Countryside Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Countryside Center for Rehabilitation and Nursing, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF882Jan 30, 2025

  Based on interviews and review of the facility's policy, it was determined the facility failed to ensure the individual assigned the responsibilities of the Infection Preventionist (IP) had received specialized training in infection control and prevention. This had the potential to affect all fifty (50) residents residing in the facility On 01/27/2025 at 7:05 PM, the entrance conference was conducted with the Administrator who revealed that the Staff Development Coordinator (SDC) was the designated Infection Preventionist (IP) for the facility. […]

• No harm, potential for more than minimal, patternF813Jan 30, 2025

  Based on observation, interview and review of facility policy, it was determined the facility failed to ensure that foods brought in by family and/or visitors were stored in a safe and sanitary manner for four of 13 sampled residents (Resident (R) 5, 6, 37, and R50) with personal in room refrigerators. The findings include: On 01/28/2025 and 01/30/2025, the State Survey Agency (SSA) requested a policy on resident refrigerators. On 01/30/2025 at 4:50 PM, the Director of Nursing (DON) stated the facility did not have a policy on resident personal refrigerators. Review of facility policy, Use and Storage of Foods Brought in by Family or Visitors, revised on 01/06/2025, revealed. […]

• No harm, potential for more than minimal, isolatedF636Feb 19, 2026

  Number of residents sampled: Number of residents cited: Based on facility policy review, record review, review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual and interview, the facility failed to ensure comprehensive Minimum Data Set (MDS) assessments were completed timely for 2 Residents (R)23 and R40 of 2 residents reviewed for resident assessment requirements. The findings include: Review of facility policy titled, RAI Assessment-MDS 3.0 Completion, revised March 2025, revealed residents were assessed, using a comprehensive assessment process, in order to identify care needs and to develop an interdisciplinary care plan. […]

• No harm, potential for more than minimal, isolatedF656Jan 30, 2025

  Based on interview, record review and review of facility policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan for one of one sampled residents (Resident (R) 12) receiving hemodialysis services. R12 began receiving off-site hemodialysis services on 12/26/2024; however, the facility failed to include the hemodialysis services on the resident's Comprehensive Care Plan. The findings include: Review of the facility policy titled, Comprehensive Care Plan with a revision date of 02/2024 revealed the Comprehensive Care Plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. […]

• No harm, potential for more than minimal, isolatedF755Jan 30, 2025

  Based on observation, interview, and review of facility policy, the facility failed to ensure that drug records were in order and that an account of all controlled drugs was maintained by the facility for one of four medication carts and one (1) of one (1) medication storage room. Observation during a narcotic count of the 100 Hall medication cart on 01/30/2025 at 11:00 AM with Licensed Practical Nurse (LPN) 2 revealed the narcotic count was incorrect for six narcotic medications belonging to four different residents (Resident (R) 4, 5, 10, and R16). […]