Countryside Nursing & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Countryside Nursing & Rehab CTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF607Jul 28, 2026

  Based on interview and record review, the facility failed to implement and follow their Abuse Prevention Policy and Procedures by failing to protect a resident (R1) from physical and verbal abuse, failed to immediately report allegations of abuse to the state agency, failed to initiate a timely investigation, and failed to take immediate actions to ensure resident safety. These failures resulted in psychosocial harm of R1 who is fearful and scared of another altercation with V5 and fearful he will be abused again. Failure of the facility not following their abuse policy puts all 147 residents at risk of being abused.The Immediate Jeopardy began on 07/05/2026 when R1 and V5 were involved in a physical altercation in the facility. […]

• Actual harm, isolatedF689May 13, 2025

  Based on interviews and record reviews the facility failed to follow their policy and procedures for behavior and substance abuse management by not adequately monitoring and communicating suspected or observed substance use in the facility; not conducting room searches per the facility's protocol of reported suspicion of substance abuse; not referring suspected substance abuse to law enforcement; and not identifying or implementing personalized care plan interventions for prevention of suicidal/self-harming behavior and substance use. This failure applied to two of two (R1, R4) residents reviewed for supervision and resulted in R1 and R4 testing positive for drug use while in the facility and R1 engaging in self-harming behavior. Findings include: 1. […]

• Actual harm, isolatedF689May 7, 2024

  Based on observation, interview, and record review, the facility failed to monitor a high fall risk resident (R2) while in bed, failed to put in additional interventions to address R2's behavior of moving/wiggling around the bed, and failed to keep the call light within reach. This affected one of three residents (R2) reviewed for fall prevetion interventions. This failure resulted in R2 suffering a brain bleed in two areas of the brain after the fall. Findings Include: R2 is a [AGE] year old with the following diagnoses: chronic obstructive pulmonary disease, and nontraumatic intracranial hemorrhage. The Admission Hospital Records, dated 2/17/24, documents R2 was sent to the hospital for altered mental status. […]

• Actual harm, isolatedF600May 11, 2023

  Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy and to prevent incidents of staff to resident verbal and physical abuse. This failure affected two residents (R1 and R7) reviewed for abuse. V4 yelled, pulled R1's hair, and hit R1's arms, and V4 grabbed R7 by the left wrist resulting in bruising. Findings include: R1's BIMS (brief interview of mental status) score, dated 4/17/23, notes R1's score is 13 out of 15. R1 is able to make needs known. R1's behavior assessment summary, dated 4/17/23, notes R1 does not exhibit any behaviors. R1's quarterly assessment, dated 4/17/23, by V11, PRSC (Psychiatric Rehabilitation Services Coordinator), noted R1 is an active speaker that communicates her concerns and desires when the need arises. […]

• Actual harm, isolatedF689Feb 22, 2023

  Based on interview and record review, the facility failed to have effective interventions in place to prevent or reduce the risk of falling for a high risk fall resident for one 1 of 3 residents (R1) reviewed for fall prevention in a total sample of 3. This failure resulted in R1 falling and getting a laceration to the back of the head requiring 17 staples. Findings Include: R1 is a [AGE] year old with the following diagnoses: dementia with behavioral disturbance, weakness, history of falling, hypertensive heart failure, and transient ischemic attacks. R1 admitted to the facility on [DATE]. […]