Country Club Retirement Ctr IV

Inspectors wroteBased on review of medical records, review of hospital and pharmacy records, and interviews with resident and staff, the facility failed to provide timely medical intervention when a resident experienced an acute change in condition. This affected one resident (#6) of two residents reviewed for hospitalization. In addition, the facility failed to provide treatment to a resident's skin tear. This affected one resident (#53) of four residents reviewed for skin conditions. The facility census was 45. Actual harm occurred on 10/02/25 when Resident #6, with a known history of gastric reflux with esophagitis, two recent emergency room visits for duodenitis and gastritis, and was taking routine ibuprofen (non-steroidal anti- inflammatory medication) and a routine Plavix (anti-platelet medication), experienced continued stomach pain with vomiting a reddish-brown liquid. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an adequately equipped call system which relayed the call directly to a staff member or centralized staff work area from each resident's bedside or toilet and bathing facility. During a call system outage, there was a delay providing hand bells and a monitoring system to monitor resident needs. There also was not a way for residents to call for assistance from a toilet or bathing area. This affected all 45 residents residing in the facility. The facility census was 45.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team. This affected four residents (#11, #41, #32 and #46) residents reviewed for care plans. The facility census was 45.1. Review of the medical record for Resident #11 revealed an admission date of 07/27/24. Diagnoses included hypothyroidism, chronic obstructive pulmonary disease, chronic combined systolic and diastolic heart failure, adult failure to thrive, chest pain, and dementia. Review of the care plan for Resident #11 revealed a focus of care for assistance from staff to meet activities of daily living (ADL) needs due to acute kidney failure, weakness, adult failure to thrive, dementia, and depression, initiated on 07/30/24. [...]

Inspectors wroteBased on record review, observation and interview, the facility failed to provide oxygen therapy according to physician order, which included the correct respiratory equipment used, care of equipment, the frequency, and the correct prescribed flow rates of the oxygen. This affected four residents (#11, #41, #15, and #35) of four residents reviewed for oxygen use. The facility census was 45.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to ensure timely responses from medical providers to pharmacy recommendations. This affected eight (#12, #14, #15, #25, #27, #41, #58, and #59) of 48 residents who had recommendations made during the facility monthly medication review for December 2025. The facility census was 45.

Inspectors wroteBased on observation, interview and policy review, the facility failed to safely store medications in a locked storage area. This had the potential to affect all resident who were independently mobile in the facility. The facility identified 20 residents (Residents #9, 4, 13, 5, 20, 22, 24, 3, 31, 32, 53, 34, 14, 7, 33, 36, 6, 2, 40, and 49) who were independently mobile, seven of which were identified as being confused (Residents #6, 40, 49, 4, 20, 22, and 32). The facility census was 45.

Inspectors wroteBased on record review, observation, interview and review of facility policy, the facility failed to maintain the respect and dignity of a resident. This affected one resident (#44) of one resident reviewed for dignity. The facility census was 45.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents receiving psychotropic medications were educated on the risks/ benefits associated with the use of psychotropic medications and failed to obtain informed consent from the resident and/or their representative prior to use. This affected three residents (#32, #42, and #4) of five residents reviewed for unnecessary medications. The facility census was 45.

Inspectors wroteBased on review of the medical record and staff interviews, the facility failed to provide necessary medical information to the receiving facility when residents were transferred to the hospital for emergent medical care. This affected two residents (#6 and #46) of two residents reviewed for hospitalization. The facility census was 45.

Inspectors wroteBased on record review and interview, the facility failed to assure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment. This affected three residents (#11, #15, and #41) of four residents reviewed for accuracy of assessments. The facility census was 45.

Inspectors wroteBased on record review and interview, the facility failed to ensure a comprehensive baseline care plan to indicate interventions for a Clostridium difficile (C. diff) infection and failed to obtain the signature of the resident and/or resident representative. This affected one resident (#46) of five newly admitted residents reviewed for baseline care plans. The facility census was 45.

Inspectors wroteBased on medical record review, observation of medication administration, and interview with staff, the facility failed to ensure routine medication was available for all residents. This affected one resident (#36) of four residents observed receiving medication during the medication administration pass. The facility census was 45.

Inspectors wroteBased on closed medical record review, review of hospice notes, review of photos, review of pharmacy records, policy review, and interviews, the facility failed to ensure Resident #40 received adequate and necessary care and services for end-of-life care. This affected one resident (#40) of three residents reviewed for quality care and services. Actual harm was identified on 11/26/25 involving Resident #40, who was admitted to the facility for end of life care and hospice services. The facility failed to ensure the resident received comprehensive assessments and adequate monitoring of his condition, including evaluation and management of ongoing pain and anxiety associated with his terminal illnesses. The facility did not implement or administer the ordered treatments and medications necessary to promote comfort and symptom relief. [...]

Inspectors wroteBased on closed medical record review, review of hospital records, policy review and interview, the facility failed to implement a comprehensive, individualized and effective pain management program for Resident #41, who had a diagnosis of migraines. Actual harm occurred on 11/29/25 (three days after admission) when Resident #41, who was diagnosed with severe intractable migraines prior to admission to the facility, did not receive ordered anti-migraine medication resulting in the resident's transfer to the hospital for intractable headaches with vomiting and hypertension. The resident was hospitalized from [DATE] until 12/06/25 for management of intractable migraines. Findings Include: [...]

Inspectors wroteBased on review of infection control log, interview, and policy review the facility failed to ensure the facility had a comprehensive infection control program that including tracking and monitoring for infection trends. This had the potential to affect all 37 residents residing in the facility. Findings Include: Review of the infection control trending of infections dated 10/2025 to 03/2026 revealed no evidence the facility was trending for infections. The facility was utilizing a map for trending. In the corner of the map was the key that indicated respiratory was blue, gastrointestinal was green, urinary tract infections (UTI) were yellow, wounds were pink and others were purple. There was no evidence of the type of infections to ensure there was not a pattern. Further review of the infection log dated 12/2025 to 03/2026 revealed the facility started utilizing a new log. [...]

Inspectors wroteBased on interview, record review, review of infection-Antibiotic (ATB) Surveillance logs and facility policy, the facility failed to have a qualified designated infection preventionist (IP) who effectively monitored and implemented the facility's Antibiotic Stewardship Program. This had the potential to affect all 39 residents residing in the facility. The facility census was 39.

Inspectors wroteBased on review of concerns forms, review of email communication, interviews, observation, and policy review the facility failed to ensure a functioning call light system that was not able to be turned off until the call light was responded to by staff. This had the potential to affect all 37 residents residing in the facility. Findings Include: Review of an email dated 02/20/26 to the previous Director of Nursing (DON) #100 from Resident #28's daughter revealed Resident #28's daughters' friend was visiting her mother and had called her because the visitor had asked someone walking down the hall to check Resident #28 after waiting a long time for someone to come. That person checked her mom and said she was dry. The friend knew that Resident #28 was not dry because she could smell the urine. Two other people and the physical therapist came in and took Resident #28 to the bathroom. [...]

Inspectors wroteBased on medical record review, review of concerns form, observation, interview, and policy review the facility failed to implement appropriate pressure relieving interventions timely to prevent pressure ulcers and failed to identify and treat pressure ulcer. This affected one resident (#28) of three residents reviewed for pressure ulcers. Findings Include:Medical record review revealed Resident #28 was admitted to the facility on [DATE] and re-admitted on [DATE] after sustaining a fall with left femur fracture. Review of Resident #28's risk for skin breakdown related to peripheral vascular disease and incontinence plan of care dated 03/02/18 and revised on 11/29/22 revealed weekly skin assessments, pressure redistribution mattress to bed, consult with wound nurse practitioner as needed, and tubi- grips to both legs on in the morning and off at bedtime. [...]

Inspectors wroteBased on medical record review, observation, interviews, and policy review the facility failed to ensure fall interventions were in-place per the resident's plan of care. This affected one resident (#28) of three residents reviewed for accident/hazards. Findings Include: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur, hypotension, urinary incontinence, dizziness, difficulty walking, and muscle weakness. Review of Resident #28's risk for falls/injury related to dizziness, impaired gait, muscle weakness, and use of psychoactive medication plan of care dated 03/02/18 and revised 10/21/25 revealed on 10/21/25 bright color paper used for visual aide to ask for help and use the call light system was added to the interventions. [...]

Inspectors wroteBased on medical record review, review of concern forms, review of meal ticket, observation, and interview the facility failed to ensure a resident received fluids per order. This affected one resident (#28) of three residents reviewed for hydration. Findings Include: Medical record review revealed Resident #28 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including urinary tract infections, hypotension, gastric reflux, protein-calorie malnutrition, and dysphagia. Review of Resident #28's dietary note dated 07/17/25 revealed the fluid intake recommendation was 1950 milliliters (ml). Review of a concern form dated 02/12/26 revealed Resident #28's daughter had concerns after her mother fractured left femur, she would be less mobile and had concerns with urinary tract infections and hydration. [...]

Inspectors wroteBased on record review and interview, the facility failed to maintain an accurate medical record. This affected three residents (#18, #27 and #30) of 11 residents reviewed for accuracy of medical records.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to implement an antibiotic stewardship program that included ensuring appropriate antibiotic use. This affected three residents (#24, #30, and #31) of three residents reviewed for antibiotic use. The facility census was 39.

Inspectors wroteBased on record review, Self-Reported Incident (SRI) review, observation and interview, the facility failed to ensure exit doors were maintained in good repair to prevent elopement for Resident #50. This affected one (Resident #50) of two residents identified as elopement risk.

Inspectors wroteBased on observation, record review, and interview, the facility failed to safely administer and appropriately document controlled substances. This had the potential to affect 26 residents (Resident #4, #29, #23, #9, #44, #13, #50, #32, #1, #10, #14, #18, #29, #15, #52, #16, #43, #2, #5, #41, #32, #53, #40, #34, #30, and #8) identified as taking controlled substances by the facility. The facility census was 46.

Inspectors wroteBased on record review, review of the Concern Log, review of the Call Light Audit Report, and interview, the facility failed to ensure staff assistance was provided timely for five dependent residents. This affected five (#7, #10, #23, #37, and #30) of six resident reviewed for activities of daily living (ADL's). The facility census was 46.

Inspectors wroteBased on review of the facility assessment, review of the daily staffing schedule, review of the Time Punch Detail Hours Report, record review, and staff and resident interviews, the facility failed to maintain sufficient levels of direct care staff to meet the total care needs of all residents. This affected five (#7, #10, #23, #30, and #37) of six residents reviewed for activities of daily living (ADLs), and had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on record review, review of facility's medication administration policy, and interview, the facility failed to ensure medical records were accurate and complete regarding the administration of controlled substances. This affected five (#9, #19, #23, #4, and #44) of six residents reviewed for medication administration. The facility census was 46.

Inspectors wroteBased on medical record review, facility investigation review, facility policy review, and interviews, the facility failed to timely report a suspicion of misappropriation of narcotics. This affected one (#19) of three residents reviewed for misappropriation. The facility census was 46.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow proper hand hygiene and management of soiled linens during incontinence care. The affected one (#5) of one resident reviewed for incontinence care. The facility census was 46.

Inspectors wroteBased on record review, facility policy review, and interview, the facility failed to ensure dietary recommendations were timely implemented and the physician was updated timely on a resident's severe weight loss. Actual harm occurred to Resident #1 when nutrition recommendations were not implemented, and the physician was not updated resulting in the resident sustaining an avoidable 16.6% severe weight loss in one month. This affected one (Resident #1) of three residents reviewed for nutrition.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to comprehensively assess residents' urinary incontinence to determine type of bladder incontinence and failed to develop and implement an appropriate treatment plan to maintain and/or restore the residents' bladder function. This affected two residents (#45 and #57) of three residents reviewed for urinary incontinence.

Inspectors wroteBased on medical record review, observation, and interviews, the facility failed to ensure a resident's oxygen concentrator alarm was addressed timely. This affected one resident (#45) of three residents observed with oxygen concentrators.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to notify the resident representative and the physician of a change in health status. This affected one resident (#35) of three residents reviewed for notification of change. The facility census was 51.

Inspectors wroteBased on observation, medical record review, and staff interview, the facility failed to ensure physician's orders were in place prior to the use of a reclining safety and enabling chair. This affected one resident (#34) of one resident reviewed for potential restraint use. The facility census was 51.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) documents accurately reflected a new diagnosis and medications. This affected two residents (#38 and #16) of four residents reviewed for PASRR documents. The census was 51. Findings Include: 1. Medical record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including bipolar disorder, dementia, diabetes mellitus, muscle weakness, and asthma. Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/31/24, revealed the resident had intact cognition and a diagnosis of dementia. Review of Resident #38's PASRR document, dated 08/29/24, revealed under Section D, no was selected incorrectly indicating there was not a diagnosis of dementia. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure Pre-admission Screening and Resident Review assessments were completed accurately upon admission to the facility. This affected two residents (#16 and #20) of four residents reviewed for admission assessments. The facility census was 51.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to provide timely treatment as ordered by the physician. This affected one resident (#35) of three residents reviewed for change of condition. The facility census was 51.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure a dependent resident received appropriate services to maintain mobility and prevent further decrease in range of motion. This affected one resident (#9) of two residents reviewed for mobility. The census was 51.

Inspectors wroteBased on record review and interview, the facility failed to obtain a physician order for oxygen therapy. This affected one resident (#35) of three residents reviewed for respiratory care. The facility census was 51.

Inspectors wroteBased on medical record review and interview the facility failed to ensure laboratory results were performed to ensure adequate monitoring of medication and failed to ensure abnormal laboratory results were addressed appropriately. This affected two residents (#28 and #47) of six resident reviewed for medication review.

Inspectors wroteBased on medical record review, hospital record review, resident interview and staff interview, the facility failed to ensure medications had an appropriate indication for use. This affected one resident (#50) of five residents reviewed for medications. The facility census was 51.

Inspectors wroteBased on medical record review and staff interview the facility failed to administer psychotropic medications as ordered. This affected one resident (#8) of five residents reviewed for medications. The facility census was 51.

Inspectors wroteBased on medical record review and interview the facility failed to ensure a resident received dental care timely for ill-fitting dentures and dentures were readily accessible to the resident. This affected one resident (#21) of two reviewed for dental.

Inspectors wroteBased on infection control log review, medical record review, policy review and staff interview the facility failed to ensure residents had an appropriate indication for the use of antibiotics. This affected three residents (#3, #16 and #44) of eight residents reviewed for antibiotic use. The facility census was 51.

Inspectors wroteBased on observation, review of the facility's concern log, record review, and interview the facility failed to maintain sufficient levels of staffing to ensure call lights were responded to in a timely manner and to meet the total care needs of all residents. This had the potential to affect all 45 residents residing in the facility.

Inspectors wroteBased on medical record review and interview the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR) Identification Screen was completed to determine if Resident #4 needed specialized services. This affected one resident (#4) of two residents reviewed for PASARR.

Inspectors wroteBased on observation, medical record review and interview the facility failed to ensure Resident #4 and Resident #96, who required staff assistance with activities of daily living received timely and adequate assistance with personal care, including facial hair removal. This affected two residents (#4 and #96) of four residents reviewed for activities of daily living.

Inspectors wroteBased on medical record review and interview the facility failed to ensure adequate monitoring and care for Resident #28 related a diagnosis of diabetes mellitus including clarification of a physician's order for administration of sliding scale insulin. This affected one resident (#28) of five residents reviewed for medication use.

Inspectors wroteBased on observation, medical record review, and interview the facility failed to ensure Resident #10, who had an indwelling urinary catheter received appropriate services to prevent urinary tract infections. This affected one resident (#10) of two residents reviewed for urinary catheters. The facility identified four residents with urinary catheters.