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
not limited to, assist with incontinent care as needed, and check and change every two hours and as needed for incontinence.At the time of exit there were no care plans or documentation in the record indicating Resident D had adverse behaviors related to refusal of incontinence care, toileting, personal hygiene or false accusations.
During an interview on 9/29/25 at 1:27 p.m. the Director of Nursing (DON) indicated Resident D's nephrostomy tube was currently dislodged and would be replaced soon at the hospital.
She indicated she was going to check Resident D's orders to see what the current orders were for the nephrostomy tube.
The DON indicated the tube did not have a bag attached to it because it was not draining due to the dislodgment.
During an interview on 9/29/25 at 1:36 p.m. the DON indicated she was going to clean up Resident D's orders, because the current order should have been to only change the dressing as needed for soilage and to 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)
Facility ID: