Countryside Health Center

In the surveyor’s words

From the most serious findings on record at Countryside Health Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF730Apr 30, 2025

  The 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. Findings included: - A review of the facility's staffing list revealed the following CNAs and CMAs were employed with the facility for more than 12 months: CMA T, hired on 04/18/18, had no yearly performance evaluation upon request. CMA S, hired on 11/27/20, had no yearly performance evaluation upon request. […]

• No harm, potential for more than minimal, widespreadF838Apr 30, 2025

  The 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. Findings included: - On 04/28/25, Administrative Nurse D provided a Facility Assessment updated 01/30/25. A review of the assessment revealed the following: The assessment identified the required staffing needs per day but failed to identify the specific staffing needs by shifts for the weekends. […]

• No harm, potential for more than minimal, widespreadF851Apr 30, 2025

  The 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. Findings included: - The PBJ report provided by the Centers for Medicare & Medicaid Services (CMS) for Fiscal Year 2024, all four quarters indicated the facility triggered for excessively low weekend staffing. On 04/29/25 at 09:10 PM, Administrative Nurse D stated that the weekend staffing was not low. Administrative Nurse D stated that the level of weekend staffing was the same as during the week for direct care staff. […]

• No harm, potential for more than minimal, widespreadF727Aug 15, 2023

  The 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. Findings included: - Review of the Registered Nursing Staffing Schedule for May, June and September 2022, recorded the facility lacked a RN for eight consecutive hours on the following dates: 05/22/22, 05/30/22, 06/04/22, 06/05/22, 06/18/22, 06/19/22 and 09/05/22. […]

• No harm, potential for more than minimal, widespreadF801Aug 15, 2023

  The 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. Findings included: - On 08/09/23 at 08:32 AM, observation revealed Dietary Staff (DS) BB supervising staff in the kitchen. DS BB stated the facility did not have a Dietary Manager and the administrator and director of nursing supervised the dietary department. On 08/14/23 at 09:34 AM, Administrative Staff A verified the facility did not have a certified dietary manager since the last one quit. […]