Countryside Meadows
COUNTRYSIDE MEADOWS in AVON, IN — inspection on September 29, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
dislodged and would be replaced soon at the hospital.
She indicated she was going to check Resident
interview on 9/29/25 at 1:36 p.m. the DON indicated she was going to clean up Resident D's orders,
flush the tube as needed.
During an interview on 9/29/25 at 2:31 p.m. the Unit Manager (UM) indicated Resident D's current nephrostomy tube that was in place was a new tube and was working properly as far as she knew.
She indicated she was just about to change the dressing for Resident D's nephrostomy tube, because to her knowledge the dressing was to be changed, and the tube was to be flushed daily and as needed.
The UM indicated the nephrostomy tube was not connected to a bag at this time because her other kidney was functioning properly and she was urinating as normal, so the nephrostomy tube was not draining.
She indicated if it did start to drain staff would then connect a drainage bag and account for the output from the tube.
The UM also indicated Resident D was not on a bowel and bladder program because the resident did not know when she needed to go, she could only feel when she had already voided.
She was on a standard two hour check and change schedule.During an interview on 9/29/25 at 3:00 p.m. the Administrator indicated the UM must have misspoke, because the current order for Resident D's nephrostomy tube was to be changed only as needed (PRN) and the tube was still dislodged.On 9/29/25 the administrator provided an electronic copy of a current facility policy titled, Bowel and Bladder Program, dated 5/2019.
This policy indicated, .If a resident is totally incontinent and unable to be placed on a toilet or bedpan, resident should be checked and changed every two hours.This citation relates to Intake 2583736.3.1-41(a)(1)
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.