Countryside Meadows: Fall and Laceration Hazards - IN
The resident, identified in inspection records only as Resident B, was moved to the secured memory care unit sometime before October 10, 2025. Her care plan that day noted she had dementia and listed an intervention: keep the environment free from hazards. Three weeks later, a nurse practitioner came to see her and found dressings covering both lower legs. The nurse practitioner wrote that the wounds were "some injuries that the nurse and staff are not aware of what could have caused it." Nobody had documented an explanation. The wounds had been scraped and re-dressed daily without anyone recording how they got there.
By October 31, the facility opened a second care plan specifically for the skin tears, this one noting injuries to her right knee and the back of her left knee. The new intervention read: observe the resident's environment for potential to cause skin trauma.
Then, on the morning of November 5, a nursing note recorded that Resident B hit her left leg against the bed frame while being transferred from a wheelchair to bed. The laceration bled moderately. Staff applied first aid and called 911.
She arrived at the emergency room just after 2 a.m. on November 6. The ER documentation described a "large deep leg laceration to left lower leg." Doctors closed the wound with six simple interrupted sutures and approximately four running sutures to approximate the areas between them, ten sutures in total to close what a bed frame did to a woman's leg during a routine transfer.
The inspection that produced this citation took place on November 10, 2025, the same day state inspectors sat down with the facility's administrator and director of nursing. The two told inspectors there was no policy to address environmental hazards. When pressed, the administrator produced a document titled "Maintenance Procedure." It was undated. It covered beds in a single line: check casters, check side rails, tighten nuts and bolts, lubricate adjusting mechanisms. Frequency: twice a year.
There was nothing in the document about what to do when a resident on a dementia unit accumulates unexplained wounds. Nothing about inspecting a room after an injury. Nothing about identifying what in the physical environment might be causing harm to someone who cannot reliably describe what happened to her.
The inspection report also noted that Resident B had an earlier fall before her move to memory care, an unwitnessed fall in her room in which she sustained a skin tear on her lower extremity. The root cause was listed as the resident trying to get up by herself, and the intervention was an occupational therapy evaluation. The record lacked any follow-up on how or where she sustained that tear either.
The citation was classified as causing actual harm.
What the records show, taken together, is a woman who fell, then moved to a unit designed to protect people with dementia, then developed wounds on both legs that nobody could explain, then had a care plan written telling staff to watch the environment for hazards, then hit the same legs on a bed frame hard enough to need emergency surgery, all while the facility operated without a policy for identifying what in her environment was hurting her.
The administrator and director of nursing learned on November 10 that no such policy existed. Resident B had already been to the emergency room and back.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Countryside Meadows from 2025-11-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
COUNTRYSIDE MEADOWS in AVON, IN was cited for violations during a health inspection on November 10, 2025.
The resident, identified in inspection records only as Resident B, was moved to the secured memory care unit sometime before October 10, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.