DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION

PRINTED:02/06/2020
FORM APPROVED
OMB NO. 0938-0391
(X3) DATE SURVEY
COMPLETED

(X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION
/ CLIA
A. BUILDING ______
IDENNTIFICATION
B. WING _____
NUMBER

155792
NAME OF PROVIDER OF SUPPLIER

04/29/2019

STREET ADDRESS, CITY, STATE, ZIP

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 0600

Protect each resident from all types of abuse such as physical, mental, sexual abuse,
physical punishment, and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** >
Based on interview, and record review, the facility failed to prevent neglect when a Licensed Practical Nurse failed to
assess a resident for injury prior to moving her after a fall, and failed to report the fall resulting in a delay of
treatment for [REDACTED].
The immediate jeopardy began on 4/13/19 when Resident B fell forward out of wheelchair on the evening of 4/13/19 when
Certified Nursing Assistant (CNA) 7 was transporting her. Licensed Practical Nurse (LPN) 5 assisted the resident up prior
to assessing the resident for injury. The resident was put to bed and no notification or documentation of the fall was
made. The morning of 4/14/19, LPN 5 observed bruising and a hematoma on Resident B's face, then notified the physician and
management of a fall indicating it had occurred on the morning of 4/14/19. Resident B was sent to the ER approximately 18
hours after the actual fall and was diagnosed with [REDACTED]. The Executive Director (ED), Director of Nursing Services
(DNS), and Regional Director of Clinical Services were notified of the immediate jeopardy at 1:13 p.m. on 4/26/19. This
immediate jeopardy was removed on 4/27/19, but noncompliance remained at the lower scope and severity level of isolated, no actual
harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:
On 4/24/19 at 2:00 p.m., the Executive Director (ED) provided a report titled, Indiana State Department of Health Survey
Report System, dated 4/15/19. The report indicated, Resident (B) had an unwitnessed fall event. Resident with bruising to
forehead and orbital (around the eyes) area bilaterally. MD (physician) and family notified and order to send resident to
ER (emergency room ) for further evaluation and treatment received .
During an interview with the Power of Attorney (POA) on 4/24/19 at 11:06 a.m., the POA indicated he was contacted on 4/14/19
around 10:54 a.m., and told Resident B was found unconscious in her room at 7:00 a.m. that morning. The POA was told the
resident fell and had a bump and a bruise. The facility staff indicated they did not feel it was necessary to send the
resident out for further evaluation and treatment, and advised against sending her out to the emergency room . Upon
receiving photos of the resident via his spouse's cellphone, the POA felt he had been lied to regarding the extent of his
mother's injuries and requested she be sent to the hospital. The resident was observed by the POA's spouse in the dining
room in a wheel chair, her face horribly bruised, and had her elbows on the dining room table propping her head up on her
hands as she couldn't hold her head up. The resident ended up with [DIAGNOSES REDACTED]. The POA could not believe the
staff had picked her up like that as they could have severed her spinal cord and killed her. The trauma doctor in the local hospital ER
told the POA the bruising on the face pooled under the skin was an indication she had laid on the floor for a
long period of time. The resident had been sent to a local emergency room , where they had been told they were not equipped to
handle that type of trauma, so she was sent by ambulance to a trauma hospital.
A record review was completed for Resident B on 4/24/19 at 10:05 a.m. The record indicated the resident was admitted on
[DATE] with [DIAGNOSES REDACTED].
A review of an Admission Minimum Data Set (MDS) assessment, dated 3/22/19, indicated Resident B had the ability to make
herself understood and to understand others. A Brief Interview for Mental Status (BIMS) score of 7 indicated she had severe
cognitive impairment. The resident required extensive assistance of 1 for bed mobility, transfers, and locomotion on and
off the unit. She required a wheelchair. She had a fall in the last month, and during the 6 month time period before
admission.
A review of Progress Notes for Resident B, dated 4/13/19 to 4/22/19, indicated:
On 4/14/2019 at 8:00 a.m., Licensed Practical Nurse (LPN) 5 indicated, writer found resident on the right side of her bed on the floor.
Resident has bruising to both eyes and to forehead. Resident stated she was trying to get up. No other injuries
noted .Family, DON (DNS) and MD notified.
On 4/14/2019 at 12:21 p.m., LPN 6 indicated, Nurse Practitioner (NP) ordered Resident B to be sent for evaluation and
treatment secondary to unwitnessed fall with bruising to bilateral orbitals. Son (POA) aware and requested her to be seen
.(Ambulance company) in building to pick resident up at this time.
On 4/14/2019 at 4:51 p.m., LPN 11 indicated she had received a call requesting copies of resident information, and was
informed Resident B had been transferred from the original nearby ER to a trauma hospital due to trauma and fractures.
On 4/14/2019 at 8:53 p.m., LPN 11 indicated updated information on Resident B was obtained from the trauma hospital,
including the resident had a fracture of C2 (referred to as the hangman's fracture, the second bone down from the skull in
the cervical (neck) vertebrae).
A review of a tab, titled, Events, for Resident B, indicated:
On 4/14/2019 at 6:50 a.m. on a Fall Event, LPN 5 indicated, Resident B had an unwitnessed fall in her room while sleeping in bed.
The resident was first observed on the right side of the bed in her pajamas and non-skid socks. There was bruising to
both eyes and to the forehead. Resident representative was notified.
On 4/14/2019 at 7:07 a.m., on a New Skin Event, LPN 5 indicated, Resident B had bruising to both eyes and forehead. Hematoma (a
solid swelling of clotted blood within the tissue) to inner corner of both eyes.
A review of document for Resident B from (name of local hospital), titled, ER Report, dated 4/14/19 at 12:40 p.m.,
indicated, Patient had unwitnessed fall today, hit front of head. Bilateral orbital (around the eyes) bruising noted
.Complaint of neck and upper back pain. C-Collar (cervical/neck collar) in place .
A review of document for Resident B from (name of local hospital), titled Final Report, dated 4/14/19 at 1:00 p.m.,
indicated, Found down this morning, unknown time of fall and unknown downtime, placed in c-collar .patient mumbling words
and history limited .moderate right frontal scalp hematoma (localized bleeding outside of blood vessels, due to either
disease or trauma including injury) and soft tissue swelling. Patient cervical spine shows acute Type II odontoid fracture
(fractures occur when the cervical spine is hyper flexed or bent severely backwards, or hyperextended and bent severely
forward and can be caused by trauma such as a fall or whiplash), acute posterior arch fractures bilaterally of C1 (vertebra that is the
uppermost vertebra in the entire spine, located roughly on the same plane as the base of the nose) .Consult
4/14/19 3:16 p.m. (names of physician and trauma hospital) accepts and requests the patient be transferred over, will be
made a Trauma 2 activation (there is evidence of significant injury or mechanism of injury that will require a team
approach to their care to expedite resuscitation and treatment) .Diagnosis: [REDACTED]. Plan: Transfer to (name of trauma
hospital)
Review of a document for Resident B from (name of trauma hospital), dated 4/14/19 at 4:46 p.m. The report indicated, from
(name of local hospital) after an unwitnessed fall suffering multiple cervical spine fractures .unclear how long down,

Level of harm - Immediate
jeopardy
Residents Affected - Few

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Event ID: YL1O11

Facility ID: 155792

If continuation sheet
Page 1 of 3

 DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION

PRINTED:02/06/2020
FORM APPROVED
OMB NO. 0938-0391
(X3) DATE SURVEY
COMPLETED

(X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION
/ CLIA
A. BUILDING ______
IDENNTIFICATION
B. WING _____
NUMBER

155792
NAME OF PROVIDER OF SUPPLIER

04/29/2019

STREET ADDRESS, CITY, STATE, ZIP

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 0600

(continued... from page 1)
patient concerned about bruise and pain on anterior forehead, replies nonsensically about other questions regarding pain
.cervical spine fractures, though confused patient is protecting airway .CT Abdomen/Pelvis .acute burst [MEDICAL CONDITION]
(located in the middle of the lumbar or the abdominal segment of the spine) vertebral body with posterior-inferior
vertebral body protrusion (extension outside the normal line) of 2 mm (millimeters) into the spine canal. L3-L4
intervertebral disc space widening .superior endplate compression deformity of L5 (lowest of the lumbar spine) vertebral
body .right frontal scalp contusion (bruise) and hematoma .mildly displaced bilaterally posterior C1 ring fractures (C1
burst fracture), non-displaced type II odontoid fracture .admit to PCU (Progressive Care Unit)
On 4/25/19 at 2:51 p.m., the ED provided copies, untitled, and indicated, it was a time line of her investigation into
Resident B's fall, reported on 4/14/19. The time line indicated, but was not limited to:
On 4/14/19, no time documented, LPN 5 notified the DNS to report Resident B had a fall and was found beside her bed. The
resident had bruising to her face. LPN 5 stated the resident was trying to get up out of bed.
On 4/14/19, no time documented, Weekend Supervisor notified of the incident. Nurse assessed Resident B's spine, head, and
neck. Neuro-checks were normal. No complaints of pain. POA reported history of wrist fracture. Range of motion was normal.
MD and family notified of fall event. Order received to send resident out for evaluation at ER.
On 4/15/19, no time documented, CNA 15, that worked day shift on 4/14/19 was interviewed and stated she was not aware of any fall
when she was providing care to her. She said she went into the room to get her up for breakfast. She was in bed and
sleeping. Resident B had bruising to forehead and around both eyes at the time she entered the room that morning.
On 4/15/19, no time documented, ED interviewed CNA 7 that worked evening shift 4/13. CNA 7 reported that after dinner she
had been assisting Resident B back to room out of dining room. She turned the corner and resident tipped forward out of her
wheelchair and landed on the floor. CNA 7 notified the charge nurse LPN 5. LPN 5 assessed Resident B and the resident was
assisted back up into wheelchair. CNA 7 assisted the resident to bed after the incident. Resident B did not have any facial bruising or
visible injuries.
On 4/16/19, no time documented, ED interviewed LPN 5. (LPN 5) described the fall event on 4/14/19. She verified the fall
occurred on 4/14/19 and that she found (Resident B) on the floor about 6:30 a.m. (LPN 5) said the bruising was almost
immediate. (Resident B's) vitals and neuros were normal, and she didn't complain of any pain. ED discussed that (CNA 15)
reported getting the resident up and that the nurse had not been in the room that morning. (LPN 5) stated she thought it
was before breakfast. ED asked (LPN 5) if the resident had a fall on Saturday. ED discussed that (CNA 7) had reported
(Resident B) came out of wheelchair. (LPN 5) said she had been on the floor but the aide was not sure what happened. (LPN
5) was in the middle of med pass and didn't think the resident had hit that hard. (LPN 5) said the resident had no injuries at the time of
the incident and denied having any pain. She felt bad the next day and then documented a fall. (LPN 5)
stated the resident only had one fall on Saturday 4/13/19. The nurse had no explanation for her documentation .
During an interview on 4/25/19 at 2:51 p.m., the ED and DNS indicated during follow-up of the fall incident with Resident B, it was
discovered the incident in the resident medical record was not an accurate account of the event. Upon interview with multiple staff
from all shifts it was discovered that Resident B had not been found on the floor beside her bed in the
early morning hours of 4/14/19, but had actually fallen out of her wheelchair in the hallway on her way from the dining
room after dinner on the evening of 4/13/19. During a conversation with the ED and DNS, LPN 5 initially relayed the events
of the fall as she had documented in the electronic medical record. When confronted with the knowledge that CNA 7 indicated on
4/13/19 the resident had fallen in the hallway from her wheel chair and reported the fall to LPN5, LPN 5 indicated she
documented her original version of the fall early Sunday morning (4/14/19) after arriving at work and seeing the bruising
on Resident B's face. She had not documented the fall from the wheelchair on Saturday evening (4/13/19) because she, did
not know if the resident had hit her head. LPN 5 indicated the fall documented on 4/14/19 had not occurred and was
documented in place of the fall that had occurred on 4/13/19. LPN 5 indicated she had notified the POA on 4/14/19 of the
inaccurate fall and he initially was hesitant to send the resident to the hospital due to it might cause her stress and he
was not in town. Only after the Weekend Supervisor saw the resident and described the symptoms to the Nurse Practitioner
(NP) was there an order to send the resident to the ER.
During an interview on 4/25/19 at 2:56 p.m., the ED and DNS indicated the protocol for notification after a resident fall
included: first assess the resident and assure they were stable. If no injury, the nurse would call family during business
hours. If an apparent injury, the nurse would call family, the MD and DNS at the time of the fall. An apparent injury could include a
hematoma, AMS (altered mental status), bleeding, or complaint of pain. If there was an apparent injury, staff
were to leave the resident on the floor and call 911. The facility was unsure of the actual timelines as the nurse did not
document or tell the truth about the incident. True assessment of the incident was not documented in the electronic medical record.
LPN 5 failed to follow the Fall Policy. She failed to notify management, the physician, and the POA at the time of
the fall, she did not document the fall when it occurred, then later falsified documentation and told a false account of
the fall, all resulting in a delay of treatment to the resident.
During a telephone interview on 4/25/19 at 4:29 p.m., LPN 5 indicated, on 4/13/19, CNA 7 was pushing Resident B from the
dining room to take to bed, while she was passing medications. Around 6:45 p.m. - 7:00 p.m., LPN 5 heard CNA 7 yelling and
she told the nurse Resident B had leaned forward in her wheel chair and fell forward onto the floor. Upon arrival, she
observed Resident B to be lying on her right side, they picked her up from the floor, she then assessed the resident to
include vital signs which were ok, and there were no injuries or bruises. CNA 7 cleaned Resident B up and put her to bed.
LPN 5 then gave the Resident B her medications, she denied pain and took her medications without issue, and her vital signs were
still fine. LPN 5 went home that evening after she finished her shift. LPN 5 indicated she worked the next morning
(4/14/19), around 7:00 a.m. -7:30 a.m., the aide brought Resident B out for breakfast and she was observed to have bruising around
her eyes. LPN 5 sent an on-line message to the on-call physician (MD) as notification of the fall. The Weekend
Supervisor came back to the unit during her routine rounds and also assessed the resident. LPN 5 told the Weekend
Supervisor about the physician being notified, but Weekend Supervisor did not think the resident was hurt enough to send
out, and thought it was normal bruising and no pain. The POA was notified by the Weekend Supervisor after the on-call
responded and said to send Resident B out for evaluation. The incident happened at the end of the shift on 4/13/19, and CNA 7 told
LPN 5 the resident fell over out of the wheel chair easily, she did not document the incident during the shift as
she was unsure of the extent of her injury, and she didn't think Resident B fell that hard. After she saw the bruising the
next morning on 4/14/19, LPN 5 indicated, she felt she needed to document, but felt it was too late to document the
incident truthfully.
On 4/26/19 at 10:38 a.m., the Weekend Supervisor indicated on the morning of 4/14/19, she had been walking around before
breakfast around 7:00 a.m.-7:30 a.m., doing rounds. When she entered the cottage unit, LPN 5 was at the nurse's cart, and
Resident B was sitting to the right of her. LPN 5 told her Resident B had fallen, and the Weekend Supervisor could see the
resident had dark purple bruising around her eyes and the bridge of her nose. The Weekend Supervisor assessed Resident B
after LPN 5 did vital signs and assessed her. Resident B denied pain. The Weekend Supervisor checked Resident B's range of
motion, from the base of the skull down her spine, her pupils were reactive, and no pain. As there were no complaints of
pain, the Weekend Supervisor told LPN 5 to continue monitoring Resident B and follow protocol. LPN 5 did not indicate a
time of the fall, and didn't indicate if she had done notifications to the family and MD yet. Around 10:40 a.m. LPN 5 came
of the unit and told the Weekend Supervisor that the NP had returned a call to the facility, and wanted Resident B sent out for
evaluation. When asked if the POA had been told, LPN 5 indicated she had spoken to the POA earlier but not since the
call from the NP. The Weekend Supervisor then called the POA to notify him the NP wanted the resident sent out. The POA was
debating to send or not, and reminded the Weekend Supervisor of Resident B's past history of a wrist fracture and stents in the brain,
so could not have an MRI. The POA wanted a picture of the residents face sent to him, and when the Weekend
Supervisor explained she could not do that, told her he would send someone to come see the resident and take pictures when
she would not. The POA had some lady come in and take pictures right before the resident was leaving.
During a telephone interview on 4/26/19 at 6:03 p.m., CNA 7 indicated after dinner on 4/13/19, sometime between 6:00 p.m.
and 7:00 p.m., she was taking Resident B from the dining room down the hall to her room for evening care to go to bed.
Resident B was in the wheelchair. She wasn't leaning forward or to the side and there was no warning signs that she might
fall. I was walking slowly, in fact slower than normal because there were a lot of residents in the hallway. CNA indicated
she looked to the side at another resident walking past her. When she looked back Resident B was on the floor. Everything
happened so fast but doesn't think she heard or felt the resident fall out of the chair, but when looked back the resident
was on the floor. She did not remember if Resident B was on her face or side, but remembered the resident was rubbing her

Level of harm - Immediate
jeopardy
Residents Affected - Few

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

Event ID: YL1O11

Facility ID: 155792

If continuation sheet
Page 2 of 3

 DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF
DEFICIENCIES
AND PLAN OF
CORRECTION

PRINTED:02/06/2020
FORM APPROVED
OMB NO. 0938-0391
(X3) DATE SURVEY
COMPLETED

(X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION
/ CLIA
A. BUILDING ______
IDENNTIFICATION
B. WING _____
NUMBER

155792
NAME OF PROVIDER OF SUPPLIER

04/29/2019

STREET ADDRESS, CITY, STATE, ZIP

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 0600

(continued... from page 2)
head after the fall. So she must have hit her head. CNA 7 looked back down the hall for the nurse. While she was looking
for and calling out for the nurse Resident B moved herself and even sat up some. LPN 5 was down the hall and responded to
the CNA calling for help. LPN 5 came down and saw Resident B rubbing her head because LPN 5 moved her hair off her forehead to
look at her forehead. LPN 5 asked Resident B if she was ok. LPN 5 indicated Resident B had fallen earlier that day on
dayshift. I work 2nd shift so I don't know. After looking at the resident's head, legs, and arms, we got her up to her
wheelchair and I took her back to her room and helped her get into bed.
On 4/25/19 at 4:50 p.m., the DNS provided a document, titled, Staff In-service Nursing, dated 4/10/19. A document among the
topics indicated, fall: 1. Assess resident before moving resident. 2. Open and complete (Fall Event). 3. Document a
progress note including details of fall. 4. Document full set of vital signs (place under vitals). 5. A neurological
assessment flow sheet will be initiated on all un-witnessed falls, witnessed falls in which resident hits head, and those
with a suspected head injury. 6. Ensure tangible immediate intervention is put in place. 7. Complete a new skin event for
each new injury noted if applicable. 8. Notify DNS or nurse manager on call. 9. Notify MD. 10. Notify family/responsible
party . There was no documentation to indicate LPN 5 had attended the in-service training.
On 4/25/19 at 2:42 p.m., the ED provided a policy, titled, Fall Management Program, revised 11/2017. The policy indicated,
It is the policy of (company name) to ensure residents residing within the facility receive adequate supervision and or
assistance to prevent injury related to falls. A fall refers to unintentional coming to rest on the ground, floor, or other lower level .Post
fall: 1. Any resident experiencing a fall will be assessed immediately by the charge nurse for possible
injuries and necessary treatment will be provided .2. If the resident experienced an injury from the fall, contact facility DNS (Director
of Nursing Services)/ED per facility policy. 3. The physician will be contacted immediately, if there are
injuries, and orders will be obtained. If there are no injuries, notify the physician during normal business hours. 4. The
family will be notified immediately by the charge nurse of falls with injury. If there are no injuries, notify the family
during the day or evening hours .5. A fall event will be initiated as soon as the resident has been assessed and cared for. The report
must be completed in full in order to identify root cause of the fall and provide immediate interventions. 6.
All falls will be discussed by the IDT at the 1st IDT meeting after the fall to determine root cause and other possible
interventions to prevent future falls .
The immediate jeopardy that began on 4/13/19 was removed on 4/27/19 when the facility had educated nurses and CNAs on what
to do if they witnessed a fall, educated nurses and nurse managers on fall management procedures, conducted resident
interviews regarding falls for all cognitively intact residents, conducted full body assessments for all cognitively
impaired residents, and reviewed of all falls for the previous 30 days to ensure fall procedures were followed. The
noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal
harm that is not immediate jeopardy because of the facility's need for continued monitoring.
This Federal tag relates to Complaint IN 256.
3.1-27(3)

Level of harm - Immediate
jeopardy
Residents Affected - Few

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

Event ID: YL1O11

Facility ID: 155792

If continuation sheet
Page 3 of 3