Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Manor Nursing And Rehabilitation Llc during CMS and state inspections, most recent first.
Unclean and unmaintained resident areas were observed throughout the facility, including a resident room with sticky amber residue and black debris around the toilet, a broken windowsill, and debris on the floor. Surveyors also found unidentified brown substance, grime, and debris in hallways and by the nursing station, plus common showers with brown and black substances, scattered debris, and broken drywall. Staff, including a CNA, RN, Housekeeping Aide, LPN, and the Administrator, verified the conditions.
Failure to Report Missing Controlled Substances: The facility failed to report missing controlled meds designated for destruction as misappropriation to the state agency after an internal investigation found the drugs were absent and there was no evidence of destruction. The missing opioids involved multiple residents, and the RCD and Administrator stated the event was reported to other boards but not as an SRI to ODH.
The facility failed to implement fall prevention interventions for two residents and failed to complete required smoking assessments for two residents. One resident with multiple neurologic and psychiatric diagnoses was transferred without the ordered dycem and without the reminder sign, while another resident with CHF, dementia, and CKD did not have the ordered bed mats in place. In addition, one resident listed as a smoker had incorrect smoking evaluations, and another resident began smoking after admission but had no smoking assessment completed until the quarterly review; the DON confirmed the gap.
The facility failed to notify the physician and resident representatives after changes in condition for two residents. One resident with a seizure disorder and dementia had multiple episodes of slurred speech, weakness, and seizure-like activity, including ER transfers, with no documented family notification for several events. Another cognitively intact resident had a fall with low O2 sat and pain, later was sent to the ED for arm pain and swelling, and returned from the hospital, but the record did not show family notification for these events.
Failure to maintain privacy during incontinence care: A resident with multiple diagnoses, including dementia and psychiatric conditions, was incontinent and required transfer to bed for care. Two CNAs removed soiled clothing and provided care with the bed near an exterior window and the curtains left open, exposing the resident’s perinium and buttock while an LPN applied barrier cream; the CNAs confirmed the resident was not given sufficient privacy.
A resident with MS, Alzheimer's disease, and major depressive disorder had moderate cognitive impairment and needed partial/moderate help with personal hygiene. Surveyors observed numerous and long facial hair on the resident's upper lip and chin on multiple occasions, and the resident stated she wanted her facial hair shaved. An UM later verified the resident had a shower the prior day but still had noticeable facial hair.
A resident with CAD, CHF, and CKD fell and later developed left arm pain, swelling, and decreased mobility. ED imaging showed a possible radial head fracture, and the resident returned with a sling and a note that orthopedics was to follow; however, the chart had no physician order for the sling and no evidence that an ortho consult was obtained.
Failure to provide timely incontinence care affected two residents who were dependent on staff and always incontinent of bowel and bladder. One resident was found heavily soiled with urine after not being checked for hours, with reddened buttocks and urine through to the bed linen. Another resident was incontinent of urine and stool, was not offered toileting despite requesting it, was not checked every 2 hours as directed, and was not properly cleansed during care; reddened skin was noted to the inner thighs.
Fluid restriction orders were not broken down by nursing and dietary amounts, and intake records and daily weights were inconsistently completed for two cognitively intact residents. One resident with anemia, psychosis, and osteoarthritis had a 1200 mL/day restriction with missing intake documentation and cups left in the room, while another resident with CHF and CKD had an 1800 mL/day restriction with repeated missing fluid intake entries and missed daily weights; staff verified the orders and documentation were incomplete.
Medication administration errors exceeded the allowed threshold when an RN gave a resident’s PEG tube medications by mixing crushed meds together in one cup and leaving residual medication behind in the cup after administration. The resident’s ordered meds included crushed tablets and levetiracetam oral solution, but there was no order to cocktail the meds together. Surveyors observed 27 medication opportunities with 7 errors, for a 25.93% error rate, and the facility policy required meds to be given separately through the enteral tube.
Unsafe Bed Frame, Mattress, and Bed Rail Conditions: Two residents had unsafe bed setups. One resident with CHF, obesity, chronic respiratory failure, and dependence for bed mobility had an undersized mattress that exposed metal bed frame and left gaps between the mattress and quarter side rail; when turned, the resident’s foot contacted the sharp metal frame. Another resident with dementia, schizophrenia, prior CVA/TIA, and dependence for bed mobility had a loose left quarter rail and no right rail, despite orders for bilateral upper quarter rails.
A resident with a history of stroke, hemiplegia, dysphagia, and prior aspiration pneumonia was ordered a mechanical soft diet with thin liquids and had documented chewing problems and a need for supervision at meals. Despite this, a CNA who knew of the altered diet order provided a regular-texture ham sandwich as an evening snack and the resident was not supervised while eating. The resident subsequently choked, was found clutching his throat and unable to cough, and multiple staff attempted the Heimlich maneuver without success before the resident became pulseless and CPR was initiated. EMS removed a large piece of meat completely obstructing the trachea, resuscitated the resident, and transferred him to the hospital, where records and the death certificate attributed anoxic brain death, cardiac arrest, and aspiration pneumonia to choking on food.
The facility did not maintain an adequate supply of clean linens for all residents on one floor, leaving staff with only a few towels and no washcloths available during morning care. CNAs reported that this shortage was a daily issue and that they sometimes used towels or pillowcases in place of washcloths to wash residents because linens were not restocked from laundry until later in the morning. The sole laundry aide acknowledged that linens sometimes ran out before they could be washed and restocked, while the housekeeping/laundry supervisor stated that although there were enough linens overall, there was not enough staff to keep them clean, contrary to the facility’s policy requiring clean bed and linens in good condition.
A resident with multiple chronic conditions, including late-onset Alzheimer's disease and hypertensive heart disease, who was documented as moderately cognitively impaired and not receiving insulin, was mistakenly given 15 units of glargine Lantus despite having no insulin prescription and not being diabetic. Nursing documentation showed the insulin was administered when the resident’s blood sugar was within normal range, and later NP documentation confirmed the error. The DON verified that insulin was given without a prescription, in contrast to facility policy requiring medications to be administered safely, as prescribed, and with proper resident identification verification.
A resident who required a two-person assist for bathing, as documented in her care plan and assessments due to fluctuating abilities and high fall risk, was given a bed bath by only one CNA. During the bath, the resident was rolled onto her side and subsequently slid off the bed, resulting in a fall and a left hip fracture that required surgery. Staff and witness statements confirmed that the care plan was not followed, leading to actual harm.
Surveyors found that insulin pens and vials for multiple residents were not consistently dated when opened and, in several cases, were used past their recommended expiration period. Staff, including LPNs and an RN, confirmed that pharmacy guidance and facility policy required dating and timely disposal of opened insulin, but these procedures were not followed, resulting in the use of undated or expired insulin.
A resident with multiple mental health diagnoses was admitted after a PASARR level II evaluation required specialized behavioral health services, including a comprehensive psychiatric assessment and mental health counseling. The facility did not complete the psychiatric assessment until months later in response to an altercation, and there was no evidence the resident ever received or was referred for mental health counseling, contrary to the PASARR requirements.
A resident with multiple disabilities who required staff assistance for personal hygiene was observed to have long, untrimmed, and discolored fingernails over several days. Staff confirmed that nail care had not been provided as required by the care plan and facility policy, resulting in a deficiency related to inadequate assistance with activities of daily living.
A resident with profound intellectual disability and multiple medical conditions was not provided with an individualized activity program to meet his interests and care needs. Despite being cognitively intact and expressing a desire for meaningful engagement, the resident was observed wandering the facility and not participating in appropriate activities. Staff and resident council interviews confirmed the lack of suitable programming and support for the resident, and facility assessments and policies did not address the needs of individuals with intellectual disabilities.
A resident with severe cognitive impairment and high risk for pressure ulcers did not receive physician-ordered interventions, including heel offloading and regular skin assessments. Staff failed to consistently reposition the resident, apply barrier cream after incontinence episodes, or document weekly skin checks. The resident was observed with reddened skin and prolonged soiling, and staff were unaware of or did not follow the care plan requirements.
A resident with hemiplegia and a right-hand contracture did not receive physical or occupational therapy, ROM exercises, restorative services, or splint/brace assistance despite documented limited mobility. The care plan and physician orders lacked interventions for the resident's contracture, and therapy staff did not conduct required quarterly screenings after an initial service refusal.
A resident with ESRD and on hemodialysis did not receive a prescribed phosphate binder medication due to the facility running out and failing to notify the resident or dialysis center. Review of records and interviews confirmed the medication was not administered for an extended period, and there was no documentation that the dialysis center or nephrologist had been informed. Facility policies requiring timely medication administration and communication were not followed.
The facility did not ensure its antibiotic stewardship program was properly implemented, resulting in two residents receiving antibiotics for urinary tract infections that did not meet McGeer criteria for treatment. The ADON confirmed antibiotics were administered despite urine cultures showing organism counts below the required threshold, and the facility's policy lacked guidance on applying these criteria.
A resident with severe cognitive impairment and total dependence on staff was not checked or changed for incontinence in a timely manner. Staff were unaware of the last incontinence care provided, and when care was finally given, the resident was found heavily soiled with urine and had developed skin redness. The care plan lacked specific time frames for checks, and staff did not communicate when care could not be provided due to the resident's combativeness.
A resident with multiple medical conditions and a need for rehabilitation did not receive timely PT, OT, and ST services as recommended, due to the facility's inability to verify insurance and obtain necessary billing information. Therapy was delayed until the payor source was confirmed, despite the resident's expressed interest and clinical need.
The facility failed to provide comprehensive nephrostomy care to a resident with hydronephrosis and acute kidney failure. The care plan lacked documented education for the resident on not handling the nephrostomy tubes, and there were inconsistencies in documenting drainage amounts. The resident was sent to the emergency room due to a non-draining nephrostomy tube, which was found to be caused by a locked stopcock.
Unclean and Unmaintained Resident Areas
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment for all 65 residents in the facility. In Resident #42's room, surveyors observed the area immediately surrounding the toilet discolored with a sticky, amber-colored substance with miscellaneous black debris adhered to the surface. The resident's restroom also had a broken windowsill that could be lifted off the wall, and miscellaneous debris was scattered throughout the room floor. Resident #42 stated she did not feel the facility did an adequate job of keeping her room and restroom clean to her satisfaction, and a CNA verified the conditions observed in the room and restroom. Surveyors also observed multiple areas of an unidentified brown substance on the floor in the 200-Hallway between Resident #42's room and Resident #28's room, along with miscellaneous grime and debris by the nursing station and nursing unit hallways. In the 300-Hallway, surveyors observed an unidentified brown and green substance and miscellaneous grime and debris by the nursing station, as well as miscellaneous grime on the floors of the B wing. A Housekeeping Aide and an RN verified these hallway conditions. In addition, the common shower next to a resident room had a toilet and floor covered in a brown substance, scattered debris including paper and a disposable glove, black substance on the shower stall floor, orange and brown substance at the base of the wall and floor, debris in the sink and on the floor, and broken drywall at the base of the wall entering the shower stall. An LPN verified the environmental conditions in both second-floor common showers, and the Administrator identified 15 residents who used those shower rooms.
Failure to Report Missing Controlled Substances
Penalty
Summary
The facility failed to report misappropriation of controlled substances for destruction to the State Survey Agency after an internal investigation found that controlled medications removed from use for disposal were not present in the facility and there was no evidence of destruction. The missing medications involved 10 residents reviewed for controlled substances for destruction, including oxycodone, oxycodone/acetaminophen, and hydrocodone products in varying quantities for Residents #82, #83, #84, #85, #87, #88, #89, #90, and #91. The facility census was 65. Review of the facility’s Self-Reported Incidents showed no SRI was filed on or around the date of the investigation for misappropriation of medications. During interview, the Regional Clinical Director stated the facility did not report the drug diversion to ODH as an SRI and instead reported it to the Ohio Board of Nursing and the Pharmacy Board. The Administrator stated the facility did not report the missing narcotics as misappropriation to ODH because the residents were no longer at the facility and the medications were considered the facility’s property since they were to be destroyed. The facility policy required suspected theft or misappropriation of resident property to be promptly reported to facility management and, when suspected abuse occurred, to the designated state agency within the required timeframe, with an investigation and findings provided to the state agency.
Fall Prevention Interventions Not Implemented and Smoking Assessments Not Completed
Penalty
Summary
The facility failed to ensure fall prevention interventions were implemented for two residents reviewed for falls. One resident had diagnoses including dementia, prior cerebrovascular events, spinal stenosis, anxiety, schizophrenia, depression, intellectual disability, CHF, HTN, and polyarthritis, and was identified as high risk for falls with a history of multiple falls. The care plan called for dycem to be placed between the resident and the Hoyer lift sling and for a sign to remind staff, but during observation the resident was transferred without dycem in place and no reminder sign was present. Staff confirmed the dycem was not in place and stated they were unaware it was to be placed between the resident and the sling. A second resident, admitted with diagnoses including bilateral knee osteoarthritis, CHF, dementia, and CKD, had a care plan that included keeping the bed in the lowest position with mats on both sides of the bed, along with other fall interventions. Observation showed the bed in a high position and no mats on the floor. Later observation again found no mats in the room, and CNA staff verified the mats were not present. The MDS coordinator confirmed the care plan still included mats on both sides of the bed. The facility also failed to ensure resident smoking assessments were completed for two residents reviewed for smoking. One resident with nicotine dependence was listed by the facility as a current smoker, but smoking safety evaluations completed in April and May stated the resident did not smoke; the MDS coordinator confirmed those evaluations were incorrect and that the resident went out on smoke breaks. Another resident’s admission smoking assessment stated the resident was not a smoker, but the quarterly assessment later identified the resident as a smoker, and there were no smoking assessments completed between admission and the quarterly assessment. The resident stated he began smoking after admission, and the DON confirmed there were no smoking assessments completed during that interval.
Failure to Notify Physician and Resident Representatives of Changes in Condition
Penalty
Summary
The facility failed to ensure that the resident representative and physician were notified after changes in condition for two residents reviewed for notification. The deficiency involved Resident #62, who had diagnoses including conversion disorder with seizures or convulsions, dementia, major depression, anxiety disorder, cerebral aneurysm, hypertension, hyperlipidemia, and malignant neoplasm of the thyroid gland, and was documented as cognitively intact on the MDS. Nursing notes showed multiple episodes of slurred speech, weakness, trembling, fixed stare, and seizure-like activity, including events that resulted in emergency room transfer or were managed in the facility, but the record did not document family notification for these episodes. Interviews with the DON and MDS Coordinator confirmed that physician and family notification did not occur for several of the events. Resident #76, who had diagnoses including acute osteomyelitis of the right ankle and foot, history of falling, disorders of bone density and structure, and fibromyalgia, was also documented as cognitively intact on the MDS. The resident was witnessed sliding to the floor from a wheelchair after being unable to eat lunch due to emesis, with low oxygen saturation, pain to the left side and hip, and the left leg abducted at an odd angle. EMS was called and the CNP and ADON were notified, but there was no documentation that the family was notified of the fall. Later, the resident was sent to the ED for decreased mobility of the upper extremity due to pain and swelling, and again there was no documentation that the family was notified. The record also showed that when Resident #76 returned from the hospital via stretcher, the on-call CNP was aware of the return and condition, but there was no documentation that the family was notified. Interviews with the MDS Coordinator verified that family notification did not occur for the fall, the transfer to the hospital for arm swelling, or the return from the hospital. The facility policy titled Acute Condition Changes-Clinical Protocol stated nursing staff would contact the physician based on urgency of the situation, including prompt response for emergencies.
Failure to Maintain Privacy During Incontinence Care
Penalty
Summary
The facility failed to ensure resident privacy during incontinence care for one resident. Resident #9 had diagnoses including dementia, transient ischemic attack, cerebral infarction, spinal lumbar stenosis, anxiety disorder, paranoid schizophrenia, major depression, intellectual disability, congestive heart failure, hypertension, and polyarthritis. The Minimum Data Set assessment dated [DATE] indicated the resident had intact cognition and was dependent on staff for activities of daily living. During observation on 05/13/26 at 11:25 A.M., an activity aide brought Resident #9 to his room and left after activating the call light. CNA #181 and CNA #170 responded and found the resident incontinent of urine through his pants and onto the mechanical lift sling. The CNAs transferred him to bed, removed his soiled pants, brief, and sling, and provided incontinence care while his bed was positioned within three feet of an exterior window facing the resident smoking area and patio. The curtains remained open throughout the procedure, exposing the resident's perinium and then his buttock while he was positioned on his left side with a moderate amount of formed stool. LPN #108 was summoned to apply zinc barrier cream to reddened skin, and the CNAs then placed a new brief and pants on the resident. Interview with CNA #181 and CNA #170 confirmed the curtain was left open and the resident was not provided sufficient privacy during the care. Facility policy titled Dignity stated staff are to promote, maintain, and protect privacy, including bodily privacy during personal care and treatment procedures.
Failure to Provide Facial Hair Grooming Assistance
Penalty
Summary
The facility failed to ensure ADL care, specifically removal of facial hair, was provided for Resident #49, who was admitted with reentry on 10/15/24 and had diagnoses including multiple sclerosis, Alzheimer's disease, and major depressive disorder. The 03/23/26 MDS assessment showed the resident had moderate cognitive impairment and required partial/moderate assistance with personal hygiene. On 05/12/26, observation revealed the resident had numerous and long facial hair on the upper lip and chin. On 05/13/26, the resident stated she would like to have her facial hair shaved. A later observation on 05/14/26 showed the resident continued to have numerous and long facial hair, and the Unit Manager verified the resident had a shower the prior day and still had noticeable facial hair on the upper lip and chin.
Missing Sling Order and Ortho Follow-Up After Fall-Related Arm Injury
Penalty
Summary
The facility failed to ensure orders were obtained for the use of a sling and failed to ensure follow-up orthopedic consults were obtained for one resident reviewed for falls. The resident had diagnoses including coronary artery disease, congestive heart failure, and chronic kidney disease, and was cognitively intact per MDS assessment. After a fall, the resident developed decreased mobility of the left upper extremity with pain and swelling, and the CNP ordered transfer to the ED for evaluation and treatment. ED documentation showed the resident complained of left arm pain and body aches after a fall three days earlier, with swelling to the left forearm. X-rays of the left forearm and elbow showed an equivocal impacted fracture of the radial head and a questionable radial head fracture, with follow-up radiographs recommended in seven to ten days. The resident returned to the facility with a sling, and a physician progress note stated orthopedics was to follow the resident. However, the medical record contained no physician order for the sling and no evidence that an orthopedic consult was made. An MDS Coordinator verified there were no orders for the sling or evidence of an orthopedic consult.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure timely and effective incontinence care for two residents who were both dependent on staff and always incontinent of bowel and bladder. Resident #5 had diagnoses including congestive heart failure, obesity, chronic respiratory failure, venous insufficiency, depression, atrial fibrillation, type 2 diabetes mellitus, generalized edema, hypertension, and venous thrombosis and embolism. Her care plan directed staff to clean the perineum with each incontinence episode, check as needed for incontinence, and change clothing as needed, and the Kardex directed staff to check her during rounds and as required for incontinence. Resident #5 stated she was not checked or changed every two hours and reported being last checked around 6:00 A.M. On observation later that day, she was found in bed and stated she had not been checked since before breakfast and was currently incontinent. When staff entered her room, CNA #501 removed her brief and found it heavily soiled with urine through to the bed linen, with a folded top sheet under her. Her buttocks were red. CNA #501 cleaned her perineum, and LPN #108 applied zinc barrier cream, a new brief, and a folded top sheet. CNA #501 verified no attempts had been made to check her for incontinence since assuming care at 7:00 A.M., and LPN #108 verified the resident was heavily soiled with urine and had reddened buttocks caused by urine and moisture. Resident #9 had diagnoses including dementia, transient ischemic attack, cerebral infarction, spinal lumbar stenosis, anxiety disorder, paranoid schizophrenia, major depression, intellectual disability, congestive heart failure, hypertension, and polyarthritis. His assessments showed he was dependent on staff and always incontinent of bowel and bladder, and his care plan directed staff to monitor frequently for incontinence, clean the peri-area with each episode, and check as needed; the Kardex instructed staff to check him every two hours. When he requested to use the toilet, staff found him incontinent of urine through his pants and onto the Hoyer sling. CNA #181 stated he was not offered toileting and was to be checked every two hours, but staff were unaware when he had last been checked. During care, staff cleansed only the groin and lower abdomen at first and did not cleanse the penis or perineum, then later cleansed stool from his buttocks after he was turned. His bilateral inner posterior thighs were reddened, and LPN #108 applied zinc barrier cream. CNA #181 and CNA #170 verified he was not properly cleansed after the incontinence episode and was not checked every two hours.
Fluid restriction orders and intake documentation were incomplete for two residents
Penalty
Summary
The facility failed to ensure that fluid restrictions were clearly broken down by discipline and shift, failed to document fluid intakes, and failed to obtain daily weights for two residents on fluid restrictions. One resident had diagnoses including polyarthritis, psychosis, hoarding disorder, adjustment disorder with anxiety, anemia, and osteoarthritis, and was assessed as cognitively intact. The care plan and physician order identified a 1200 mL/day fluid restriction, but neither specified how much dietary staff were to provide at meals or how much nursing staff were allowed to provide during the 24-hour period. The treatment record for April 2026 showed missing fluid intake documentation on multiple shifts, and during observation the resident was lying in bed with multiple Styrofoam cups and plastic cups on the over-bed table. The resident stated he was not really on a fluid restriction and drank when thirsty, while the RN confirmed the resident had access to water in his room and that nursing gave approximately 600 mL daily. The second resident had diagnoses including coronary artery disease, CHF, and CKD, was cognitively intact, and had physician orders for an 1800 mL/day fluid restriction and daily weight. The order and care plan did not specify how much fluid dietary was to provide at each meal or how much nursing was allowed to provide over 24 hours. Review of the treatment record showed repeated missing documentation of fluid intake on day shift across October, November, and December 2025, and multiple dates when daily weights were not obtained or not documented. During interview, the MDS staff verified that the physician orders and care plans did not break down the fluid restrictions by nursing and dietary amounts and confirmed the documentation was not completed per order. The facility policy stated that fluid intake should be accurately recorded in mL and that when a resident is on restricted fluids, the water pitcher and cup should be removed from the room.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
Medication administration errors exceeded the facility’s allowed rate when RN #502 administered medications to Resident #45 via PEG tube. During observation, RN #502 crushed one multivitamin, glycopyrrolate 1 mg, furosemide 20 mg, Eliquis 5 mg, Baclofen 10 mg, and famotidine 20 mg together in the same cup with 50 ml of tap water, then prepared levetiracetam oral solution separately. RN #502 placed the medications at the bedside, checked PEG placement and residual, flushed the tube with 30 ml of water, and poured the cocktailed medications into the tube. Multiple medication residual particles remained in the cup, and 10 ml of levetiracetam remained in the medication cup after administration. RN #502 did not attempt to administer the remaining medication and discarded the cups in the room. RN #502 confirmed that Resident #45 did not receive the entire prescribed dose of the medications. Review of the medical record showed current physician orders for the medications to be crushed and administered via PE tube, with levetiracetam ordered as an oral solution 20 ml twice daily. There was no physician order for the medications to be mixed together before PEG administration. The facility policy titled Administering Medications Through an Enteral Tube stated medications should not be mixed together prior to administration and should be given separately with flushing between medications. Survey observations identified 27 medication opportunities with 7 errors, resulting in a 25.93 percent error rate.
Unsafe Bed Frame, Mattress, and Bed Rail Conditions
Penalty
Summary
The facility failed to ensure resident beds were properly maintained in a safe manner for two residents. One resident had diagnoses including congestive heart failure, obesity, chronic respiratory failure, venous insufficiency, depression, atrial fibrillation, type 2 diabetes mellitus, hypertension, and venous thrombosis and embolism, and was dependent on staff for activities of daily living including bed mobility. Although the resident’s care plan included quarter upper bilateral side rails for bed mobility and transfer ability, observation showed the mattress was undersized, leaving approximately four inches of exposed metal bed frame on the right side and a four-inch gap between the mattress and the right upper quarter side rail. When staff turned the resident, the resident’s right foot contacted the metal bed frame with sharp edges, and the LPN verified the mattress was undersized and exposed the frame with a gap between the rail and mattress. The Maintenance Director later measured gaps of six inches at the foot of the bed, four inches in the middle, and three inches between the rail and mattress, and stated he was unaware when the bed and mattress were assessed for proper fit. A second resident had diagnoses including dementia, transient ischemic attack, cerebral infarction, spinal lumbar stenosis, anxiety disorder, paranoid schizophrenia, major depression, intellectual disability, congestive heart failure, and hypertension, and was dependent on staff for bed mobility and transfers with a history of falls. The resident’s care plan and physician order included upper quarter bilateral side rails for bed mobility and transfer ability enabler. Observation showed the bed had a loose quarter side rail on the left side and no quarter side rail on the right side. CNAs verified the left rail was loose and the right rail was missing, and stated the resident used the side rails when being positioned in bed and was fearful of falling without them. Later, an RN also verified the left bed rail was loose and the right bed rail was missing, and the Maintenance Director stated he was unaware of the loose and missing bed rail.
Improper Diet Texture and Lack of Meal Supervision Lead to Fatal Choking Event
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received food in the correct mechanically altered texture as ordered and to accurately assess and implement needed supervision during eating. The resident had a physician’s order for a low concentrated sweet, no added salt, mechanical soft diet with thin liquids and a divided plate. The care plan and Nutrition and Hydration Status Assessment documented that the resident had chewing problems and required supervision or assistance at mealtimes, including that the resident fed self with supervision. Speech therapy records showed a history of dysphagia, aspiration pneumonia due to food inhalation, cerebrovascular disease, hemiplegia, and muscle weakness, with recommendations for mechanical soft/chopped textures, upright positioning, alternating food and liquids, and small bites. The resident’s DOSS score indicated restricted diet consistencies and a need for distant supervision during meals. On the day of the incident, a CNA who knew the resident was on a mechanical soft diet provided a regular-texture ham sandwich as an evening snack after the resident requested a sandwich. The CNA later admitted she was aware of the altered diet order but believed the thinly sliced ham was acceptable, even though it was not chopped or otherwise modified to a mechanical soft consistency. The DON confirmed that the ham sandwich given was not of the appropriate texture for a mechanical soft diet. The resident was not being supervised while consuming this snack, despite documentation in the Nutrition and Hydration Status Assessment that the resident required supervision during meals. The DON stated she interpreted “supervision” on the assessment as only meaning set-up assistance, and the dietetic technician later stated that the documentation of supervision needs on the assessment was a human error and that the resident only required set-up assistance. Later that evening, during medication pass, an RN observed the resident in the doorway of his room in a wheelchair, clutching his throat with both hands and attempting to gag himself with his finger. The RN asked if he was choking, and the resident nodded yes but was unable to cough or speak. The RN inspected the resident’s mouth and did not see an obstruction, then called for help and initiated the Heimlich maneuver and back blows. Multiple staff, including CNAs and a respiratory therapist, responded and each attempted the Heimlich maneuver without success. The resident became unresponsive and pulseless, and staff initiated CPR with use of a backboard, crash cart, oxygen, and bag-valve-mask ventilation until EMS arrived. EMS found the resident pulseless and apneic with a reported full airway obstruction, used video laryngoscopy and forceps to remove a large piece of meat completely obstructing the trachea, and then intubated and resuscitated the resident before transferring him to the hospital. Hospital records and the death certificate documented that the resident experienced acute hypoxic respiratory failure, aspiration pneumonia, cardiac arrest, and ultimately anoxic brain death due to choking on food.
Removal Plan
- RN responded to Resident #77, EMS was called, and the resident was transferred to the hospital.
- RN notified Resident #77's physician of the incident.
- The DON reviewed Resident #77's diet order for accuracy.
- The DON initiated an investigation of events surrounding Resident #77's choking incident.
- The DON conducted a root cause analysis and determined Resident #77 choked when CNA #151 provided Resident #77 with the incorrect diet texture during the evening snack.
- The DON reviewed all facility residents' care plans to ensure they accurately reflected current diet orders.
- The DON conducted a full house audit to ensure no additional residents received incorrect diet consistency or improper feeding assistance.
- The DON educated CNA #151 on ensuring each resident received their diet as ordered.
- The DON educated all nursing staff and the Dietetic Technician on ensuring resident care plans accurately reflected current diet needs.
- The DON educated all nursing staff on the facility policy to ensure each resident received their diet as ordered and where to verify a resident's diet order.
- The Administrator, the DON, the LPN/UM, the RDO, and the RCD reviewed facility policies on assisting residents with in-room meals, snack serving, and therapeutic diets.
- An ad hoc QAPI meeting was held to review the choking incident and the facility's corrective action plan.
- The Dietary Manager posted a list of mechanical soft approved foods in the nutrition rooms on each floor of the facility.
- The Dietary Manager posted a list of residents with mechanically altered diets in the nutrition rooms on each floor of the facility.
- The Dietary Manager and/or designee will monitor and update the lists as diet orders change, with new admissions, and as needed.
- The Dietary Manager placed separate bins identifying regular snacks and mechanically altered snacks in the nutrition rooms.
- The Dietary Manager and/or designee will ensure appropriate food items are placed in each bin based on safe foods for each diet texture.
- The DON will audit nursing staff to ensure understanding of mechanically altered diets, with results reported to the QAPI committee.
- The DON will audit residents to ensure meals and snacks being served are appropriate based on the ordered diet, with results reported to the QAPI committee.
- The DON audited all Nutrition and Hydration Status Assessments to ensure accuracy regarding residents' feeding capabilities, including supervision and assistance.
- Any inaccuracies in Nutrition and Hydration Status Assessments were corrected immediately by the Dietetic Technician.
- The DON reviewed all residents' care plans to ensure they accurately reflected the residents' feeding and eating capabilities, including supervision and assistance.
- The DON educated all nursing staff on following the care plan and Kardex to identify a resident's level of assistance required when eating.
- The Registered Dietitian educated the Dietetic Technician on completing Nutrition and Hydration Status Assessments to accurately reflect a resident's level of assistance required when eating.
- The DON will audit residents to ensure they are receiving feeding assistance and supervision as needed, with results reported to the QAPI committee.
- The DON will complete random audits of resident charts for the most recent admission, quarterly, and change of condition Nutrition and Hydration Status Assessments for accuracy of the resident's level of assistance required when eating, with results reported to the QAPI committee.
Inadequate Supply and Availability of Clean Linens for Resident Care
Penalty
Summary
The facility failed to ensure an adequate supply of clean linen was available to meet residents' needs on the third floor, affecting all 46 residents residing there. During an early morning observation of the third-floor linen storage, surveyors found only six towels and no washcloths available for use. Certified Nursing Assistants reported that at the start of their shifts there were no linens available to wash and get residents up, and that this was a daily concern. Staff stated that linens were typically not brought up from the laundry until later in the morning, leaving them without appropriate supplies during morning care. CNAs reported that, due to the lack of linens, towels and even pillowcases were sometimes used instead of washcloths to wash residents. The laundry aide reported being the only laundry staff member on duty, working from early morning until mid-afternoon, and acknowledged that at times they ran out of linens before laundry could wash and restock. The housekeeping/laundry supervisor stated there was sufficient linen inventory but no one available at the facility to keep the linen clean. The facility’s Quality of Life policy stated that residents were to be provided with a safe, clean, comfortable, and homelike environment, including clean bed and linens in good condition, which was not met based on these findings.
Unprescribed Insulin Administration to Non-Diabetic Resident
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when nursing staff administered insulin that was not prescribed. The resident, who had diagnoses including multiple sclerosis, late-onset Alzheimer's disease, essential hypertension, and hypertensive heart disease with heart failure, was documented on the MDS as moderately cognitively impaired and not receiving insulin. A nursing progress note recorded that the resident was given 15 mg of glargine Lantus, a long-acting insulin, even though there was no prescription for insulin. At the time of this administration, the resident’s blood sugar was 109 mg/dl. Subsequent documentation by the NP confirmed that the resident was not diabetic and had mistakenly received 15 units of Lantus. The NP note indicated that vitals were assessed and the resident’s glucose was 107 mg/dl following the error. The DON later verified in interview that the resident had received insulin when it was not prescribed. The facility’s medication administration policy required that medications be administered safely, timely, and as prescribed, and that staff verify resident identity before administration using methods such as checking the identification band, photograph, or confirming identity with other personnel. This incident was identified incidentally during a complaint investigation.
Failure to Provide Required Two-Person Assist During Bed Bath Results in Resident Fall and Hip Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent for bathing and required the assistance of two staff members according to her care plan, was provided a bed bath by only one certified nurse aide (CNA). The resident's care plan and Minimum Data Set (MDS) assessments indicated that her abilities fluctuated and that she was a high fall risk, necessitating two-person assistance for bathing and bed mobility. Despite these documented needs, the resident was rolled onto her side by a single CNA during a bed bath, which resulted in her sliding off the bed and falling to the floor. The incident led to the resident sustaining a left hip fracture, as confirmed by hospital documentation and x-ray, which required surgical intervention. The resident reported that her legs went over the side of the bed while powder was being applied to her back, causing her to fall. Staff interviews and witness statements corroborated that only one CNA was present at the time of the incident, and the resident was turned away from the caregiver, which was not in accordance with proper nursing care or the resident's care plan requirements. The facility's investigation and staff interviews confirmed that the care plan specified the need for two caregivers during bathing and repositioning, and that this protocol was not followed at the time of the incident. The failure to provide the appropriate level of care and assistance as outlined in the resident's care plan directly resulted in an avoidable fall and actual harm to the resident.
Failure to Properly Label and Store Insulin Medications
Penalty
Summary
Surveyors observed that the facility failed to store and label insulin medications in accordance with professional standards and facility policy. Multiple insulin pens and vials prescribed to nine residents were found either without the date they were opened or being used beyond their recommended expiration period after opening. Specifically, several insulin pens and vials, including Lantus, aspart, lispro, Semglee, and glargine, were discovered on various medication carts and in storage rooms without proper dating or with dates indicating use past the 28-day expiration period as outlined in pharmacy guidance. Staff interviews confirmed awareness of the pharmacy's instructions and facility policy requiring opened insulin to be dated and not used beyond the specified period, yet these procedures were not consistently followed. The facility's own policies, as well as pharmacy guidance available on medication carts, required nursing staff to mark insulin vials and pens with the date opened and to check expiration or beyond-use dates prior to administration. Despite this, observations revealed that insulin for several residents was either not dated when opened or continued to be used after the expiration date. Staff, including LPNs and an RN, acknowledged these lapses during interviews, and the Director of Nursing confirmed that insulin vials and pens are to be marked with the date opened to prevent administration of expired medications.
Failure to Provide Required Specialized Behavioral Health Services After PASARR Level II Evaluation
Penalty
Summary
The facility failed to provide required specialized behavioral health services to a resident with significant mental health diagnoses, as mandated by the state-designated mental health authority following a PASARR level II evaluation. The resident, who had diagnoses including anxiety, depression, bipolar disorder, and psychophysiologic insomnia, was admitted after being approved for nursing facility placement with the stipulation that specialized services, such as a comprehensive psychiatric assessment and mental health counseling, be provided. However, review of the medical record showed that a comprehensive psychiatric assessment was not completed until several months after admission, and only in response to a resident-to-resident altercation and ongoing aggression, rather than as part of the required specialized services. Additionally, there was no evidence that the resident was ever seen, assessed for, or referred to mental health counseling, as required by the PASARR level II determination. Staff interviews confirmed the absence of documentation for mental health counseling and indicated a lack of awareness regarding the completion of the required psychiatric assessment. The facility's policy outlined the process for PASARR screenings and the provision of specialized services, but these requirements were not met for the resident in question.
Failure to Provide Timely Nail Care and Personal Hygiene Assistance
Penalty
Summary
A deficiency was identified when a resident with profound intellectual disability, cerebral palsy, seizures, scoliosis, lactose intolerance, and gluten sensitivity did not receive adequate and timely assistance with personal hygiene, specifically nail care. The resident was cognitively intact and required supervision or touching assistance for activities of daily living, including personal hygiene. The care plan specified that staff should check, trim, and clean the resident's nails on bath days and as necessary. However, multiple observations revealed that the resident's fingernails were long and tinged brown, and staff interviews confirmed that the nails had not been trimmed for several weeks. Further review of the facility's policy on nail care indicated that the purpose was to keep nails clean and trimmed to prevent infections. Despite this, the resident's nails remained untrimmed over several days of observation, and staff acknowledged the lapse in care. The deficiency was substantiated by direct observation, resident and staff interviews, and review of medical records and facility policy.
Failure to Provide Individualized Activities for Resident with Intellectual Disabilities
Penalty
Summary
The facility failed to provide an individualized activity program tailored to the interests and care needs of a resident with profound intellectual disability, cerebral palsy, seizures, scoliosis, lactose intolerance, and gluten sensitivity. Despite being cognitively intact and requiring supervision or assistance with daily activities, the resident was observed repeatedly wandering the halls and dining area, appearing bored and disengaged. Interviews with the resident revealed a desire to go out and participate in meaningful activities, such as work programs, which he had attended prior to admission. Staff interviews confirmed the resident did not attend any day or work programs for individuals with intellectual disabilities, and there was uncertainty among staff as to why this was the case. The care plan for the resident included interventions to support emotional, intellectual, physical, and social needs, such as arranging community activities and ensuring compatibility with his capabilities. However, observations and interviews indicated these interventions were not effectively implemented, as the resident was left to wander and was not engaged in appropriate activities. Resident council members also expressed concerns about the lack of activity and involvement for the resident, noting his tendency to enter other residents' rooms and wander into restricted areas. The facility's assessment and policies did not specifically address the needs of individuals with intellectual disabilities, and staff training did not include working with this population.
Failure to Implement Pressure Ulcer Prevention Interventions as Ordered
Penalty
Summary
The facility failed to implement physician-ordered interventions for pressure ulcer prevention for a resident with multiple risk factors, including severe cognitive impairment, incontinence, contractures, and limited mobility. The resident was assessed as high risk for pressure ulcer development and had specific orders for heel offloading while in bed, weekly skin assessments, and application of barrier cream after each incontinence episode. Despite these orders, observations over two days revealed the resident was repeatedly found in bed with heels and feet resting on the mattress and pressed against the footboard, without any heel offloading devices in place. Staff interviews indicated a lack of awareness and adherence to the resident's care plan and physician orders. Certified nurse aides (CNAs) were unaware of the requirement to offload the resident's heels and did not consistently communicate care refusals or difficulties to nursing staff. One CNA did not notify the nurse when unable to provide care due to the resident's combativeness, resulting in prolonged periods without incontinence care or repositioning. When care was eventually provided, the resident was found with significant soiling and reddened skin on the buttock and left heel, indicating the development of skin issues. Further review revealed that required weekly skin assessments were not documented as completed for two consecutive weeks, contrary to physician orders and facility policy. The facility's policy mandates regular risk assessments, daily skin inspections, and timely repositioning for residents at risk of pressure ulcers. The lack of adherence to these protocols and physician orders directly contributed to the deficiency identified during the survey.
Failure to Provide Individualized Restorative Program for Limited Range of Motion
Penalty
Summary
A resident with a history of acute and chronic respiratory failure, congestive heart failure, depression, and hemiplegia/hemiparesis following cerebrovascular disease was admitted to the facility and exhibited limited mobility on one side, affecting both upper and lower extremities. Multiple quarterly and significant change MDS assessments documented this limited mobility, yet the resident did not receive physical therapy, occupational therapy, range of motion (ROM) exercises, restorative services, or splint/brace assistance. Physician progress notes indicated the presence of a right-hand contracture, but there was no evidence in the comprehensive care plan or physician orders addressing limited ROM or contractures. Therapy documentation over an extended period showed no evaluation, screening, or intervention for the resident's limited mobility or contracture. During interviews and observations, the resident demonstrated an inability to open her right hand and confirmed she had not received therapy, splints, or any treatment to prevent worsening of her condition. The Director of Therapy Services verified that the resident had not been screened or evaluated for her limited mobility or contracture during the review period, except for an initial screening where the resident declined services. The Director also confirmed that, following a refusal, residents should be re-screened quarterly, which did not occur in this case.
Failure to Administer Physician-Ordered Dialysis Medication and Notify Providers
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease (ESRD) and dependent on hemodialysis did not receive a physician-ordered phosphate binder medication as prescribed. The resident, who had multiple comorbidities including chronic anemia, heart failure, and hypertension, was admitted with a care plan that included administration of medications as ordered and monitoring for side effects. Despite this, the facility failed to ensure the resident received Xphozah 30 mg, a phosphate absorption inhibitor, as ordered twice daily. The resident reported that the facility frequently ran out of the medication and did not notify her or the dialysis center to reorder it. Medical record review confirmed the medication had not been administered since a specific date, and there was no documentation that the dialysis center or nephrologist had been informed of the lapse. Further investigation revealed that the medication cart contained an empty bottle of the prescribed medication, and review of the dialysis communication book and forms showed no indication that the need for the medication or its absence had been communicated to the dialysis center or physician. The facility's policies required medications to be administered in a safe and timely manner and for the care plan to reflect the resident's needs related to ESRD and dialysis care. However, these policies were not followed, resulting in the resident not receiving the necessary medication and the responsible parties not being notified of the issue.
Failure to Implement Antibiotic Stewardship Program per McGeer Criteria
Penalty
Summary
The facility failed to properly implement its antibiotic stewardship program, resulting in the inappropriate use of antibiotics for two out of three residents reviewed for antibiotic use. For one resident with dementia, hypertension, and anxiety, a urine culture showed 10-15,000 CFU/ml of two organisms, but antibiotics were administered despite not meeting the McGeer criteria, which require at least 100,000 CFU/ml. The Assistant Director of Nursing (ADON) confirmed that the criteria were not met and incorrectly believed that the presence of two organisms justified treatment. Another resident with chronic respiratory failure, type II diabetes, and morbid obesity received antibiotics on two occasions for urine cultures that also did not meet the McGeer criteria, as both cultures showed less than 100,000 CFU/ml. The ADON acknowledged that antibiotics were given despite the cultures not meeting the required threshold. Review of facility documentation and policy revealed that while a checklist referencing the McGeer criteria was in use, the facility's antibiotic stewardship policy lacked guidance on implementing these criteria for monitoring antibiotic use.
Failure to Provide Timely Incontinence Care Resulting in Prolonged Exposure and Skin Redness
Penalty
Summary
A deficiency occurred when staff failed to provide timely incontinence care to a resident with severe cognitive impairment, multiple comorbidities, and total dependence on staff for activities of daily living. The resident was incontinent of bowel and bladder, at risk for pressure ulcer development, and required regular checks and care as outlined in the care plan. However, the care plan did not specify a time frame for incontinence checks. Staff interviews and observations revealed that the resident was last checked for incontinence and repositioned at 5:00 A.M., and subsequent staff were unaware of when the resident was last checked or changed. At approximately 10:15 A.M., a CNA attempted to provide care but was unable to do so due to the resident's combativeness and did not notify the nurse of the refusal or inability to provide care. Later, when care was finally provided, the resident was found to be heavily soiled with urine, which had soaked through the brief, blanket, and mattress sheet onto the mattress surface. The resident's buttock was also observed to be reddened, a change from a previous assessment. The lack of timely incontinence care and communication among staff led to prolonged exposure to urine and the development of skin redness. Facility policy required staff to check and clean residents after each incontinence episode, but this was not consistently followed, resulting in the deficiency.
Failure to Provide Timely Rehabilitation Services Due to Insurance Verification Delays
Penalty
Summary
A resident admitted with diagnoses including type II diabetes mellitus, bipolar disorder, and depression was identified as needing physical, occupational, and speech therapy upon admission. The resident's comprehensive assessment showed intact cognition, limited range of motion in both lower extremities, and dependence on staff for transfers and toileting. Physician orders and therapy evaluations recommended therapy services to address mobility and strength. Despite these recommendations, the resident did not receive the prescribed therapy services in a timely manner. The delay in providing therapy was due to the facility's inability to confirm the resident's insurance information, which prevented the initiation of rehabilitation services. Staff interviews confirmed that therapy was not started because the facility could not verify the resident's payor source and did not have the necessary insurance documentation. As a result, the resident did not receive therapy as recommended until the facility resolved the billing issue, despite the resident expressing a desire to participate in therapy and improve mobility.
Failure to Provide Comprehensive Nephrostomy Care
Penalty
Summary
The facility failed to provide comprehensive nephrostomy care to a resident, which led to a deficiency. The resident, who had diagnoses including hydronephrosis, mild protein calorie malnutrition, and acute kidney failure, required maximal assistance with various activities and had nephrostomy tubes. The care plan for the nephrostomy tubes included checking tubing for kinks every two hours, monitoring and documenting intake and output, and ensuring stopcocks were open as ordered. However, there was no documented education provided to the resident about not handling the nephrostomy tubes, nor was there documentation regarding the resident being non-compliant with the tubes. On specific dates, the treatment administration record showed inconsistent documentation of the nephrostomy tubes' drainage amounts. A progress note revealed that the left nephrostomy tube was leaking and not draining into the bag, leading to the resident being sent to the emergency room. The emergency room documentation indicated that the issue was due to the stopcock being in the locked position, and once opened, the tube drained clear. The Director of Nursing confirmed that the resident had a history of tampering with the nephrostomy tubes and that staff had been educating the resident not to touch them. The facility's policy on nephrostomy tube care included guidelines for checking tubing placement and integrity, ensuring drainage below kidney level, and measuring output at specified intervals, but these were not adequately followed in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 170 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Valley View Health Campus | 0.4 mi | ★★★★★ | 3 | 0 |
| Elmwood Assisted Living & Skilled Nursing Of Fremo | 1.8 mi | — | 0 | 0 |
| Parkview Care Center | 2.6 mi | ★★★★★ | 13 | 0 |
| Bethesda Care Center | 3.1 mi | ★★★★★ | 17 | 0 |
| Spring Creek Nursing And Rehabilitation Center Llc | 7 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Countryside Manor Nursing And Rehabilitation Llc.
100% money-back within 48 hours.
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.