Inspection·May 15, 2024

F 0691 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview, and policy review, the facility failed to provide comprehensive nephrostomy care to a resident. This affected one (#47) of one resident reviewed for nephrostomy tubes. The facility identified one resident who had a nephrostomy tube used in his care at the facility. The facility census was 67. Findings include: Review of Resident #47's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included hydronephrosis, mild protein calorie malnutrition, and acute kidney failure. Review of the admission Minimum Data Set (MDS)3.0 assessment dated [DATE] revealed Resident #47 had mild cognitive impairment with no behaviors, nephrostomy tubes and was always continent of bowel. Resident #47 required maximal assistance with toileting, lower body dressing, and chair to bed transfers, moderate assistance with showering, and supervision with personal hygiene and bed mobility. Review Resident #47's care plan revealed the resident had nephrostomy tubes dated 03/06/24. Interventions in the care of the nephrostomy tubes included: check tubing for kinks every two hours each shift, dated 03/06/24. Monitor and document intake and output as per facility policy, dated 03/06/24. Check stopcocks on nephrostomy tubes and ensure they are open as ordered, dated 04/30/24. Resident #47's care plan had no documented education provided to the resident to not handle the nephrostomy tubes or documentation regarding the resident being non compliant with the nephrostomy tubes. Review of April 2024 treatment administration record revealed the nephrostomy tubes had the following drainage amounts documented: On 04/25/24, night shift right tube: 50 cc; on 04/25/24, night shift left tube: zero cc; on 04/26/24, day shift right tube: 50 cc; on 04/26/24, day shift left tube: zero cc; on 04/26/24, night shift right tube: documentation was blank; and on 04/26/24, night shift left tube: documentation was blank Review of the progress note 04/26/24 at 2:16 P.M. revealed the nurse attempted to call the nephrologist in regards to nephrostomies. Right one patent and draining. Left one leaking at the site and no drainage was going into the bag. A message was left and waiting on a call back. Telehealth reference note dated 04/26/24 revealed the nurse reported late this evening that resident's left nephrostomy tube was not patent and urine was seeping out around the tube. There had been no urine noted in the drainage tube for a short time. Order given to send out to the emergency room to verify correct (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 2 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 05/15/2024 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)