Inspection·March 22, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to correctly enter and follow a physician's order for one resident of three residents (R1) reviewed for steroid injections in the sample of three. Findings include: The Administering Medication policy dated 10/15/23 documents Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: 3. Medications shall be administered according to physician's written/verbal orders upon verification of the right medication, dose, route, time, and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. 20. Should a dosage seem excessive considering the resident's age and medical condition, or a medication order seems to be unrelated to the resident's current diagnosis or medical condition, the person preparing/administering the medication shall contact the resident's attending physician or the facility's medical director for further instructions. The Medication Errors policy dated 11/5/19 documents Purpose; It is the policy of this Facility to establish and follow a uniform process of medication error management, in regards to reporting medication errors and ensuring accurate and appropriate use of medications. Policy interpretation and implementation: The nurse that has noted the Med Error will contact the Director of Nursing, Physician, Resident/POA (Power of Attorney)/Guardian and the Facility Pharmacy. This Facility feels that reporting of errors or potential errors will help us to identify and remediate problem processes or to identify areas of needed staff or individual staff education. Medication Errors include A. Wrong person B. Wrong drug C. Wrong dosing D. Wrong time E. Wrong route. The Registered Nurse Job Description (not dated) documents Responsibility for complying with facility policies and procedures and making recommendations for revisions. Receives and transcribes written, verbal and telephone orders to the chart, MAR (Medication Administration Record), TAR (Treatment Administration Record), etc. (etcetera), and assures execution of same. Responsible for interpretation and execution of physician's orders and calling physicians as indicated. Is responsible for administering and documenting medications according to the physician's order, pharmacy policy, plan of care. Review medication cards for completeness of information, accuracy in the transcription of the physician's order, and adherence to stop orders. Is responsible for competent administration of care and treatments according to physician orders and facility policy. R1's Face Sheet documents R1 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses which included Other Pulmonary Embolism without Acute Cor Pulmonale, Coronary Artery (continued on next page) 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 3 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 03/22/2025 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)