Countryside Estates

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure residents were offered the right to formulate an advanced directive for five (#6, 12, 14, 31, and #35) of eight sampled residents reviewed for advanced directives. DON #1 identified 70 residents resided in the facility. Findings: 1. Res #6 admitted to the facility on [DATE]. Res #6's medical record did not contain an advanced directive acknowledgement form. 2. Res #14 admitted to the facility on [DATE]. Res #14's medical record did not contain an advanced directive acknowledgement form. 3. Res #31 admitted to the facility on [DATE]. Res #31's medical record did not contain an advanced directive acknowledgement form. 4. Res #12 admitted to the facility on [DATE]. Res #12's medical record did not contain an advanced directive acknowledgement form. 5. Res #35 admitted to the facility on [DATE]. Res #35's medical record did not contain an advanced directive acknowledgment form. On 01/08/25 at 11:07 a.m, the social services director reported they…

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 a resident was assessed, a care plan was completed, and a physician order was obtained for the use of a physical restraint for one (#25) of one sampled resident reviewed for physical restraints. The ADON identified one resident who utilized a wheelchair lap seat belt. Findings: An undated Use of Restraints policy, read in parts, All restraints must have a physician's order and an order for evaluation by designee for the least restrictive device that is appropriate for the resident .Restraints shall be used only for safety or postural support of a resident to prevent injury to self or others .An assessment regarding the need of restraint for the resident will be completed and documented .The physician's restraint order must be detailed and specific; the order must include type of device, specific duration of use, reason for use and frequency of release .Informed consent for physical restraint will be obtained from the resident or legal representative .The plan of care will identify the need for…

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, record review, and interview, the facility failed to ensure a comprehensive care plan was developed for one (#21) of 18 sampled residents reviewed for comprehensive care plans. DON #1 identified 70 residents resided in the facility. Findings: A facility policy titled Care Planning - Interdisciplinary Team, revised 09/2013, read in parts, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .A comprehensive care plan for each resident is developed with seven (7) days of completion of the resident assessment (MDS) .The care plan is based on the resident's comprehensive assessment. A facility policy titled Care Plans, Comprehensive Person-Centered, revised 12/2016, read in part, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Resident #21…

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 update the care plan related to wound/treatment care for one (#6) of 18 sampled residents reviewed for care plans. DON #1 identified 70 residents who resided in the facility. Findings: Res #6 admitted to the facility with diagnoses which included traumatic brain injury, dependence on respirator, and tracheostomy. A physician's order, dated 12/14/24, documented to apply Betadine to scabbed area to left dorsal lateral foot daily until resolved. The resident's record was reviewed and the care plan had not been revised to document the wound to the left foot. On 01/09/25 at 8:40 a.m., DON #2 was asked to review the resident's care plan. They stated it should have been revised to document the area to the left foot.

Based on observation and interview the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The DON documented 40 residents received meals from the kitchen. Findings: 1. On 10/19/23 at 9:21 a.m., an initial tour of the kitchen was conducted. A cut tomato in a sealed bad, dated 10/17/23, a cut up onion in a sealed bad, dated 10/13/23, and vegetable soup in a sealed container, dated 10/09/23 were observed in the refrigerator. On 10/19/23 at 9:30 a.m., [NAME] #1 entered the kitchen with a sack containing salad and other items. [NAME] #1 was not observed to wash their hands when they entered the kitchen. [NAME] #1 was observed to start dating the bags of salad and placing them in the refrigerator. On 10/25/23 at 11:09 a.m., [NAME] #1 was observed to touch their face and put their hand on their hip and then continue to prepare the pureed meals. [NAME] #1 was not observed to wash their hands during this observation. On 10/25/23 at 11:14 a.m., [NAME] #1 was observed to touch their glasses, cleaned the can opener,…

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, record review, and interview the facility failed to ensure residents with limited ROM received the appropriate treatment and services to increase ROM and/or to prevent further decrease in ROM for four (#12, 23, 53, and #69) of six residents reviewed for position/mobility. The DON documented 41 resident with contractures resided in the facility. Findings: 1. Res #23 had diabetes mellitus, cerebral palsy, CVA, and TIA. A quarterly assessment, dated 08/09/23, documented the resident was intact in cognition and required extensive assistance with ADLs. The assessment documented the resident had limited ROM of the upper and lower extremity on one side. A care plan, updated 09/18/23, documented the resident had limited mobility due to left side hemiparesis related to CVA. A physical therapy Discharge summary, dated [DATE], documented the resident would discharge from physical therapy to the care of restorative nursing. A order for restorative care was not found in the EHR. On 10/19/23 at 11:11…

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 have a program designed to help prevent the development of Legionellosis and Pontiac fever caused by Legionella Bacteria. The Resident Census and Conditions of Residents form documented 77 residents resided in the facility. Findings: A policy titled Legionella Surveillance and Detection documented .Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella . On 10/26/23 at 10:08 a.m., the maintenance staff stated they did not have a documented plan for Legionella. On 10/26/23 at 10:19 a.m., the ADON stated the plan for Legionella was a work in progress.

Based on observation, record review, and interview, the facility failed to ensure regular inspection of all bed frames, mattresses, and bed rails, were conducted as part of a regular maintenance program to identify areas of possible entrapment. The DON documented 75 residents living in the facilty had bed rails in use. Findings: A Proper Use of Side Rail policy, undated, read in part, .2. Side rails are only permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents .13. When side rail usage is appropriate, the facility will assess the space between mattress and side rail to reduce the risk for entrapment (the amount of safe space may very, depending on the type of bed and mattress being used) . On 10/26/23 at 10:09 a.m., the maintenance man stated the side rails on the beds were not inspected as the policy stated. The maintenance man stated if there was a problem with the bed or rails nursing would report the problem to them and the problem would be fixed immediately.

Based on record review and interview, the facility failed to permit a resident to return to the facility after a hospitalization for one (#126) of three residents reviewed for hospitalization. The facility identified nine residents who had been discharged in the past three months. Findings: A form titled Admission, Transfer and Discharge Rights, read in part, .You may not be transferred or discharged unless your needs cannot be met, your safety is endangered, or services are no longer required .Notice of transfer or discharge must be given to you 30 days prior, except in cases of health and safety needs . Res #126 was admitted to the facility with diagnoses which included methicillin susceptible staphylococcus aureus infection, non-pressure chronic ulcer of right foot, and diabetes mellitus. The admission assessment, dated 12/25/22, documented the resident was cognitively independent for decision making and required extensive assistance with dressing and toileting. A progress note, dated 03/15/23 at 9:16 p.m., documented the resident requested to be sent to the hospital. The 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 record review and interview, the facility failed to ensure recommendations from a resident's PASRR II was incorporated into the resident's plan of care for one (#56) of one sampled resident whose PASRR was reviewed. The DON documented 29 residents with PASRR II evaluations resided in the facility. Findings: Res #56 had diagnoses which included post traumatic stress disorder and schizophrenia. A PASRR level II, dated 11/14/22, documented the resident should receive a dental evaluation and treatment as required; visual examination and treatment as required; the residents room should be personalized and appear non institutional; and the resident should be encouraged to make independent choices regarding room decorations like bedding. The PASRR level II documented the resident to have ADL training in dining skills and dressing and have community integration including but not limited to shopping at a variety of stores, movie rental, going out to eat at a variety of restaurants. The PASRR evaluation documented community outings should be provided to include medical appointments;…

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 with a diagnosis of PTSD received culturally competent trauma informed care in order to eliminate or mitigate triggers which could cause re-traumatization of the resident for one (#56) of one resident reviewed for behaviors. The DON documented one resident with PTSD resided in the facility. Findings: Res #56 had diagnoses which included paraplegia, PTSD, and schizophrenia. A significant change assessment, dated 03/21/23, documented the resident had a PASRR II for serious mental illness. The assessment documented the resident had modified independence with some difficulty in new situations only and required extensive assistance with most ADLs. The assessment documented the resident had no behaviors during the look back period. A care plan, dated 06/26/23, documented the resident received antipsychotic medications for diagnosis of schizophrenia for target behaviors of anger, hostility, and self-harm. The care plan documented the resident had been identified as having a PASRR positive status…

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 written information concerning the right to formulate an advanced directive for three (#55, 56, and #122) of three sampled residents reviewed for advance directives. The Resident Census and Conditions of Residents report, dated 01/31/22, documented 71 residents resided in the facility. Findings: The Advance Directive policy read in part, .Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . 1. Resident (Res) #55 was admitted to the facility on [DATE]. There was no documentation the resident had been provided information related to formulating an advance directive. On 02/01/22 at 4:40 p.m., the director of nurses (DON) stated an advance directive acknowledgement form was in the resident's clinical record, but had not been signed by the resident or the resident's representative. She stated…

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, it was determined the facility failed to provide baths/showers as scheduled for four (#14, 25, 68 and #10) of five sampled residents. The census and condition, dated 1/31/22, documented census of 71 residents residing in the facility. Findings: A facility policy and procedure, revised February 2018, documented female residents would shower on Monday, Wednesday, and Friday. The policy documented male residents would shower on Tuesday, Thursday, and Saturday. The policy documented the staff would report to the supervisor/charge nurse if the resident refused a shower, and the staff would document the refusal and why the resident refused. 1. Resident (Res) #14 was admitted on [DATE] with diagnoses which included heart failure, hypertension, anemia, diabetes, and hyponatremia. A quarterly assessment, dated 11/27/21, documented the resident was cognitively intact and required one person assist for bathing. On 01/31/22 at 9:42 a.m., the resident reported she had one…

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 it was determined the facility failed to ensure a comprehensive care plan was in place for one (#68) of 16 residents who were reviewed for care plans. The administrator reported there were 71 residents in the facility. Findings: Resident #68 was admitted on [DATE] with diagnoses of heart failure, hypertension, and end stage renal disease. An admission assessment, dated 01/18/22, documented the resident's cognition was moderately intact and required assistance with ADLs. The clinical record contained no comprehensive care plan. On 02/07/22 10:25 a.m., the minimum data set (MDS) coordinator reported the resident's comprehensive care plan had not been completed.