Countryside Post-Acute and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jan 27, 2021

  Based on policy review, medical record review, facility investigation, Weather Service Website, observation, and interview, the facility failed to ensure a safe environment that provided adequate supervision to a cognitively impaired resident with exit seeking behavior for 1 of 3 sampled residents (Resident #1) reviewed for wandering and elopement. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide adequate supervision when Resident #1 exited the facility by crawling through a window, traveled across the facility lawn, up a 4 foot embankment onto a 2 lane highway and was… […]

• Immediate jeopardy, isolatedF835Jan 27, 2021

  Based on job description review, policy review, medical record review, facility incident report review, facility in service sign in sheets review, facility Performance Improvement Plan (PIP) review, and interview, the facility Administration failed to provide oversight and training of staff, ensure staff supervision, and ensure a safe environment for 1 of 3 sampled residents (Resident #1) reviewed for effective administration. Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide adequate supervision related to the facilty's failure to maintain the well-being of a resident with… […]

• Immediate jeopardy, isolatedF867Jan 27, 2021

  Based on policy review, job description review, facility in-service sign in sheet review, facility Performance Improvement Plan (PIP) review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that identified opportunities for improvement related to elopement, failed to develop and implement corrective actions and performance improvement activities for elopement to provide a safe environment for residents, and failed to ensure systems and processes were in place and consistently followed by staff and administration. […]

• No harm, potential for more than minimal, widespreadF812Sep 10, 2021

  Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by expired food items in the cooler, 1 of 5 Kitchen staff (Cook #1) failed to practice infection control while performing tray line temperatures, and 2 of 3 (West and East Hall) nourishment refrigerators were dirty. This had the potential to affect 75 of 85 residents who had received a tray from the Kitchen. The findings include: Review of the facility's undated policy titled, Getting Ready to Take Food Temperatures Sanitizing The Thermometer, revealed .The thermometer must be first sanitized and calibrated .The thermometer must be sanitized to avoid contaminating the food being tested .wipe the stem of the thermometer with an… […]

• No harm, potential for more than minimal, widespreadF880May 20, 2021

  Based on the Centers for Disease Control and Prevention (CDC) guidelines, Labor Detail Reports, Employee/Visitor/Vendor Check-In logs, staffing schedules, and interview, the facility failed to follow CDC infection control guidelines to properly prevent and/or contain COVID-19 when 68 of 114 staff members (Cook #1, #2, #3, #4, #5, #6 and #7, Registered Nurse (RN) #1, #2 and #3, Licensed Practical Nurse (LPN) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 #14 and #15, the Social Worker, Housekeeper #1, #2, #3, #4, #5, #6 and #7, Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #21 and #22, Restorative Aide #1, #2, and #3, the Director of Recreation, the Physical Therapy Assistant (PTA), the Physical Therapist… […]