Country Club Retirement Center

Inspectors wroteBased on observation and staff interview, the facility failed to clean dishes in a safe and sanitary manner. This affected all 68 residents residing at the facility.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, review of Self-Reported Incident (SRI) and policy review, the facility failed to ensure residents' controlled substances were not misappropriated. This affected five (#40, #54, #85, #86 and #87) of 52 residents receiving controlled substances. The facility census was 68.

Inspectors wroteBased on interview and record review, the facility failed to ensure after visit summary (AVS) notes were obtained following a provider appointment and failed to initiate a new medication in a timely manner. This affected one, (Resident #7) out of two residents reviewed for urinary tract infections. The facility census was 68.

Inspectors wroteBased on interview and record review the facility failed to ensure re-weights were obtained after significant weight loss and significant weight gain. This affected one, (Resident #22) out of four residents reviewed for nutrition. The facility census was 68.

Inspectors wroteBased on observation, review of pest control work orders and invoices, interviews and facility policy review, the facility failed to maintain a pest-free environment. This deficient practice had the potential to affect all 68 residents receiving food from the kitchen. The facility census was 68.

Inspectors wroteBased on observation and interview, the facility failed to post updated daily nursing staff form. This deficient practice had the potential to affect all 68 residents residing at the facility.

Inspectors wroteTHIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the facility Self-Reported Incident (SRI), staff interview, family interview and policy review, the facility failed to maintain a safe environment and provided adequate supervision to prevent Resident #10, who was cognitively impaired, from eloping from the facility without staff knowledge. This affected one (Resident #10) of three residents reviewed who were identified by the facility as having exit seeking and/or wandering behavior. The facility census was 65.

Inspectors wroteBased on observation, medical record review, review of emergency room records, review of the facility incident and accident logs, interview and facility policy review, the facility failed to develop and implement a comprehensive and individualized fall prevention program to prevent falls including a fall with major injury for Resident #60. Actual Harm occurred on 09/04/24 at 7:45 P.M. when Resident #60, who was identified as a high fall risk and experienced recent falls without individualized fall prevention interventions implemented to prevent further falls, climbed out of bed, unassisted and had to be lowered to the floor by State Tested Nursing Assistant (STNA) #222 when she became unsteady and began to fall. The resident denied pain on 09/04/24 and was assisted back to bed; however, on 09/05/24 at 8:29 A.M. [...]

Inspectors wroteBased on record review, review of a facility Self-Reported Incident (SRI), facility investigation review, personnel file review, facility policy review and interview, the facility failed to ensure Resident #51 was free from an incident of staff to resident physical abuse when State Tested Nursing Assistant (STNA) #267 slapped the resident during the provision of care. This affected one resident (#51) of three residents reviewed for abuse. The facility census was 69. Findings Include: Review of the medical record for Resident #51 revealed an admission date of 06/28/23 with diagnoses including unspecified dementia, high blood pressure, asthma, and muscle weakness. [...]

Inspectors wroteTHIS IS AN INCIDENCE OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on review of a facility Self-Reported Incident (SRI), facility investigation review, medical record review, staff interviews, and facility policy review the facility failed to prevent misappropriation of resident narcotic medication. This affected one resident (Resident #12) of three residents reviewed for abuse The facility census was 69. Findings Include: Review of the medical record for Resident #12 revealed an admission date of 04/26/24 with diagnoses including rheumatoid arthritis (RA), osteoporosis, gastric ulcer, and restless leg syndrome. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #12 required assistance from staff for activities of daily living (ADL) tasks including medication administration. The resident was cognitively intact. [...]

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to ensure food was served at a palliative and warm food temperature. The deficient practice had the potential to affect all residents who received meals from the kitchen. The census was 60.

Inspectors wroteBased on record review and interview the facility failed to provide Resident #12, #22, #28, #30, and #43, who were dependednt on staff for care, with scheduled bathing. This affected five residents (#12, #22, #28 #30, and #43) out of six residents reviewed for activities of daily living (ADL). The facility census was 60.

Inspectors wroteBased on observations, staff interviews, and facility policy review, this facility failed to ensure enhanced barrier precautions were implemented in a timely manner for Residents #50 #34, #58, #265, #35, and #119, who were noted to have indwelling medical devices. This affected six residents (#50 #34, #58, #265, #35, and #119) of the six residents reviewed for infection control. The facility census was 60.

Inspectors wroteBased on record review and interview, the facility failed to have the correct advance directives in Resident #22's medical record. This affected one resident (#22) out of three reviewed for advance directives. This had the potential to affect all 60 residents. The facility census was 60.

Inspectors wroteBased on record review, self-reported incident (SRI) review, facility policy review, and interviews, the facility failed to protect Resident #4 from staff-to-resident physical abuse and Resident #17 from staff-to-resident verbal abuse. This affected two residents (#4 and #17) out of two residents reviewed for abuse. This had the potential to affect all 60 residents. The facility census was 60.

Inspectors wroteBased on record review, interview, review of the self-report incidents (SRI), and facility policy review, the facility failed to report an allegation of staff-to-resident verbal abuse against Resident #47 to the state agency as required. This affected one resident (#47) of two residents reviewed for abuse. The facility census was 60.

Inspectors wroteBased on record review, self-reported incident (SRI) review, facility policy review, and interviews, the facility failed to thoroughly investigate allegations of abuse for Residents #4 and #17. This affected two residents (#4 and #17) out of two residents reviewed for abuse. This had the potential to affect all 60 residents. The facility census was 60.

Inspectors wroteBased on record review, facility policy review, Hospice agreement review, and interview the facility failed to follow the bowel policy for Residents #22 and #39. This affected two residents (#22 and #39) out of five residents reviewed for unnecessary medications. The facility also failed to ensure Hospice communication was onsite for Resident #9. This affected one resident (#9) out of one resident reviewed for Hospice. The facility census was 60.

Inspectors wroteBased on observation, record review, facility policy review, and interview the facility failed to comprehensively assess and provide adequate interventions and treatment for Resident #31. Resident #31 developed a stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure ulcer and stage II (partial-thickness skin loss involving the epidermis and dermis) pressure ulcer to buttocks. This affected one resident (#31) out of one resident reviewed for pressure ulcers. The facility census was 60.

Inspectors wroteBased on medical record review and staff interview, the facility failed to offer an alternative meal choice or nutritional shake for Resident #42 when less than 50% of the meal was consumed. This affected one resident (#42) of the two residents reviewed for nutritional support. The facility census was 60.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to ensure dialysis communication forms were completed post dialysis treatment and returned to the facility for Resident #267. This affected one resident (#267) of one resident reviewed for dialysis treatment. The facility census was 60.

Inspectors wroteBased on medical record review, pharmacy recommendation review, and staff interview, the facility to address pharmacy recommendations in a timely manner for Residents #22 and #32. This affected two residents (#22 and #32) of five residents reviewed for pharmacy recommendations. The facility census was 60.

Inspectors wroteBased on closed record review, review of resident fund statements, review of withdrawal transaction report, review of check, review of receipts, policy review and interview the facility failed to ensure accounting principles were followed for resident funds. This affected one (Resident #68) of one resident reviewed for misappropriation.

Inspectors wroteBased on closed record review, review of the self-reported incident (SRI), review of the police report, policy review, and interview the facility failed to ensure resident's money was not misappropriated. This affected one (Resident #68) of one review for misappropriation.

Inspectors wroteBased on closed record review, review of the self-reported incident (SRI), review of the police report, policy review, and interview the facility failed to thoroughly investigate misappropriated funds. This affected one (Resident #68) of one review for misappropriation.

Inspectors wroteBased on observation, record review, staff interviews, resident interviews, review of SANI-CLOTH instructions, and policy review the facility failed to ensure the glucometer used to complete finger stick blood sugar (FSBS) testing was cleansed properly. This had the potential to affect three residents (#70, #90, and #100) who utilized the same glucometer. In addition, the facility failed to ensure ice used for ice pass was free of contamination. This had the potential to affect all 63 residing in the facility. Findings Include: 1. Observation of Licensed Practical Nurse (LPN) # 240 on 11/07/23 at 7:38 A.M. performing a FSBS test on Resident #90, revealed the LPN took the glucometer, test strip container, lancet and alcohol prep pad into the resident's room and laid the items directly on the blanket on top of the resident's bed. The nurse completed hand hygiene and donned gloves. [...]

Inspectors wroteBased on observation, record review, staff interview, and manufacturer instruction review the facility failed to administer insulin via an insulin pen according to the manufacturer's guidelines. This affected one resident (#100) of one resident observed for insulin injection. The facility census was 63.

Inspectors wroteBased on observation, record review, staff interviews, and resident interviews the facility failed to ensure residents received diet items as ordered. This affected two residents (#10 and #30) of three residents reviewed for therapeutic diets. The facility census was 63.

Inspectors wroteBased on observation, staff interviews, and facility policy review the facility failed to ensure safe and proper storge of food items in the dry storage, refrigerator, and freezer. This had the potential to affect all residents, as all residents receive food from the kitchen. The facility also failed to ensure proper handwashing by staff while passing meal trays to resident rooms. This affected five residents (#7, #34, #50, #59, and #120) observed to be affected during the tray passing observation. The facility census was 70.

Inspectors wroteBased on observations, staff interviews, resident interviews, record review, and facility policy review the facility failed to maintain a clean and sanitary environment. This affected two residents (#35 and #56) and had the potential to affect 17 additional residents (#4, #10, #16, #21, #22, #23, #25, #28, #37, #40, #49, #51, #52, #53, #55, #58, and #221) in the affected hallway. The facility census was 70.

Inspectors wrote2. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including displaced fracture of the right femur, atrial fibrillation, benign prostatic hyperplasia, diabetes, hyperlipidemia, Stage IV sacral pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle. Slough may be present on some parts of the wound bed. Often include undermining and tunneling), hypothyroidism, and hypertension. Review of the five-day MDS assessment dated [DATE] revealed Resident #54 had intact cognition and a Stage IV pressure ulcer present upon admission. Review of the April 2023 physician's orders revealed Resident #54 had an order dated 04/20/23 for a sacrum wound negative pressure wound vacuum therapy continuously at 125 millimeters of mercury (mmHg) with white foam and black foam. [...]

Inspectors wroteBased on medical record review and staff interview the failed to ensure the advance directives and plan of care were accurate in the medical record for Resident #18. This affected one resident (#18) of 24 medical records reviewed. The facility census was 70.

Inspectors wroteBased on observation, interview with staff, and review of the facility policy the facility failed to provide resident privacy for Residents #54 and #271 when staff failed to knock before entering the room. This affected two residents (#54 and #271) of two reviewed for privacy. The facility census was 70.

Inspectors wroteBased on interview, medical record review, and review of the Department of Medicaid informational slide presentation titled PASRR - What Nursing Facility Needs to Know the facility failed to update Preadmission Screening and Resident Review (PASRR) with new mental illness diagnoses. This deficient practice affected three residents (#5, #43, and #33) out of three residents reviewed for PASRR requirements. The facility census was 70.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #18 had a care plan developed for the use of oxygen. This affected one resident (#18) of 23 residents reviewed for care plans. The facility census was 70.

Inspectors wroteBased on record review and interviews the facility failed to ensure neurological checks were completed for Resident #56 after a fall with a head injury. This affected one resident (#56) of five residents reviewed for falls. The facility census was 70.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review the facility failed to ensure fall interventions were implemented for two residents (#42 and #56) and failed to initiate a new fall prevention intervention for Resident #56 after a fall. This affected two residents (#42 and #56) of five residents reviewed for falls. The facility census was 70.

Inspectors wroteBased on observation, record review, interview, review of the continuous positive airway pressure (CPAP) cleaning instructions, and facility policy review the facility failed to ensure respiratory equipment was dated and maintained in a clean and sanitary manner for Residents #18, #29, and #36. This affected three residents (#18, #29 and #36) of 13 residents who received oxygen/respiratory therapy. The facility census was 70.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy the facility failed to ensure laboratory tests ordered by the physician were completed. This affected one resident (#19) of five residents reviewed for unnecessary medications. The facility census was 70.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure timely dental services for Resident #18. This affected one resident (#18) of two residents reviewed for dental services. The facility census was 70.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide Residents #14 and #21 all items on the specified diet menu. This affected two residents (#14 and #21) of two residents reviewed for pureed diets. The facility census was 70.

Inspectors wroteBased on observations, interviews, record review, review of recipe instructions, and review of the facility policy the facility failed to make pureed food according to the recipe to ensure high nutritional value. This affected two residents (#14 and #21) of two residents who were on a pureed diet. The facility census was 70.