Evergreen Crossing And The Lofts

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

pink or red base) on the coccyx. Daily wound care included no cover dressing, and no documented treatment. The note lacked documentation of a date when the resident had acquired the pressure injury, root cause, or a description and size of the injury. During an interview on 11/14/25 at 2:50 p.m., LPN 11 indicated, the Minimum Data Set (MDS) nurse was responsible for care planning new or worsening wounds. On 11/14/25 at 3:20 p.m., the RVRM provided documentation she felt would prove past non-compliance to include,a. On 10/24/25, care plan audits were completed for residents with known skin concerns/wounds (Residents B, F, L, P, Q, R, S, T, U, V, W, and X). The RVRM indicated, approximately 75% of those residents required their care plans to be updated, but she did not know the names of the residents who had care plans revised. b. On 10/25/25 a skin sweep of every resident was completed and documented on bath/skin sheets for the 97 residents residing in the facility. To her knowledge there were no new pressure ulcer/injuries identified, but residents were found with undocumented skin tears, bruises, and other skin issues.c. On 10/31/25, follow-up audits were initiated. Ten (10) residents with wounds were to be visually validated per week for 4 weeks to ensure family had been notified, wound treatments were completed per orders, monitoring had occurred daily, Wound NP recommendations were being followed, LAM were in place per orders, and care plans were up to date. On 11/14/25 at 2:49 p.m., the [NAME] President Risk Management provided a Plan of Care Overview policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, The facility will: i. Provide an RN assessment of the resident as on on-going, periodic review that provides the foundation for resident focused care and the care planning process.iii. Review care plans quarterly and/or with significant changes

in care.vii. Support and encourage resident/representative participation including but not limited to working cooperative to.3. Schedule meetings to accommodate a resident's representative that may include conference calls, video conference sessions or live sessions.II. Care Plan Team.b. Members of the care planning team will coordinate care to meet resident preferences and care needs utilizing a holistic approach of care. On 11/14/25 at 2:49 p.m., the [NAME] President Risk Management provided a Skin Care & Wound Management Overview policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, 4. Develop a care plan with individualized interventions to address risk factors. 5. Communicate risk factors and interventions to the care giving team. 6. Evaluate for consistent implementation of interventions and effectiveness at clinical meeting. 7. Modify and document goals and interventions as indicated. 8. Communicate changes to the care giving team. This deficient practice was corrected by 10/31/25 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included staff education, skin assessments and wound care plan audits, and ongoing monitoring was in place. Cross reference tag F-F686. This citation relates to Intake 2655006. 3.1-35(d)(2)(B)

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

11/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Crossing and the Lofts

5404 Georgetown Road Indianapolis, IN 46254

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

the corporate support to help intervene. On 11/14/25 at 3:20 p.m., the RVRM provided documentation she felt would prove past non-compliance to include,a. On 10/24/25, internal education was sent out to 130 staff members. Education regarding wounds included assessment of skin conditions, information to be documented to include a description and measurements, notification of the wound, where to document the wound, care planning the wound, and what to do if the nurse disagreed with the providers choice of treatment or wound description.b. On 10/24/25 - 10/27/25, nursing management met with staff in-person, and nursing staff signed to verify they had received the education, if they understood the education, and if there were questions. The clinical education for the nurses and aides included skin observation, wound documentation, wound assessments, and who was to be notified of a new wound. The nurses were also encouraged to notify nursing management if the nurse felt like she/he was not being heard, or if he/she felt

a wound was not being managed/documented accurately by internal or external sources. c. On 10/24/25, care plan audits were completed for residents with known skin concerns/wound and updated with interventions as needed. d. On 10/25/25 a skin sweep of every resident was completed and documented on bath/skin sheets for the 97 residents residing in the facility. There were no new pressure wounds/injuries identified. Approx. 75% of known residents with wounds had their care plans updated with new interventions.e. On 10/25/25, notifications to the MD/NP, resident representatives, and wound NP were made, and treatment orders were obtained for any resident found to have a skin issue. New wound orders were obtained as needed.f. On 10/27/25, LPN 9 was hired for the in-house wound nurse position and replaced LPN 15. LPN 9 then initiated completion of a skin assessment on all new residents on her next day on shift.g. On 10/31/25, follow-up audits were initiated. Ten (10) residents with wounds were to be visually validated per week for 4 weeks to ensure family had been notified, wound treatments were completed per orders, monitoring had occurred daily, Wound NP recommendations were being followed, LAM were in place per orders, and care plans were up to date. On 11/14/25 at 2:49 p.m., the VPRM provided a Skin Care & Wound Management Overview policy, undated, and indicated the policy was the one currently being used by the facility. The policy indicated, Each resident is evaluated upon admission and weekly thereafter for changes in skin condition. Resident skin condition is also re-evaluated with change in clinical condition, prior to transfer to the hospital and upon return from the hospital.Prevention: 1.

Complete the Braden Scale.2. Complete an admission Observation Tool.3. Identify diagnoses or conditions to place the resident at risk for pressure ulcer development . [co-morbid conditions, cognitive impairment, decreased activity, decreased sensory perception, diabetes, poor nutrition/hydration.healed pressure ulcer, increased moisture on skin] .4. Develop a care plan with individualized interventions to address risk factors.

1. 5. Communicate risk factors and interventions to the care giving team. 6. Evaluate for consistent

implementation of interventions and effectiveness at clinical meeting. 7. Modify and document goals and interventions as indicated. 8. Communicate changes to the care giving team. This deficient practice was corrected by 10/31/25 prior to the start of the survey and was therefore Past Noncompliance. The facility implemented a systemic plan that included staff education, skin assessments, and wound care plan audits, and ongoing monitoring was in place. This citation relates to Intake 2655006. 3.1-40(a)(1)3.1-40(a)(2)

Event ID:

Facility ID:

If continuation sheet