Countryside Health Center

Inspectors wroteThe facility identified a census of 95 residents. The sample included 19 residents, two Certified Nurse Aides (CNA), and three Certified Medication Aides (CMA) were reviewed for yearly performance evaluations and the associated in-service training. Based on record review and interview, the facility failed to ensure five of the two CNAs and three CMA staff reviewed had yearly performance evaluations completed. This placed the residents at risk for inadequate care.

Inspectors wroteThe facility identified a census of 95 residents. The sample included 19 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. This failure affected all 95 residents residing in the facility.

Inspectors wroteThe facility had a census of 95 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ - Staffing Data Report). This placed the residents at risk for impaired care due to unidentified staffing issues.

Inspectors wroteThe facility reported a census of 95 residents. The facility identified 85 residents who had requested to be full code (term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest). Based on interview and record review, the facility failed to establish and maintain a system to ensure nursing staff maintained current cardiopulmonary resuscitation (CPR - a life-saving medical procedure that consists of chest compressions to allow oxygenated blood to circulate to vital organs, such as the brain and heart and artificial ventilation) certification for healthcare providers. This deficient practice placed these residents who desired CPR if needed at risk for inadequate resuscitative measures.

Inspectors wroteThe facility identified a census of 95 residents. The sample included 19 residents, with two medication rooms. Based on observation, record review, and interviews, the facility failed to properly label and store medications in the medication room, and further failed to secure medication carts containing residents' insulin (a hormone that lowers the level of glucose in the blood) pens and needles. This placed the residents at risk for adverse outcomes or ineffective medication regimens.

Inspectors wroteThe facility identified a census of 95 residents. The facility identified three residents on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact care). Based on record reviews, observations, and interviews, the facility failed to implement signage or indicators within the physical environment to alert staff and visitors of the required EBP and personal protective equipment (PPE) for Resident (R) 36 and R52. The facility additionally failed to cover linens in the hallways and further failed to ensure the dirty laundry sorting area was equipped with a gown and mask. This defiant practice placed the residents at risk of infectious diseases.

Inspectors wroteThe facility identified a census of 95 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to develop a plan of care, and implement skin care interventions for Resident (R) 36, who developed at Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This deficient practice placed R36 at risk for pain, complications, and possible infection associated with pressure ulcers.

Inspectors wroteThe facility identified a census of 95 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to recognize or address the potential for developing a pressure ulcer. The facility failed to identify the risks, develop a plan of care, and implement interventions when Resident (R) 36 developed at Stage 2 (partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters) pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This deficient practice placed R36 at risk for pain, complications, and possible infection associated with pressure ulcers.

Inspectors wroteThe facility identified a census of 96 residents. The sample included 19 residents, with four residents reviewed for trauma-informed care (treatment or care directed to prevent re-experiencing or reducing the effects of traumatic events). Based on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Residents (R) 45's and R10 post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization. These deficient practices placed R45 and R10 at risk for decreased psychosocial well-being and ineffective treatment.

Inspectors wroteThe facility had a census of 87 residents. The sample included 18 residents. Based on record review, and interview, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, for the 87 residents who resided in the facility. This placed the facility and residents at risk for inadequate nurse guidance and decreased quality of care.

Inspectors wroteThe facility had a census of 87 residents. Based on observation, interview, and record review the facility failed to employ a full time certified dietary manager for the 87 residents who resided in the facility and received meals from the facility kitchen. This deficient practice placed the 87 residents at risk for receiving inadequate nutrition.

Inspectors wroteThe facility had a census of 87 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to label Resident(R)41, R53, R65, R72, R55 and R56s' insulin (hormone which allows cells throughout the body to uptake glucose) flex pens and non-insulin flex pens with the date opened and expiration date and failed to discard expired stock medication on one medication cart. These deficient practices placed the affected resident at risk for ineffective medications.

Inspectors wroteThe facility had a census of 87 residents. The sample included 18 residents of which Resident (R) 14 was reviewed for dignity. Based on observation, record review and interview the facility failed to promote dignity for R14 who had a urinary catheter (a tube in the bladder to drain urine). This placed the resident at risk for embarrassment and an undignified experience.

Inspectors wroteThe facility had a census of 87 residents. The sample included 18 residents with one reviewed for hospitalization. Based on observation, interview, and record review the facility failed to provide a written notice of bed hold for Resident (R) 11 when he was hospitalized . This placed the resident at risk of being unable to return to the facility and in his prior room.

Inspectors wroteThe facility had a census of 87 residents. The sample included 18 residents with Resident (R) 14 reviewed for Hospice services. Based on observation, record review and interview, the facility failed to ensure R14 had a hospice plan of care in place and available for facility staff direction on hospice provided care. This deficient practice placed R14 at risk for unmet hospice care/services and a decline in his well-being.

Inspectors wroteThe facility had a census of 87 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to provide the necessary services to maintain activities of daily living (ADLs) for two sampled residents, Resident (R)71 and R78. This placed the residents at risk for poor hygiene and decline in ADLs.