Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Countryside Health Center during CMS and state inspections, most recent first.
Five nursing staff, including CNAs and CMAs, did not have documented yearly performance evaluations despite being employed for over 12 months. Administrative staff confirmed that these evaluations had not been completed as required, and no policy for yearly reviews was available.
A facility-wide assessment failed to specify staffing needs by shift for weekends, despite evidence of low weekend staffing throughout the year. The administrator confirmed that the assessment did not differentiate between weekday and weekend staffing, even though staffing patterns differed. This deficiency affected all residents in the facility.
The facility did not submit complete and accurate direct care staffing information to CMS via the PBJ system, as reports indicated excessively low weekend staffing for all four quarters, despite administrative staff stating that weekend staffing was consistent with weekday levels.
The facility did not have a system to track or verify that nursing staff maintained current CPR certification, resulting in an inability to confirm that staff on evening and night shifts were qualified to provide CPR to residents who had requested full code status.
Surveyors found that medication carts were left unlocked and unattended, with insulin pens, needles, and a glucose monitor accessible, and an opened, undated vial of tuberculin test serum stored in the medication refrigerator. Staff confirmed that facility policy requires all medications and biologicals to be securely stored and locked, but these procedures were not followed.
The facility did not provide required signage for two residents on Enhanced Barrier Precautions, leading to a lack of clear communication to staff and visitors about necessary PPE. Linens were observed being transported uncovered in hallways, and the laundry area lacked appropriate PPE for staff handling soiled items. Staff interviews revealed inconsistent understanding of infection control protocols.
A resident with multiple health conditions developed a Stage 2 pressure ulcer, but the facility failed to update the care plan to include skin care and pressure ulcer prevention interventions. Although wound care and nutritional support were provided following physician orders, these actions were not incorporated into the care plan, and staff confirmed the absence of necessary updates. This deficiency was identified despite facility policy requiring comprehensive care planning for pressure ulcer prevention and management.
A resident with multiple health conditions developed a Stage 2 pressure ulcer after the facility failed to include skin care and pressure ulcer prevention in the care plan, despite known risk factors and policy requirements. Staff confirmed that the care plan lacked necessary interventions both before and after the wound was identified.
Two residents with PTSD did not have their trauma-based triggers identified or individualized interventions implemented in their care plans. Although both residents had documented mental health diagnoses and care plans addressing general symptoms, the plans lacked specific information about their trauma histories and triggers. Staff interviews confirmed that care plans should include this information, but it was missing, contrary to facility policy.
Failure to Complete Yearly Performance Evaluations for Nursing Staff
Penalty
Summary
The facility failed to complete yearly performance evaluations for five staff members, including two Certified Nurse Aides (CNAs) and three Certified Medication Aides (CMAs), all of whom had been employed for more than 12 months. Record review showed that none of these staff had a documented yearly performance evaluation available upon request. Administrative staff confirmed that the responsibility for completing these evaluations rested with the employees' supervisors and acknowledged that the required reviews had not been conducted in the past 12 months. Additionally, the facility was unable to provide a policy outlining the requirement for yearly performance reviews.
Failure to Conduct Comprehensive Facility-Wide Assessment for Staffing Needs
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. The assessment, last updated on 01/30/25, identified required staffing needs per day but did not specify staffing needs by shift for weekends. Review of the facility's Payroll Based Journaling (PBJ) Staffing Data Report for the previous year showed excessively low weekend staffing in all four quarters. The administrator confirmed that nursing hours were set by the corporate office and that the assessment did not differentiate between weekday and weekend staffing, despite weekends being staffed differently due to increased staff presence on weekdays. The facility's policy required a documented assessment of resources needed for resident care during both regular operations and emergencies, but this was not fully implemented.
Failure to Accurately Report Direct Care Staffing Data
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare & Medicaid Services (CMS) through the Payroll Based Journaling (PBJ) system. Review of the PBJ report for all four quarters of Fiscal Year 2024 indicated that the facility triggered for excessively low weekend staffing. However, the administrative nurse stated that weekend staffing levels were the same as during the week and suggested there was an error in the reporting of hours. The facility's policy required direct care staffing information to be submitted to the PBJ system on the schedule specified by CMS, but the submitted data did not accurately reflect actual staffing levels.
Failure to Track and Verify Staff CPR Certification
Penalty
Summary
The facility failed to establish and maintain a system to ensure that nursing staff maintained current cardiopulmonary resuscitation (CPR) certification for healthcare providers. During a review of staff records for specific dates and shifts, the facility was unable to provide verification of CPR certification for staff members who worked on the evening and night shifts. Administrative staff confirmed that there was no system in place to track staff CPR certification. The facility had a census of 95 residents, with 85 residents identified as full code, indicating their desire to receive resuscitative measures such as CPR in the event of cardiac arrest. The facility's policy required that basic life support and CPR be provided in accordance with physician orders and residents' advance directives. However, the lack of a tracking system for staff CPR certification resulted in the inability to verify that staff on duty were qualified to provide these life-saving measures when needed.
Failure to Properly Label and Secure Medications and Biologicals
Penalty
Summary
Surveyors observed multiple instances where medications and biologicals were not properly labeled or securely stored. On one occasion, a medication cart was found unlocked in the dining room with an insulin pen placed on top, and the cart contained a box with several residents' insulin pens, needles, and a glucose monitor. Additionally, the medication refrigerator contained an opened, undated vial of tuberculin test serum. Another medication cart was found unsecured in the commons area. These observations were confirmed by staff interviews, where it was stated that medication carts should never be left unattended and that insulin pens and needles must be locked when not in use. Facility policy requires that medications and biologicals be stored safely, securely, and properly, accessible only to authorized personnel. Staff interviews further confirmed that medication carts should be locked at all times and that keys should be kept on the person of the responsible staff member. The failure to follow these procedures resulted in medications and biologicals being accessible in unsecured areas, contrary to facility policy and accepted professional standards.
Failure to Implement Infection Control Signage and PPE Practices
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for residents on Enhanced Barrier Precautions (EBP). Specifically, there was no signage or indicator in the rooms of two residents on EBP to alert staff and visitors of the required precautions and personal protective equipment (PPE). Observations confirmed the absence of EBP indicator signage in both rooms. Staff interviews revealed inconsistent knowledge about which residents were on EBP and what PPE was required, with some staff relying on an orange dot on the resident's name plate as the only indicator, and no signage present inside the rooms. Additionally, the facility did not ensure that linens transported in the hallways were covered, as observed when a staff member pushed an uncovered cart of blankets. The laundry area also lacked appropriate PPE for staff sorting dirty laundry, and a staff member reported being unaware of the need for PPE during this task. The facility's infection control policy required measures to prevent and control infections, but these were not consistently implemented as observed during the survey.
Failure to Update Care Plan for Pressure Ulcer Prevention and Management
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan addressing skin care and pressure ulcer prevention for a resident who developed a Stage 2 pressure ulcer. The resident, who had diagnoses including type 2 diabetes mellitus, seborrheic dermatitis, schizoaffective disorder, and COPD, was assessed as being at low risk for pressure ulcer development using the Braden Scale and had a pressure-reducing device for his bed. Despite these risk factors and the presence of a formal assessment indicating potential for altered skin integrity, the care plan did not include a specific area for skin care or pressure ulcer prevention, nor was it updated after the development of the pressure ulcer. The resident's medical record documented the emergence of two open areas on the right upper buttock, which were first observed and treated by staff, and subsequently confirmed as a Stage 2 pressure ulcer. Physician orders were obtained for wound care, including cleansing, application of wound gel with collagen, and use of a foam dressing, as well as nutritional supplementation to support wound healing. The wound and the resident's condition were communicated to the physician, family, and dietitian, and interventions such as a pressure-relieving cushion and hygiene education were provided. However, these interventions were not reflected in the resident's care plan, and staff interviews confirmed that the care plan lacked necessary updates and interventions related to skin care and wound prevention. Facility policy required the development of a comprehensive, individualized care plan to address pressure ulcer prevention and management, including collaboration among the resident, representative, physician, dietitian, and clinical staff. The failure to update the care plan with appropriate interventions after the development of the pressure ulcer constituted a deficiency, as it did not meet the facility's own standards or regulatory requirements for care planning and risk management.
Failure to Address Pressure Ulcer Risk and Prevention in Resident Care Plan
Penalty
Summary
The facility failed to recognize and address the risk of pressure ulcer development for a resident with multiple medical conditions, including type 2 diabetes mellitus, seborrheic dermatitis, schizoaffective disorder, and COPD. Despite the resident being identified as at risk for pressure ulcers and having a Braden Scale assessment completed, the care plan did not include a specific area for skin care or pressure ulcer prevention. The resident was independent with most activities of daily living and had a pressure-reducing device for the bed, but the care plan lacked individualized interventions to address skin integrity and prevent pressure injuries. The first observation of a Stage 2 pressure ulcer on the resident's upper right buttock was documented in the medical record, with subsequent physician orders for wound care and nutritional supplementation. Prior to the identification of the wound, there was no evidence that the care plan had been updated to include interventions for skin care or pressure ulcer prevention, despite the resident's risk factors. Staff interviews confirmed that the care plan should have included such interventions and that it was not updated after the wound developed. Facility policy required comprehensive assessment, individualized care planning, and implementation of interventions to prevent pressure ulcers, as well as regular monitoring and modification of care plans as needed. However, the facility did not follow these procedures for the resident, resulting in a failure to prevent the development of a pressure ulcer and to address the resident's risk in a timely manner.
Failure to Identify PTSD Triggers and Implement Trauma-Informed Interventions
Penalty
Summary
The facility failed to provide trauma-informed care for two residents diagnosed with post-traumatic stress disorder (PTSD). For one resident, the care plan documented diagnoses including hypertension, anxiety, nicotine dependence, PTSD, schizoaffective disorder, bipolar disorder, and insomnia. Although the care plan addressed general symptoms of anxiety and included some interventions such as maintaining routines and monitoring medication, it did not identify the specific trauma that caused the PTSD or any individualized triggers that could lead to re-traumatization. The care plan also lacked personalized interventions to assist the resident in coping with PTSD, and the assessment documented no PTSD issues reported, despite the diagnosis being present in the medical record. For the second resident, the care plan acknowledged a history of PTSD and noted that the resident could be easily startled or feel detached from others. However, the care plan did not provide staff with specific information about the trauma, potential triggers, or interventions to prevent re-traumatization. The resident's assessments included regular PTSD screenings, but these did not document the specific trauma or possible triggers. Staff interviews revealed an expectation that care plans should include this information, but it was not present in the documentation reviewed. The facility's policy on trauma-informed care required that residents who are trauma survivors receive care that accounts for their experiences and preferences, including the identification of trauma and potential triggers. Despite this policy, the care plans and assessments for both residents did not meet these requirements, as they failed to identify trauma-based triggers or implement individualized interventions to prevent re-traumatization.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Topeka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy On 10th Avenue | 0.6 mi | ★★★★★ | 22 | 0 |
| Providence Living Center | 0.7 mi | ★★★★★ | 52 | 1 |
| Brighton Place North | 2 mi | ★★★★★ | 13 | 0 |
| Brewster Health Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Brighton Place West | 4.2 mi | ★★★★★ | 1 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.