Inspection·November 26, 2019

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure advanced directives listed in the medical record were accurate. This had the potential to affect two residents (#19 and #45) of three reviewed for advanced directives. The facility census was 54. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 08/29/19 with diagnoses including pulmonary fibrosis, depressive disorder, epilepsy, chronic kidney disease, and pneumonia. Review of Resident #19's physician order dated 08/29/19 revealed an order for the resident to be a Full Code. Review of Resident #19's Do Not Resuscitate (DNR) identification form dated 09/18/19, revealed the resident was identified as having Do No Resuscitate Comfort Care (DNRCC). The DNRCC form was signed by the physician. Review of Resident #19's Medication Administration Record (MAR) dated November 2019 listed the resident as a Full Code. Review of Resident #19's information profile of the electronic medical record identified the resident's code status as full code. Interview on 11/25/19 at 9:09 A.M. with Director of Nursing (DON) verified Resident #19 MAR listed the resident as a Full Code and the physician had signed an order for the resident to be a DNRCC on 09/18/19. 2. Review of the medical record for Resident #45 revealed an admission date of 03/02/16 with diagnoses including major depression, dementia with behavioral disturbance and hyperlipidemia. Review of the face sheet located in Point Click Care (PCC) revealed Resident #45 was a Full Code status. Review of the physician orders dated 11/21/19 code status changed to DNR. (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 4 Event ID: 365418 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 365418 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/26/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Manor Nursing and Rehabilitation LLC 1865 Countryside Drive Fremont, OH 43420 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)