Countryside Manor Nursing and Rehabilitation LLC

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to safely store refrigerated and freezer items. This had the potential to affect all residents who receive food from the kitchen. The facility identified one (#45) resident who does not receive food from the kitchen. The facility census was 65. Observation on 05/11/26 at 9:00 A.M. of the walk-in freezer revealed the thermometer was placed in the cooling fan. The thermometer read 20 degrees Fahrenheit. Further observation revealed what appeared to be melted vanilla ice cream on the floor and on the container lids below the ice cream. All six three gallon ice cream containers were soft and felt melted from the outside of the cardboard container. Observation on 05/11/26 at 9:05 A.M. [...]

Inspectors wroteBased on observation, staff interviews, and review of facility policy, the facility failed to maintain a clean, sanitary, and homelike environment. This affected all 65 residents residing in the facility.

Inspectors wroteBased on review of Self-Reported Incidents (SRIs), review of facility investigation, interviews, and policy review the facility failed to report misappropriation of controlled substances for destruction to the State Survey Agency. This affected ten (#82, #83, #84, #85, #86, #87, #88, #89, #90, and #91) of 20 residents reviewed for controlled substances for destruction. The facility census was 65.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to ensure fall prevention interventions were implemented for two (#9, #32) of three residents reviewed for fall prevention. In addition, the facility failed to ensure resident smoking assessments were completed affecting two (#13, #40) of two residents reviewed for smoking. The facility identified 11 residents (#13, #20, #29, #36, #40, #42, #52, #56, #58, #61, and #64) as smokers in a facility census of 65. Findings Include: 1. Review of the medical record revealed Resident #9 admitted to the facility on [DATE]. Diagnoses included dementia, transient ischemic attack, cerebral infarction, spinal lumbar stenosis, anxiety disorder, paranoid schizophrenia, major depression, intellectual disability, congestive heart failure, hypertension, and polyarthritis. [...]

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure resident representative and physician notification after a change in condition. This affected two (#62 and #76) of two residents reviewed for notification. The facility census was 65.

Inspectors wroteBased on observation, medical record review, staff interview, and policy review, the facility failed to ensure resident privacy was provided during incontinence care. This affected one (#9) of 20 residents observed for privacy in a facility census of 65.

Inspectors wroteBased on record review, review of bed hold notifications, interview, and policy review, the facility failed to ensure the bed hold notifications contained all the required criteria and bed hold policies were provided upon a hospital transfer. This affected two (#2 and #76) of two residents reviewed for bed holds. The facility census was 65.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure activities of daily living (ADL) care with removal of facial hair was provided to one (#49) of three residents reviewed for ADLs. The facility census was 65.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure orders were obtained for the use of a sling and failed to ensure follow up orthopedic consults were obtained for one (#76) of four residents reviewed for falls. The facility census was 65.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to ensure incontinent residents received timely and effective incontinence care. This affected two (#5, #9) of two residents reviewed for incontinence care and services in a facility census of 65.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure fluid restrictions identified how much allowed per discipline and shift, failed to document fluid intakes, and failed to obtain daily weights. This affected two (#11 and #76) of two residents reviewed for fluid restrictions. The facility census was 65.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility programing, the facility failed to provide purposeful and meaningful engagement and activities to residents in the secured dementia unit. This affected two (#17 and #47) of three residents reviewed for dementia care with the potential to affect all 14 residents in the secure dementia unit. The facility census was 65. 1. Review of the medical record revealed Resident #17 was admitted on [DATE]. Diagnoses included Alzheimer's disease, panlobular emphysema, unspecified dementia with psychotic disturbance, generalized anxiety disorder, and depression. Review of the Minimum Data Set (MDS) assessment, dated 03/02/26, revealed the resident was severely cognitively impaired. [...]

Inspectors wroteBased on staff interview, record review, and review of facility policy, the facility failed to offer clinical rationale to support a provider's disagreement with a gradual dose reduction (GDR) as suggested by the pharmacist. This affected one (resident #3) of five residents reviewed for unnecessary medications. The facility census was 65.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy, the facility failed to ensure medications were administered as prescribed by the physician with an error rate of less than five percent. This affected one (#45) of one resident observed for gastrostomy tube medication administration. A total of 27 medication opportunities with seven errors were observed for an error rate of 25.93 percent. The facility census was 65.

Inspectors wroteBased on observation, medical record review, staff interview and facility policy review, the facility failed to ensure enhanced barrier infection control precautions were implemented for residents at risk for infection. This affected two (#45, #5) of 20 residents reviewed for infection control practices in a facility census of 65.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure resident beds were properly maintained in a safe manner. This affected two (#5, #9) of 20 residents reviewed for safe integrity of beds in a facility census of 65.

Inspectors wroteBased on closed medical record review, staff interview, review of the Emergency Medical Services (EMS) run report, review of hospital records, review of the death certificate, review of staff witness statements, and review of facility policy, the facility failed to ensure residents were served foods in the correct texture to meet individual needs and further failed to ensure residents were accurately assessed for supervision needs during meals. This resulted in Immediate Jeopardy on 01/16/26 for one (#77) resident who experienced serious life-threatening harm and negative health outcomes resulting in death when Certified Nursing Assistant (CNA) #151 served Resident #77, who had a physician ordered mechanical soft texture diet (foods are ground, chopped, or naturally soft), a regular texture sandwich during an evening snack. [...]

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure an adequate supply of clean linen was available to meet the residents' needs. This had the potential to affect all 46 (#32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, #44, #45, #46, #47, #48, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62, #63, #64, #65, #66, #67, #68, #69, #70, #71, #72, #73, #74, #75, #76, and #78) residents who resided on the third floor. The facility census was 76.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (#47) of two residents reviewed for medication administration. The facility census was 76.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY Based on medical record review, resident and staff interview, review of a facility investigation, review of hospital documentation, policy review, and review of facility corrective action documentation, the facility failed to ensure the appropriate level of care and assistance was utilized during resident bathing which resulted in an avoidable fall. Actual harm occurred when Resident #22 was being bathed by one staff member when the resident's care plan indicated the resident required a two-person assist for bathing and the resident's abilities were known to fluctuate. Resident #22 was rolled to her side while in bed and was rolled onto the floor which necessitated the resident to be sent to the hospital for an evaluation. [...]

Inspectors wroteBased on observation, staff interview, review of pharmacy documentation, and facility policy review, the facility failed to store resident insulin in a safe and sanitary manner. This affected nine of (#16, #22, #36, #41, #44, #53, #56, #59, and #272) 14 residents identified by the facility to receive insulin administration in a facility census of 69.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure services required by the state-designated mental health authority were provided to residents. This affected one (#18) of two residents reviewed for pre-admission screening and resident review (PASARR) requirements. The facility census was 69.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of a facility policy, the facility failed to to ensure residents who required staff assistance with activities of daily living received adequate and timely care to maintain appropriate personal hygiene including nail care. This affected one (#46) of four residents reviewed who required assistance with nail care and personal hygiene. The facility census was 69.

Inspectors wroteBased on observation, resident and interview, medical record review, review of a facility policy, and review of the Facility Assessment, the facility failed to provide an individualized activity program designed to meet the interests and care needs of residents with intellectual disabilities. This affected one (#46) of one residents reviewed for activities. The facility census was 69.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure pressure ulcer prevention interventions were implemented as ordered by the physician. This affected one (#39) of three residents reviewed for pressure ulcer care and treatment in a facility census of 69.

Inspectors wroteBased on observation, resident and staff interview, medical record review, and review of therapy documentation, the facility failed to ensure an individualized restorative program was implemented to ensure residents maintained range of motion and mobility. This affected one (#35) of one residents reviewed for limited range of motion and mobility. The facility census was 69.

Inspectors wroteBased on observation, medical record review, staff interview, and facility policy review, the facility failed to ensure timely incontinence care was provided. This affected one (#39) of three residents reviewed for incontinence care and treatment in a facility census of 69.

Inspectors wroteBased on observation, medical record review, staff interview, dialysis communication documentation, and facility policy, the facility failed to ensure residents received physician ordered medication for residents receiving hemodialysis. This affected one (#38) of two residents reviewed for the administration of hemodialysis in a facility census of 69.

Inspectors wroteBased on medical record review, resident and staff interview, and therapy documentation review, the facility failed to ensure residents received timely rehabilitation services. This affected one (#272) of three residents reviewed for rehabilitation services. The facility census was 69.

Inspectors wroteBased on medical record review, staff interview, review of a McGeer criteria checklist, and policy review, the facility failed to ensure the facility's antibiotic stewardship program was appropriately implemented with use of antibiotic medications. This affected two (#22 and #59) of three residents reviewed for antibiotic use. The facility census was 69.

Inspectors wroteBased on record review, facility staff interview, and policy review, the facility failed to provide comprehensive nephrostomy care to a resident. This affected one (#47) of one resident reviewed for nephrostomy tubes. The facility identified one resident who had a nephrostomy tube used in his care at the facility. The facility census was 67.

Inspectors wroteBased on medical record review, staff interview, review of written statements, review of self-reported incidents, and review of a facility policy, the facility failed to report an allegation of potential abuse to the State Survey Agency as required. This affected one (#74) of three residents reviewed for abuse. The facility census was 73.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interview, policy review, and review of facility corrective action, the facility failed to provide adequate supervision to prevent a resident elopement. This affected one (#38) of three residents reviewed for elopement. The facility census was 73.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure nurse staffing information was posted daily as required. This had the potential to affect all 73 residents residing in the facility. The facility census was 73.

Inspectors wroteBased on medical record review, resident and staff interview, interview with Wound Care Nurse Practitioner (NP) #700, review of hospital records, review of an incident report, review of a facility self-reported incident (SRI), review of the facility investigation, review of witness statements, and review of a policy, the facility failed to ensure a resident (#09) was free from avoidable burns inflicted by a staff member. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries and/or death when on 12/05/23 at approximately 2:45 A.M., State Tested Nurse Aide (STNA) #195 used her personal lighter in an attempt to remove a diabetic wound dressing from Resident #09's right foot. [...]

Inspectors wroteBased on medical record review, resident and staff interview, review of a facility self-reported incident (SRI), and review of the facility investigation, the facility failed to ensure resident preferred bathing schedules were honored. This affected one (#09) of three residents reviewed for activities of daily living (ADLs). The facility census was 65.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of a facility self-reported incident (SRI), review of the facility investigation, review of the witness statements, review of nursing staff schedules, review of local law enforcement records, resident interview, staff interview, review of a facility policy, and review of facility corrective action, the facility failed to ensure a resident received assistance with incontinence care in a timely manner. This affected one (#05) of three residents reviewed for incontinence care. The facility census was 65.

Inspectors wroteBased on medical record review, resident and staff interview, review of a facility self-reported incident (SRI), and review of the facility investigation, the facility failed to maintain adequate staffing to ensure a resident's preferred bathing schedule was honored. This affected one (#09) of three residents reviewed for activities of daily living (ADLs). The facility census was 65.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure care plans provided accurate activities of daily living (ADL) interventions. This affected four residents (#19, #39, #51, and #57) out of 16 resident care plans reviewed. The facility census was 64.

Inspectors wroteBased on observation, staff interview, review of the facility's temperature logs, and review of the facility's posted guidance, the facility failed to ensure food items reached the appropriate internal temperature before serving the items to residents. This affected 12 residents (#04, #14, #15, #16, #17, #18, #34, #36, #42, #54, #57, and #214) out of 64 residents receiving meals in the facility. The facility census was 64.

Inspectors wroteBased on observation, resident and staff interview, and policy review, the facility failed to ensure resident rooms were maintained in good repair. This affected one resident (#17) out of 64 residents reviewed. The facility census was 64.

Inspectors wroteBased on family and staff interview, review of the medical record, review of the grievance log, review of the self reported incidents, and policy review, the facility failed to investigate allegations of misappropriation. This affected one resident (#01) out of one resident reviewed for misappropriation. The facility census was 64.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident assessments were accurate. This affected three residents (#20, #57, and #61) out of 22 residents reviewed for accurate assessments. The facility census was 64.

Inspectors wroteBased on observation, resident and staff interview, review of the medical record, and policy review, the facility failed to ensure a wound dressing was completed per physician orders. This affected one resident (#22) out of six residents reviewed for wound care. The facility census was 64.

Inspectors wroteBased on observation, staff interview, review of the medical record, and review of the facility in-service, the facility failed to ensure staff reheated food to a safe temperature to prevent burns. This affected one resident (#16) out of one resident reviewed for hazards. The facility census was 64.

Inspectors wroteBased on observation, medical record review, staff interview, and facility urinary catheter care policy, the facility failed to ensure appropriate technique was implemented to prevent cross contamination. This affected one resident (#22) out of three residents identified with an indwelling urinary catheter. The facility census 64.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to provide accurate documentation of wound care completed in the medical record. This affect resident two residents (#19 and #22) out of six residents reviewed for wound care. The facility census was 64.

Inspectors wroteBased on observation of the daily staff posting, staff interview, and review of the Facility Assessment, the facility failed to ensure the staff posting included the actual hours worked by nurses and aides in the facility. This had the potential to affect all residents in the facility. The facility census was 64.