening of her DTI or prevent new pressure ulcers from occurring.A Wound Nurse Practitioner (NP) progress note, dated 10/21/25, indicated Resident J had an open ulcer to the left heel. The wound bed was 100% soft eschar (dead skin); wound edges irregular and attached; peri wound pink without redness or induration; no odor; and no bone present. There was a small amount of serous (clear) drainage on the old dressing. Interventions were to offload, use positioning devices, and low air loss mattress.A nurse note, dated 10/21/25 at 3:26 p.m., written by Facility Wound Nurse 9, indicated Resident J had been seen by the wound NP for an unstageable pressure ulcer to

the left heel. The wound measured 1.5 cm by 1.5 cm and was covered with eschar tissue. The wound NP ordered treatment to the heel: clean the area with normal saline/wound cleanser, pat dry. Apply nickel thick layer of Santyl (enzyme removal of eschar) to the wound bed, cover with ABD pad and secure with kerlix and tape. The treatment was to be done daily and as needed for soilage or dislodgement.A Medication Administration Record (MAR), dated October 2025, indicated interventions to prevent worsening of the DTI, observed on 10/18/25 by Resident J's family and reported to staff, were not put in place immediately. The MAR indicated the resident's heels were to be floated as tolerated and heel protector placed on her left heel beginning 10/21/25. Staff were to monitor the unstageable pressure ulcer to the left heel for abnormalities every shift beginning 10/21/25. An air mattress, ordered on 10/21/25 and initialed by nurses

in the MAR as being present, was not observed on the resident's bed on 10/21/25, 10/22/25, or 10/23/25.Current facility policies, titled Pressure Injury Prevention and Management Policy and Skin and Wound Care Best Practices were provided by the Administrator on 10/24/25 at 10:20 A.M. New pressure injuries would not develop unless the resident's clinical condition demonstrated they were unavoidable.

Residents were to be assessed for pressure injury upon admission, quarterly and with a significant change

in condition using the Braden Scale for Predicting Pressure Ulcer Risk. Preventative skin care and wound treatments would be put in place to prevent avoidable skin complications. At risk residents would have their heels offloaded/suspended; re-positioned to avoid pressure to bony prominences; and provided pressure redistribution/relief devices as recommended. All standard mattresses were pressure relieving/redistributing and would be used for all residents unless provider orders were for a higher level of pressure reduction.This Citation relates to Intake 2647972.3.1-40

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