Country Club Ret Center I I I

Inspectors wroteBased on observation and interviews, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 70 of the 72 residents who received food from the facility kitchen. The facility identified two residents, Residents #14 and #70, who received no food from the kitchen. The facility census was 72.

Inspectors wroteBased on observation, interview, record review, facility assessment review, and review of infection-Antibiotic (ATB) Surveillance logs and facility policy, the facility failed to have a designated infection preventionist (IP) who effectively monitored and implemented the facility's Infection Prevention and Control Program (IPCP). This had the potential to affect all 72 residents residing in the facility.

Inspectors wroteBased on observation, interview and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to follow transmission-based precautions for infection control. This affected one resident (#69) and had the potential to affect 12 residents on Certified Nursing Assistant (CNA) #289's assignment (#4, #13, #18, #22, #33, #37, #40, #41, #47, #53, #69 and #73). The facility census was 72.

Inspectors wroteBased on record review, interview, and review of facility policy and the antibiotic surveillance infection logs, the facility failed to maintain an effective antibiotic stewardship program that monitored antibiotic use including reducing the risk of adverse effects of the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use. This affected 25 residents (#1, #2, #3, #5, #10, #14, #15, #19, #28, #29, #32, #33, #34, #36, #37, #45, #46, #47, #48, #49, #50, #55, #56, #65 and #72) who were ordered antibiotics but did not meet McGeer's criteria (infection surveillance definitions for long term facilities for antibiotic use) during the months of December 2025, January 2026 and February 2026. The facility census was 72.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to maintain accurate and thorough documentation for Resident #2's wound assessments in the medical record. This affected one resident (#2) out of two residents reviewed for medical record accuracy with wounds documentation. The facility census was 72.

Inspectors wroteBased on interview, record review and review of facility policy, the facility failed to ensure Resident #32 was current with her pneumococcal vaccination and had no documentation she was offered the vaccine. This affected one resident (#32) out of six residents reviewed for immunizations. The facility census was 72.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the environment remained free of accident hazards for residents who used the designated outdoor smoking area. The facility did not provide a safe environment for the disposal of smoking materials, resulting in potential fire hazard. This had the potential to affect all residents, employees, and visitors who use the facility smoking areas. The facility census was 72.

Inspectors wroteBased on observation, interview, record review, facility policy review, review of the memorandum from the Department of Health & Human Services, and review of guidelines from the Centers for Disease Control and Prevention, the facility failed to implement and utilize required enhanced barrier precautions (EBP) for Residents #35, #36, #163, #170 and #172, and use appropriate standards of practice with use of gloves during catheter care and tracheostomy care for Residents #36 and #170. This affected five residents (#35, #36, #163, #170 and #172) and had the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on interview, record review and policy review, the facility failed to implement the abuse policy and procedure after receipt of an allegation of abuse for Resident #52. This affected one resident (Resident #52) of one reviewed for abuse and had the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide individualized and sufficient care to manage edema for Resident #24. This affected one resident (#24) of one resident reviewed for edema. The facility census was 68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide tracheostomy care for Resident #170. This affected one resident (#170) of one resident reviewed for tracheostomy care. The facility census was 68.

Inspectors wroteBased on record review and staff interview, and the facility failed to ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days or had a determined stop date. This affected three residents (#51, #28 and #48 ) of five reviewed for unnecessary medications. The facility census was 68.

Inspectors wroteBased on record review and interview the facility failed to accurately document the resident's diagnoses to justify use of ordered medications. This affected one resident (#48) of five residents reviewed for medications. Facility census was 68. Findings Include: Review of the medical record for Resident #48 revealed an admission date of 12/13/23. Diagnoses included diabetes, muscle weakness, need for assistance with personal care, difficulty in walking, other abnormalities of gait and walking, cognitive communication deficit, other specified disorders of bone density and structure, chronic kidney disease, osteoarthritis, encephalopathy, and a history of falling. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment for Resident #48, dated 04/05/24, revealed impaired cognition. [...]

Inspectors wroteBased on interviews, record review, documented staff statements, and facility policy review, the facility failed to ensure the physician and family were notified timely of Resident #50's fall which resulted in a fracture on 12/08/22. This affected one resident (#50) of three residents reviewed for falls. The census was 62.

Inspectors wroteBased on interviews, record review, documented staff statements, and facility policy review, the facility failed to ensure a fall was documented, investigated, fall interventions were implemented, and the care plan was updated for Resident #50. This affected one resident (#50) of three residents reviewed for falls. The census was 62.

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure facility temperatures of common areas and resident rooms were monitored and documented during a power outage. This had the potential to affect all residents residing in the facility. The census was 62.