F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review the facility failed to implement post fall interventions for one (R1) of three
residents reviewed for falls in the sample list of four.
Findings include:
R1's plan of care dated 8/30/24 documents R1 was admitted to the facility on [DATE]. R1's fall risk
assessment dated [DATE] documents R1 has a history of multiple falls and is at high risk for falls.
R1's fall investigation report dated 9/19/24 documents R1 slipped in room while self-ambulating at 5:30 PM.
This report documents a new intervention of requesting therapy.
R1's fall investigation report dated 9/25/24 documents R1 fell attempting to change undergarment at 9:50
AM. This report documents a new intervention to order physical and occupational therapy.
R1's plan of care documents a new fall intervention dated 9/25/24 for physical and occupational therapy to
evaluate and treat for strengthening.
R1's fall investigation report dated 10/21/24 documents R1 fell in the dining room at 11:00 PM.
R1's plan of care documents a new fall intervention dated 10/21/24 for physical and occupational therapy to
evaluate and treat.
On 11/2/24 at 8:48 AM, V13 Occupational Therapy Assistant stated R1 was on therapy for a couple weeks
after she was admitted (8/5/24). V13 stated R1 hasn't been on therapy since that time.
On 11/2/24 at 9:07 AM, V14 Regional Occupational Therapist stated R1 received therapy from August 5th
through August 21st. V14 stated the therapy company did not receive an order to evaluate R1 for therapy in
September or October 2024. V14 stated the therapy company has not received orders to evaluate R1 for
therapy since R1's admission [DATE]).
On 11/2/24 at 9:17 AM, V2 Director of Nursing stated a therapy evaluation was recommended as a new
intervention for R1's falls that occurred on 9/19/24, 925/24, and 10/21/24. V2 stated she could not find
documentation in R1's medical record that therapy evaluated R1 for physical or occupational therapy.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
146080
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
146080
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/02/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Countryside Care Center
400 West Grant Street
Macomb, IL 61455
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on interview and record review the facility failed to develop a plan of care for the use of an
antipsycotic medication, implement behavioral interventions, and limit a prn (as needed) antipsychotic
medication to 14 days. This failure had the potential to affect one (R1) of three residents reviewed for
medications in the sample list of four.
Findings include:
The facility's Psychotropic Medication Policy with a revision date of 11/2917 documents the care plan will
identify target behaviors and will address the problem, approaches and goals to address the behaviors.
This policy documents the Behavioral Tracking sheet will be implemented to ensure behaviors are
monitored. This policy documents PRN orders for antipsychotic medications have a time limit of 14 days
and if the physician or prescribing practitioner wishes to write a new order, they must first evaluate the
resident to determine if the new order for the PRN is appropriate.
R1's Preadmission Screening and Resident Review (PASRR) screen dated 8/2/24 documents R1 does not
have a history of Mental Illness.
R1's physician order dated 9/17/24 documents an order for haloperidol (antipsychotic medication) five
milligams intramuscularly every 12 hours as needed for increased behaviors.
R1's physician order dated 10/2/24 documents an order to increase haloperidol to 10 milligrams
intramuscularly every eight hours as needed. As of 11/1/24, the order for the haloperidol was active for
thirty days (10/2/24 to 11/1/24).
R1's Medication Administration record for October of 2024 documents R1 received 10 milligrams of
haloperidol on 10/13/24, 10/15/24, 10/17/24, 10/19/24, 10/20/24, and 10/24/24.
R1's care plan with an initiation date of 8/30/24 does not include a plan of care for the use of psychotropic
medications. This care plan does not include behavioral interventions.
The facility's behavior tracking binder did not include a behavior tracking sheet for R1. R1's medical record
did not include behavioral interventions or a behavior tracking sheet.
On 11/2/24 at 9:17 AM, V2 Director of Nursing stated R1's haloperidol was ordered due to R1 having
increased behaviors. V2 stated the medication order for the haloperidol did extend past 14 days. V2
confirmed R1's medical record nor the behavior tracking binder contained behavioral interventions for R1's
behaviors. V2 confirmed that R1's care plan did not contain a plan of care for R1's use of haloperidol.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146080
If continuation sheet
Page 2 of 2
