Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 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.
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.
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
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Illustrative
What surveyors actually found near you
We read the 82 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
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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 | — | 0 | 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 | — | 7 | 0 |
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