Countryside Post Acute

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, the facility failed to conduct a thorough investigation for an allegation report of sexual abuse for one resident (R) (R3) from a sample of 5 residents. The deficient practice increased the risk that allegations went without a thorough investigation resulting in potential harm to residents.

Inspectors wroteBased on staff interviews, record review, review of the facility policy titled Departmental Supervision, Nursing, and review of the [NAME] Payroll-Based Journal (PBJ) dated January 1, 2025, through March 31, 2025, the facility failed to ensure the required Registered Nurse (RN) coverage of at least eight consecutive hours per day, seven days per week. This deficient practice had the potential to adversely affect all residents residing in the facility. The facility census was 52 residents.

Inspectors wroteBased on observations, staff interview, review of manufacturer package inserts, and review of the facility policies titled Medication Labeling and Storage and Insulin Administration, the facility failed to ensure one opened insulin vial was discarded on the discard date and failed to date one opened insulin vial when opening on one of two medication carts. This deficient practice had the potential to place the residents receiving the insulin at increased risk of receiving insulin with altered effectiveness. Findings Include: Review of the facility's policy titled Medication Labeling and Storage, revised 2/2023, revealed the Medication Labeling section included, . 5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial. [...]

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Resident Trust Policy, the facility failed to ensure money was taken from the Resident Trust Account and used for resident needs for 39 out of 50 (census at time of misappropriation on 2/9/2024) resident.

Inspectors wroteBased on staff and local police interviews, record review, and review of the facility policy titled Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property-Reporting and Investigating, the facility failed to protect the resident's right to be free from abuse by misappropriation of funds by staff for two of 24 sampled residents (R) (R203 and R45) who had trust accounts. Substandard Quality of Care was identified related to Misappropriation of Funds.

Inspectors wroteBased on staff interviews and review of the Facility Assessment Tool and the Payroll-Based Journal (PBJ) Staffing Data Report Quarter (Q) 1 2024, the facility failed to ensure there was adequate nursing staff to serve their residents. The deficient practice had the potential to adversely affect the care and services provided to the facility residents. The facility census was 48 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Food Temperature, the facility failed to ensure proper sanitation measures were followed and to uphold appropriate sanitation practices when checking food temperatures. Specifically, the incorrect sanitization of the thermometer between use did not align with food safety standards. The deficient practice posed a risk of foodborne illness for 45 of 48 residents receiving an oral diet.

Inspectors wroteBased on staff interviews, record review, police investigation reports, and review of the facility policies titled, Freedom from Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property-Reporting and Investigating, the Administrator failed to ensure an allegation of exploitation was reported to the State Agency in a timely manner for one resident (R) (R45). The facility census was 48 residents. Finding Include: A review of the facility policy titled Abuse, Neglect, Exploitation, or Misappropriation- Reporting and Investigating revised date January 2022 under Policy Statement in both policies revealed: [...]

Inspectors wroteBased on observations and resident and staff interviews, the facility failed to uphold the right of dignity for one of three residents (R) (R8) receiving catheter care by not providing necessary privacy measures.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to provide adequate space to meet the needs for one of three residents (R) (R8) in a shared room, compromising the resident's comfort and mobility.

Inspectors wroteBased on resident, facility staff and Hospice staff interviews, and review of the facility policy titled, Renal Dialysis Management, the facility failed to provide a meal or any snacks before leaving the facility for hemodialysis for one of one Resident (R) (R33) reviewed for dialysis. The deficient practice caused the time span between dinner and breakfast to be greater than 14 hours.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that the staff designated as Dietary Manager possessed the required certification as a Certified Dietary or Food Service Manager.

Inspectors wroteBased on observations, interview, and review of the facility's policy titled, Storage and Expiration Dating of Medications, Biologicals, the facility failed to ensure that two of two medication carts were locked and secured when the carts were out of view of the nurse. The deficient practice had the potential to allow unauthorized staff, visitors, and residents access to unsecured medications.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Cleaning and Sanitizing Dietary Areas and Equipment, the facility failed to ensure all kitchen areas and equipment were maintained in a sanitary manner and provide sanitary food service that meets state and federal regulations. This deficient practice had the potential to affect all residents who received an oral diet from the kitchen.

Inspectors wroteBased on observation, record review, and staff and resident interviews, the facility failed to accommodate the needs for one of 30 sampled residents (R) (R#5) related to providing a Hoyer lift pad to get into a wheelchair for mobility out of the room. The deficient practice had the potential to prevent R#5 from maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with R#5's needs and preferences.

Inspectors wroteBased record review, staff interviews, and review of the facility's policy titled, Pre-admission Screening and Resident Review, the facility failed to apply for Level two (2) PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one of one resident (R) (R#25) reviewed for positive Level I PASRR for mental illness and diagnoses of Bipolar and Anxiety Disorder prior to and on admission to the facility. This deficient practice had the potential for R#25 to be denied specialized services for psychological, psychiatric, and functional needs. Findings Include: Review of the facility's policy titled, Pre-admission Screening and Resident Review dated August 2022 revealed a policy of: [...]

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility's policy titled, Pharmacy Services Psychotropic Drug Therapy, the facility failed to document the intended duration of therapy for one of one resident (R) (R#28) that had order for as needed (PRN) antianxiety medication.

Inspectors wroteBased on observations and staff interview, the facility failed to ensure that four handrails were firmly and securely attached to the wall on one of two halls (100 Hall). This deficient practice had the potential to cause injury for any resident who used the unsecured handrails.