Countryside Health & Rehab Of Newton County

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to ensure staff performed hand hygiene during meal service; failed to ensure insulated meal cart door remained closed when not accessing meal trays; failed to ensure proper infection control practices were performed during medication pass for 1 (Resident #21) failed to ensure measures were taken to prevent resident's from using bathroom sink water in oral care for 1 (Resident #22) resident of 17 sampled residents, and water fountains were marked/labeled/taken out of service from use by residents, staff and visitors. Findings include: A review of a facility policy titled, Hand Hygiene, dated 01/30/2024, indicated, performing proper hand hygiene procedures prevented the spread of infection and should be performed as outlined in the attached table. No table was attached. During an observation on 100 hall on 11/12/2024 at 12:25 PM, an insulated meal cart was on 200 hall, Certified Nursing Assistant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 2 (Resident #33 and Resident #27) of 17 sampled residents reviewed for MDS accuracy. Specifically, the facility failed to ensure information regarding the resident's hospice care was accurately completed for Resident #33 and failed to ensure information regarding enteral feeding was accurately completed for Resident #27. Findings include: A review of the admission Record, indicated the facility admitted Resident #33 with diagnoses that included paraplegia, wedge compression fracture of vertebra, cord compression, injury to lumbar spinal cord, chronic kidney disease, and disorder of the prostate. The annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/27/2024, revealed Resident #33 had a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact, was dependent for toileting, dressing, showering/bathing, had a urinary catheter, and had active…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility document review, it was determined the facility failed to ensure staff performed accurate medication administration to a resident; and failed to ensure a resident's current diagnoses were documented in the medical record; and failed to ensure the Minimum Data Set (MDS) and care plan accurately reflected a residents current diagnoses and medications, and care required for 1 (Resident #20) resident; and the facility failed to ensure medication was prepared for administration in accordance with current acceptable standards of practice and facility policy for 2 (Resident #20 and Resident #21) residents; and the facility failed to ensure staff used a mechanical lift according to facility policy and manufacturing guidelines for 1 (Resident # 27) resident of 17 sampled residents. Findings include: A review of a facility policy titled, Administering Medications, dated 11/14/2024 indicated the Director of Nursing (DON) would direct and supervise personnel administering medications and related functions. Medications must be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to ensure its medication error rate was not 5% or greater. There were three errors out of 36 opportunities for 2 (Resident #20 and Resident #21) of 6 residents, which resulted in a medication error rate of 8.33%. Findings include: A review of a facility policy titled, Administering Medications, dated 11/14/2024 indicated, The Director of Nursing (DON) would direct and supervise personnel administering medications and related functions. Medications must be administered in required time frames and per physician orders. Number 7. Indicated the person administering the medication must' verify the five rights that included the resident, medication, dosage, time, and route by checking the label THREE (3) times before administering the medication. Staff shall follow facility infection control procedures when administering medications. A review of the admission Record, indicated the facility admitted Resident #20 with diagnoses that included abdominal pain, hernia, heart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview, the facility failed to ensure residents were free from significant medication errors related to hypothyroid (replacement for deficient or low thyroid hormone level) medication, antiulcer (to prevent development of ulcerations in the stomach and upper small intestine) medication, and insulin administration, for 2 (Resident #20 and Resident #21) of 6 residents reviewed for medication administration. This failed practice resulted in Resident #20 receiving an inaccurate dose of hypothyroid and antiulcer medication from 07/21/2024 through 11/15/2024. Findings include: A review of a facility policy titled, Administering Medications, dated 11/14/2024 indicated the Director of Nursing (DON) would direct and supervise personnel administering medications and related functions. Medications must be administered in required time frames and per physician orders. Number 7. Indicated the person administering the medication must' verify the five rights that included the resident, medication, dosage, time, and route by checking the label THREE (3)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility's policy, the facility failed to ensure staff completed proper handwashing during food preparation and food was prepared safely and properly. The failed practices had the potential to affect all forty-four residents. The findings are: On 11/14/2024 at 10:30 AM, Dietary [NAME] #8 was observed preparing lunch. Dietary [NAME] #8 washed hands turned off the faucet touching the faucet, and dried hands. Dietary [NAME] #8 was observed with long hair, on both the left and right side, hanging out of the hairnet. Surveyor asked Dietary [NAME] #8 to look in the mirror. After noticing the hair in the mirror, Dietary [NAME] #8 secured hair under the hairnet. Dietary [NAME] #8 touched their face after washing hands. Dietary [NAME] #8 touched several dirty surfaces, such as opening drawers, touching clothing, and dishwashing area and then went to preparing food at least three times. Dietary [NAME] #8 donned gloves five times during preparing pureed foods and obtaining temperatures of the prepared foods without washing hands in between each…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, it was determined the facility failed to document and complete a person-centered care plan to facilitate the ability to plan and provide necessary care and services for 1 (Resident #18) sampled resident whose care plan was reviewed. The findings are: A review of an admission Record indicated the facility admitted Resident #18 with diagnosis of pressure ulcer (injury to skin from prolonged pressure) of sacral region (portion of the lower back), stage 2. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/18/2024 revealed Resident #18 had Brief Interview Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section M part M0300 subpart B revealed one stage 2 pressure ulcer. Review of Resident #18's Care Plan, with revision on 9/23/2024, revealed the resident did not have pressure ulcer care planned or treatments for it. During an interview on 11/14/2024 at 5:00 PM, Licensed Practical Nurse/Minimal Data Set/Assistant Director of Nurse (LPN/MDS/ADON) revealed Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to develop and implement a comprehensive resident -centered care plan for 3 (Residents #14, #15, and #34) of 3 sampled residents. The findings are: On 10/05/23 at 8:15 AM, a review of Resident #14's annual Minimum Data Set (MDS) dated [DATE], showed an antidepressant and an opioid medication administered 7 of 7 days. On 10/05/23 at 8:25 AM, a review of Resident #14's Order Summary Report showed physician orders to administer the following: a. Antidepressant medications for dementia, mood disturbance, and anxiety. b. A medication for pain. Review of Resident #14's care plan showed no documentation of medications for mood disturbance, anxiety, or pain. Review of Resident #15's Order Summary Report showed a diagnosis of cirrhosis of the liver and signs and symptoms of depression. On 10/05/23 at 8:46 AM, review of Resident #15's admission MDS dated [DATE] showed an antidepressant and a diuretic administered 7 of 7 days, but no documentation of a diagnosis of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure the mask on the Bilevel Positive Airway Pressure (BiPAP) was stored in a plastic bag to minimize the potential for infections of 1 (Resident #22) of 2 (Resident's #22 and #6) sampled residents. The findings are: During observation on 10/02/23 at 10:40 AM, Resident #22's mask was on top of the BiPAP machine on the bedside table and not inside a plastic bag. During observation on 10/03/23 at 9:30 AM, Resident #22's BiPAP mask was on the bedside table and not inside a plastic bag. During interview on 10/05/2023 at 09:44 AM, Registered Nurse (RN) #1 said a resident's mask on a Bilevel Positive Airway Pressure (BiPAP) should be stored in a plastic bag. During interview on 10/05/2023 at 9:54 AM, Licensed Practical Nurse (LPN) #1 said a resident's mask on a Bilevel Positive Airway Pressure (BiPAP) should be stored or contained when not in use in a plastic lock bag. During interview on 10/05/2023 at 12:09 PM, the Director of Nursing (DON), said a resident's mask should be stored or contained when not in use. in a plastic bag…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure medications and supplies were readily available for 1(Resident #34) of 2 sampled residents. The findings are: Review of Resident #34 Physician Order Summary Report dated 10/3/23 showed an order for Lantus 24 units one time a day, with a start date of 10/2/23. On 10/04/23 at 7:45 AM, Registered Nurse (RN) #1 cleaned the end of the Lantus insulin pen with an alcohol prep pad then withdrew 24 units of insulin from the pen with an insulin syringe. At 7:59 AM, RN #1 administered 24 units of Lantus insulin to Resident #34. During an interview on 10/04/23 at 8:02 AM, RN #1 said the insulin was drawn up in a syringe because there are no needles for the pen, and they were ordered over a week ago. On 10/04/23 at 8:06 AM, observed the clean utility room and the medication room with the DON and RN #1. There were no needles for the Lantus Insulin Pens. During an interview on 10/06/23 at 11:20 AM, the Director of Nursing (DON) said the Lantus pen comes with its own set of needles, and confirmed the insulin should not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to maintain a medication error rate of less than 5% for 3 (Residents #23, #29, and #34) of 9 residents observed during the medication pass. The findings are: The medication error rate was 6.45% based on observation of 31 medications opportunities, and a total of 2 medication errors. Review of Resident #29 Physician Order Summary Report, dated 10/4/23 showed an order for Albuterol Sulfate (sensor) Inhalation Aerosol Powder Breath Activated 108 (90 Base), 1 puff by mouth every 4 hours as needed for Shortness of breath, with a start date of 9/22/23 . On 10/04/2023 at 7:39 AM observed Licensed Practical Nurse (LPN) #2 administer 1 puff of Albuterol Sulfate HFA 90 mcg to Resident #29. LPN #2 waited 30 seconds and administered 1 puff of Albuterol Sulfate HFA 90 mcg to Resident #29. The order was for 1 puff. During an interview on 10/05/23 at 9:44 AM LPN #1, said you wait 3-5 minutes between puffs when using an inhaler. Review of Resident #34 Physician Order Summary Report dated 10/3/23 showed an order for Lantus 24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and interview the facility failed to ensure physician's orders were followed to prevent a significant medication error, which could result in complications for1(Resident #34) of 2 sampled residents. The findings are: Review of Resident #34's Physician Order Summary Report dated 10/3/23, showed an order for Lantus 24 units one time a day, with a start date of 10/2/23. On 10/04/23 at 7:45 AM, Registered Nurse (RN) #1 cleaned the end of the Lantus insulin pen with an alcohol prep pad then withdrew 24 units of insulin from the pen with an insulin syringe. At 7:59 AM, RN #1 administered 24 units of Lantus insulin to Resident #34 During an interview on 10/04/23 at 8:02 AM, RN #1 said the insulin was drawn up in a syringe because there are no needles for the pen, and they were ordered over a week ago. On 10/04/23 at 8:06 AM observed the clean utility room and the medication room with the DON and RN #1, there were no needles for the Lantus Insulin Pens. During an interview on 10/06/23 at 11:20 AM, the Director of Nursing (DON) said the Lantus pen comes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure safe and secure storage and administration, of medications to minimize the potential of harm. This failed practice had the potential to harm residents that are ambulatory on the 100 hall. The findings are: During observation on 10/03/23 at 8:37 AM, Resident #33 was in the bathroom and a medicine cup with medications were on the Resident's bedside table unsupervised. During interview on 10/3/2023 at 10:40 AM, Registered Nurse (RN) #1 confirmed she left the medication in the cup on the bedside table. During interview on 10/05/2023 at 11:23 AM, the Director of Nursing (DON) said medications should not be left on a resident's bedside table unattended. Review of facility policy with a revision date of 09/26/23 titled Medication Storage showed, during a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area or cart.

Based on observation, record review and interview, the facility failed to ensure infection control measures were consistently implemented to reduce the spread of disease and infection during a procedure and medication administration for 4 of 4 (Residents #22, #25, #34, and #39) sampled residents. The findings are: During observation on 10/03/23 at 11:42 AM, Registered Nurse (RN) #1 obtained a blood glucose from Resident #22 using a multi resident glucometer without performing hand hygiene or clean the glucometer device before, during, or after the procedure. During observation on 10/03/23 at 11:48 AM, RN #1 administered eye drops to Resident #22's eyes and did not perform hand hygiene before or after administration. During observation on 10/03/23 at 11:54 AM, RN #1 performed a blood glucose testing procedure on Resident #34 using a multi resident glucometer without performing hand hygiene or clean the glucometer device before, during, or after the procedure. RN #1 said, I forgot to clean the glucometer machine, we used to have wipes, but I'll clean it with this now. RN #1 used an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.