Countryside Manor Health & Living Community

Based on record review and interview, the facility failed to ensure Skilled Nursing Facility Advanced Beneficiary Notices (SFN ABN) were provided to residents and/or resident representatives at the end of Medicare A covered services and failed to ensure the forms were completed appropriately when provided to residents and/or resident representatives for 2 of 3 residents reviewed for Beneficiary Notice. (Residents 104 and 41) The deficient practice was corrected on 2/9/26, prior to the start of survey, and was therefore past noncompliance. Findings include: On 2/20/26 at 11:11 a.m., the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review Forms were reviewed, and indicated the following:1.Resident 104 was admitted to Medicare Part A Skilled Services on 7/10/25. The last covered day of Part A services was 8/4/25. The SNF Notice of Medicare Non-Coverage (NOMNC) was reviewed with the resident's representative by phone on 8/1/25. The NOMNC indicated the resident had exhausted their Medicare A benefits.The clinical record lacked the SNF ABN.A 8/1/25, progress note…

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 insulin (a medication to treat diabetes mellitus) pens were labeled with resident identifiers, dated when opened, and disposed of when expired for 2 of 5 carts reviewed for medication storage. (300 south cart and 300 short cart)Findings include:1.During a medication storage observation, on 2/19/26 at 9:59 a.m., of the 300-hall south cart, accompanied by the Unit Manager, the following was observed:One open Lantus (long-acting) insulin pen dated 1/17/26; the pen had approximately 80 units remaining.One open Novolog (rapid-acting) insulin pen dated 1/10/26; the pen had approximately 175 units remaining.During an interview at the time of the observation, the Unit Manager indicated that insulin was good for 30 days and all expired insulin needed to be disposed of properly. The Unit Manager confirmed the open insulin pens had expired. She indicated only two residents received insulin from this medication cart.2.During a medication storage observation, on 2/19/26 at 10:18 a.m., of the 300-hall short cart, accompanied by QMA…

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 interview and record review, the facility failed to ensure staff followed resident care plan interventions and facility protocol while utilizing a mechanical lift during a transfer of a dependent resident for 1 of 4 residents reviewed for accidents. (Resident B) Findings include: Resident B's clinical record was reviewed on 4/11/25 at 10:40 a.m. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease affecting right dominant side, diabetes mellitus, hypertension, dysphagia, and chronic kidney disease. The most current Significant Change Minimum Data Set (MDS) assessment, dated 3/18/25, indicated the resident was depended for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, chair/bed-to-chair transfer, and tub/shower transfer. A current care plan titled CNA Assignment Sheet Resident has specific needs related to their care, dated 11/09/22, had an intervention dated 11/09/22, of the resident is assisted with two person…

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 observation, interview, and record review, the facility failed to ensure completion of wound care treatment as ordered to promote healing of a pressure injury for 1 of 3 residents reviewed for pressure injuries. (Resident 63) Finding Includes: Resident 63's clinical record was reviewed on 12/30/24 at 11:04 a.m. Diagnoses included an unspecified fracture of lower end of right femur, unspecified disorder of the skin and subcutaneous tissue, and end stage renal disease. A quarterly Minimum Data Set (MDS) assessment, dated 11/8/24, indicated the resident did not have any pressure injuries, was occasionally incontinent of bowel and bladder, required partial staff assistance for bed mobility, and did not transfer to utilize the toilet. A current care plan, dated 11/13/24, indicated Resident 63 was at risk for skin breakdown. Interventions included to assist with bed mobility (11/23/24), turn and reposition per resident's needs (11/13/24), and monitor skin for signs of breakdown (11/13/24). The clinical record…

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 observation, interview, and record review, the facility failed to follow infection prevention and control procedures related to contact isolation (additional precautions used when standard precautions may not be enough to stop the spread of infection) precautions for 2 of 3 resident reviewed for transmission-based precautions. (Resident 61 and 227) Finding includes: 1. During an observation, on 12/27/24 at 2:09 p.m., Resident 227 was lying in bed and indicated she had been in the facility for roughly five days. She was going to the gym for therapy. On the door to Resident 227's room was an orange Contact Precautions sign, and three (3) signs with directions on putting on and taking off personal protective equipment (PPE). The PPE was hanging on the door inside plastic dividers. The dividers contained gowns, gloves, face masks, and face shields. During an observation, on 12/30/24 at 2:19 p.m., Resident 227 was being propelled in her wheelchair down the hallway towards her room, by PTA 4. PTA 4 and…

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 interview and record review, the facility failed to thoroughly investigate an allegation of misappropriation of resident property for 1 of 3 residents reviewed for misappropriation. (Resident B) Finding includes: Review of a facility investigation, on 9/9/24 at 3:20 p.m., indicated a statement signed on 8/2/24 by the Regional Marketing Consultant of a conversation held with the resident B's Family Member 2. It indicated Family Member 2 reported money was stolen from a plastic envelope out of the resident's purse in her nightstand. The statement lacked information regarding when it was identified missing, to whom it was reported, and who reported it missing prior to 8/2/24. The statement was not signed by Family Member 2. Five staff Abuse Allegation Questionnaires were included, but were not completed by direct staff members who were on duty when the alleged theft was reported. The investigation lacked how much money was reported missing, names or statements from staff who received the initial alleged…

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 interview and record review, the facility failed to report an incident of a resident leaving the facility and the facility being unsure of her whereabouts for 1 of 1 resident reviewed for an unusual occurrence. (Resident C) Findings include: Resident C's clinical record was reviewed on 6/24/24 at 10:27 a.m. Diagnoses included unspecified severe protein-calorie malnutrition, adult failure to thrive, difficulty in walking, type II diabetes mellitus without complications, history of falling, attention and concentration deficit following other cerebrovascular disease, and other speech and language deficits following other cerebrovascular disease. Orders included insulin lispro (short acting) insulin per sliding scale three times daily, metformin (treat diabetes) 750 mg twice daily, mirtazapine (treat depression) 7.5 mg daily, acetaminophen (treat pain) 1000 mg three times daily, and cleanse coccyx wound with wound cleanser, pat dry, apply Medihoney (for wound healing) to wound bed and cover with a foam…

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 medication carts were kept locked when unattended, and failed to ensure proper labeling of medications for 2 of 3 carts observed for medication storage on the 200 Hall. Findings included: On 6/24/24 at 3:12 p.m., the two medication carts on the Southeast 2 unit were observed to be unlocked and unattended by staff. Residents were observed in the hallways and in the lounge area at this time. During an interview on 6/24/24 at 3:17 p.m., RN 1 indicated the nurse (LPN 2) responsible for the medication cart had stepped off the unit. She indicated the nurse also had the keys for the 2nd (overflow) medication cart. The overflow medication cart contained oral pills. The top drawer contained oral pills (identified as 19 melatonin (supplement for sleep) and 8 potassium chloride 10 meq) without resident indicators. RN 1 indicated she did not know why theses medications were not in a box with a resident's name or identifiers. During an interview on 6/24/24 at 3:22 p.m., LPN 2 she would normally lock the medication…

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 interview and record review, the facility failed to resolve resident council concerns related to call lights being turned off prior to assistance and long call light wait times. (Residents 2, 9, 10, 16, 20, 38, 49, 54 and 73) Findings include: During the Resident Council meeting on 11/29/23 at 2:35 p.m., Residents 2, 9, 10, 16, 20, 38, 49, 54 and 73 indicated the wait for call lights to be answered was long, and staff would turn off the call light without completing care. During an interview on 11/27/23 at 10:58 a.m., Resident 67 indicated the call light wait time ranged from 1 to 2 hours, with the average being around an hour. During review of the resident council minutes, on 11/28/23 at 9:57 a.m., the following was observed: The 8/23/23 minutes indicated residents were concerned about the call light issues not being addressed, and the resident council meeting was the only place to voice a grievance. The record lacked a facility follow-up. The 9/25/23 minutes indicated residents were concerned about staff turning call lights off prior to providing care and long call light…

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 interview and record review, the facility failed to provide notification of Medicare non-coverage for 3 of 3 residents reviewed for beneficiary protection notifications. (Resident 68, 185, and 71) Findings include: On 11/28/23 at 2:25 p.m., the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review Forms were reviewed, and indicated the following: 1. Resident 68 had admitted to the facility on [DATE] under Medicare Part A Skilled Services. The last covered day of Part A Services was 8/5/23. The resident remained in the facility. The clinical record lacked both Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Non-coverage (NOMNC) notices. 2. Resident 185 had admitted to the facility on [DATE] under Medicare Part A Skilled Services. The last covered day of Part A Services was 10/12/23. The resident discharged home on [DATE]. The clinical record lacked a NOMNC notice. 3. Resident 71 had admitted to the facility on [DATE] under…

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 record review and interview, the facility failed to educate resident council members on the facility grievance process. (Residents 9, 16, 20, 38, 54, and 73) Findings include: During the Resident Council meeting on 11/29/23 at 2:30 p.m., residents 9, 16, 20, 38, 54, and 73 indicated they did not know the grievance process or how to file a grievance. During a record review on 11/28/23 at 9:57 a.m., the resident council binder lacked a record of grievances filed. During an interview on 11/30/23 at 9:25 a.m., the Administrator indicated there were no grievances from the resident council meetings and the Social Services Director (SSD) was the facility's grievance designee. During an interview on 12/1/23 at 2:03 p.m., the SSD indicated she has not received grievance forms from the resident council meetings, as Resident Council concerns were handled during the meetings. During an interview on 12/4/23 at 10:56 a.m., the Activities Director (AD) indicated she utilized the Resident/Family Concern/Grievance Form, when resident council members present concerns during the meeting. She…

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 record review and interview, the facility failed to ensure comprehensive assessments were completed per the Resident Assessment Instrument (RAI) specified timeline. (Resident 63, 38, 47, 79 and 287) Findings include: 1. Resident 63's clinical record was reviewed on 11/28/23 at 2:10 p.m. Current diagnosis included acute renal failure, aphasia, and dysphagia. The resident had a 10/17/23 significant change Minimum Data Set (MDS). The assessment was signed by the MDS Coordinator on 11/08/23 (22 days after the assessment date). This resulted in the assessment being signed eight days late. During an interview on 12/4/23 at 10:57 a.m., the MDS Coordinator indicated Resident 63's MDS was signed late due to the lack of an MDS assistant during that time period and the inability to complete all tasks in a timely manner. 2. Resident 38's clinical record was reviewed on 11/28/23 at 2:14 p.m. Current diagnosis included end stage renal disease, complete traumatic amputation of left lower leg, and diabetes mellitus. The resident was readmitted to the facility 9/25/23. The resident had a…

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 narcotics were reconciled per facility policy for 2 of 3 medication carts reviewed for medication storage. (41 South cart and 41 North cart) Findings include: 1. During a medication storage observation of the 41 South cart, accompanied by LPN 6 on 12/4/23 at 11:10 a.m., the Nurse's Narcotic Sign In/Out Sheet record was reviewed and the following dates lacked shift to shift reconciliation of controlled medications: In November 2023- 11/2 on day and evening shifts, 11/3 on day shift, 11/4 on night shift, 11/8 on day and night shifts, 11/13 on night shift, 11/15 on day and evening shifts, 11/16 on day and evening shifts, 11/18 on evening and night shifts, 11/19 on day shift, and 11/30 on day shift. 2. During a review of the 41 North cart, Nurse's Narcotic Sign In/Out Sheet record, provided by the DON on 12/4/23 at 12:10 p.m., the following dates lacked shift to shift reconciliation of controlled medications: In November 2023- 11/1 on day shift, 11/4 on all three shifts, 11/5 on day shift, 11/10 on day…

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 appropriately label medications brought in to the facility by the resident or resident family and stored in the medication cart in 1 of 3 medication carts. (34 South Hall medication cart) Findings include: On 12/4/23 at 11:30 a.m., during observation of the 34 South Hall medication cart, accompanied by LPN 5, the following was observed: a. Four bottles of Omega XL 300 mg (milligram) (dietary supplement), lacked a resident name or pharmacy label. b. On bottle of D3 5000 units (vitamin supplement), lacked a resident name or pharmacy label. c. Sleep XL (dietary supplement), lacked a resident name or pharmacy label. During an interview at the time of observation, LPN 5 indicated there was no resident name or prescribing information on the bottles. Review of current, undated facility policy titled, Medication Labeling, provided by the Nurse Consultant on 12/4/23 at 12:34 p.m., indicated the following: .Procedure .8. Over the counter medications used for a specific resident must identify that resident and have an appropriate…

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.