A list of the most recent deficiencies for Countryside Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-16 | 2023-06-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-01 | 2023-02-06 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-01 | 2023-02-06 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-26 | 2022-10-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-26 | 2022-10-11 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-15 | 2022-09-07 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-07-15 | 2022-09-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-07-15 | 2022-09-07 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-07-15 | 2022-09-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-15 | 2022-09-07 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-07-15 | 2022-09-07 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-07-15 | 2022-09-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-15 | 2022-09-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-15 | 2022-09-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-15 | 2022-09-07 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-07-15 | 2022-09-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-07-18 | 2022-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-18 | 2022-08-02 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-07-18 | 2022-08-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-18 | 2022-08-02 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2022-02-25 | 2022-03-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-25 | 2022-03-22 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-24 | 2022-03-22 | Y |
| Dispose of garbage and refuse properly. | Health | 2022-02-24 | 2022-03-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-03-08 | 2021-08-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-03-08 | 2021-08-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-10-10 | 2020-01-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-10 | 2020-01-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-10 | 2020-01-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-10 | 2020-01-08 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-10-10 | 2020-01-08 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-10 | 2020-01-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-24 | 2019-12-24 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-10-24 | 2019-12-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-24 | 2019-12-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-24 | 2019-12-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-24 | 2019-12-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-16 | 2019-01-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-11-16 | 2019-01-16 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2018-11-16 | 2019-01-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-12-27 | 2019-01-15 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-12-27 | 2019-01-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-27 | 2019-01-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-27 | 2019-01-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-27 | 2019-01-15 | N |
