Country Court

Inspectors wroteBased on observation and interviews with staff, the facility failed to ensure the washcloths used for resident care were not stained or discolored. This had the potential to affect all 48 residents in the facility. Findings Include: Observations conducted during the initial tour on 05/26/26 from 9:05 A.M. through 9:11 A.M. revealed all of the washcloths, 70 in total, in three of the linen closets were completely discolored/stained gray to dark brown. On 05/26/26 at 9:20 A.M. an interview with Certified Nursing Assistant (CNA) #106 revealed she did not know why all the washcloths in the linen closets were discolored and stained. Interview and observation of the laundry room on 05/26/26 at 9:35 A.M. with Laundry Staff #111 revealed a pile of unfolded stained/discolored washcloths on the top of the table and about a dozen white washcloths folded in the laundry cart to go out on the units. [...]

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call emergency medical services (EMS) for a resident with advance directives for a Full Code (indication for healthcare providers to perform all possible life-saving measures in the event of a cardiac or respiratory arrest). This resulted in Immediate Jeopardy and Actual Harm/Subsequent Death on [DATE] at 5:30 A.M. when Resident #50 was found unresponsive without vital signs and Licensed Practical Nurse (LPN) #79 and Registered Nurse (RN) #75 failed to initiate CPR or contact EMS. LPN #79 and RN #75 did not review Resident #50's code status and determined Resident #50 was deceased at 5:30 A.M. On [DATE] at 10:11 A.M., the Administrator and Registered Nurse (RN) #162 were notified Immediate Jeopardy began on [DATE] at 5:30 A.M. [...]

Inspectors wroteBased on observation of facility crash cart (a mobile cart utilized in emergency situations that contains emergency medications and equipment), review of the crash cart binder, interview, and review of facility policy, the facility failed to maintain emergency patient care medications and equipment in safe operating condition. This had the potential to affect all residents. The census was 48. Findings Include:Observation of the facility crash cart on [DATE] at 3:47 P.M. revealed the following expired items: [...]

Inspectors wroteBased on closed record review, review of self reported incidents (SRI), staff interview, and policy review, facility failed to ensure a concern of resident neglect was reported to the State agency. This affected one resident (#50) of three reviewed for resident death. The facility census was 48.

Inspectors wroteBased on closed record review, review of facility self reported incidents (SRI), staff interview, and policy review, facility failed to ensure a concern of resident neglect was thoroughly investigated. This affected one resident (#50) of three reviewed for resident death. The facility census was 48.

Inspectors wroteBased on record review, observation, interviews, and review of facility policy, the facility failed to report an allegation of an injury of unknown origin to the State Survey Agency as required. This affected one (Resident #49) of three residents reviewed for abuse.

Inspectors wroteBased on observation, medical record review, facility policy review, and interview, the facility failed to complete a thorough investigation following an allegation of an injury of unknown origin. This affected one (#49) of three residents reviewed for abuse. The facility census was 48.

Inspectors wroteBased on record review, review of facility policy and interviews, the facility failed to ensure showers were provided to dependent residents as scheduled and/or per plan of care. This affected two residents (Resident #38 and #49) of three residents reviewed for activities of daily living. The census was 48.

Inspectors wroteBased on record review, observation, interview, and policy review the facility failed to ensure meal intakes were documented to ensure residents maintained appropriate nutritional parameters to prevent potential weight loss and meet nutritional needs. This affected three residents (Resident #44, #49 and #53) of three residents reviewed for nutrition.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all residents residing in the facility. The census was 53. Finds Included: Observation on 02/18/25 at 8:37 A.M. of the kitchen with the Dietary Manager #300 revealed serving pans of various sizes were being stored wet. There were six serving pans stacked on the shelf that were still wet. Interview on 02/18/25 at 8:40 A.M. with the Dietary Manager #300 verified after serving dishes are washed they have to be air dried completely before being stacked and put away. Review of the facility policy Cleaning Dishes/Dish Machine, dated 2023 revealed dishes should be air dried on the dish racks, not dried with towels. Dishes are to be inspected for cleanliness and dryness and put dishes away. [...]

Inspectors wroteBased on observation, water management plan review and interview, the facility failed to maintain a comprehensive water management plan and utilize appropriate disinfectants to prevent the spread of communicable disease. This had the potential to affect all residents who reside in the facility. The facility census was 53.

Inspectors wroteBased on record review, staff interview, resident interviews and policy review the facility failed to provide showers per resident preference. This affected six of six residents (Resident #19, #21, #26, #30, #43, and #47) reviewed for showers. The census was 53. Findings Include: 1. Review of the medical record for Resident #47 revealed an admission date of 05/23/24. Diagnosis included chronic obstructive pulmonary disease, hemiplegia and hemiparesis affecting the right dominant side and diabetes. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 was cognitively intact and under the area of preferences Resident #47 indicated it is very important to choose between a tub bath, shower, bed bath or sponge bath. The resident's cognition, according to subsequent MDS Assessments, has remained intact. [...]

Inspectors wroteBased on medical record review, observations, interviews, and facility policy review the facility failed to ensure fall/safety measures were in place for a high fall risk resident. This deficient practice affected one resident (Resident #19) of four residents reviewed for accidents and hazards. The facility census was 53. Findings Include: Review of Resident #19's medical record revealed admission date 12/28/23 with diagnoses including but not limited to Parkinson's Disease, hemiplegia on the left side, anxiety, depression and history of stroke. Review of Resident #19's annual Minimum Data Set (MDS) dated [DATE] revealed the resident was cognitively intact with a Brief Interview Mental Status (BIMS) score of 15 out of a possible 15 dated 01/04/25. [...]

Inspectors wroteBased on medical record review, interview, and facility policy review the facility failed to implement indwelling urinary catheter care orders. This deficient practice affected one resident (Resident #21) of two residents reviewed for urinary catheter care. The facility census was 53. Findings Include: Review of Resident #21's medical record revealed admission date 05/26/23 with diagnoses including but not limited to end stage renal disease, obstructive uropathy, and high blood pressure. Review of Resident #21's urinary catheter care plan dated 06/02/23 revealed Resident #21 had a suprapubic indwelling urinary catheter with interventions including catheter care every shift. [...]

Inspectors wroteBased on medical record review, interview and facility policy review the facility failed to obtain urinary testing prior to administration of an antibiotic medication for a possible urinary tract infection and failed to complete criteria for the use of an antibiotic medication. This deficient practice affected one resident (Resident #21) of two residents reviewed for antibiotic medication use. The census was 53. Findings Include: Review of Resident #21's medical record revealed admission date 05/26/23 with diagnoses including but not limited to end stage renal disease, obstructive uropathy, and high blood pressure. Resident #19 had moderately impaired cognition with a BIMS score of 10 out of possible 15 dated 01/20/25. Resident #21 required assistance with completion of ADL tasks including transfers, bathing/showering, personal hygiene, and had an indwelling urinary catheter. [...]

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to ensure Resident #9 and Resident #17, received education regarding the benefits and potential side effects of the the influenza vaccination. This affected two residents (Resident #9 and #17) of five residents reviewed for vaccinations. The facility census was 52.

Inspectors wroteBased on observation, medical record review, facility investigation review, Emergency Medical Services report review, hospital record review, staff interview and policy review, the facility failed to provide Resident #50, who was identified to have intermittent confusion, adequate supervision, and assistance to prevent a fall with injury. Immediate Jeopardy and serious harm and injury occurred on 11/07/23 when staff assisted Resident #50 to the facility front porch to be transported to an outside appointment. The resident was left unattended in a wheelchair thought to not have properly functioning brakes. After being left unattended, the resident moved her wheelchair from the facility porch/portico and began to roll approximately 50 feet across the parking lot toward six concrete steps. [...]

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to properly date opened food items in the refrigerator, freezer, and dry storage areas. The facility also failed to use proper hand hygiene during lunch meal service. The deficient practices had the potential to affect all 51 residents who resided in the facility as there were not any residents who were on a nothing by mouth (NPO) diet. Findings Include: 1. During the initial tour on 12/12/22 from 10:30 A.M. to 10:39 A.M. with Dietary Manager #134, the following items were observed not properly dated: In the refrigerator: A bag of garnish lettuce, opened and not dated A bag of leaf lettuce, opened and not dated A bag of green peppers, not dated A bag of red peppers, not dated A large plastic uncovered bin of onions, not dated Interview on 12/12/22 at 10:34 A.M. [...]

Inspectors wroteBased on observation and staff interview the facility failed to maintain a safe and comfortable environment. This affected all the residents in the facility. The facility census was 51.

Inspectors wrote4. Review of Resident #31's record revealed an admission date of 03/15/22. Diagnoses included heart failure, congestive heart failure, and hypertension. Review of Resident #31's December 2022 physician orders, revealed an order, dated 03/16/22, for Digoxin 125 micrograms daily for hypertension. Review of Resident #31's pharmacy recommendation, dated 06/09/22, revealed a recommendation for a Digoxin level to be done. Continued reviewed revealed that the physician accepted and agreed to obtaining the level. Review of Resident #31's lab work revealed she had no evidence of a Digoxin level ever being obtained. Interview on 12/15/22 at 1:12 P.M. the Director of Nursing revealed Resident #31's Digoxin level was never obtained. She confirmed the order was missed. 2. Review of the medical record for Resident #4 revealed an admission date on 03/05/2004. [...]

Inspectors wroteBased on observations, staff interview, review of resident diets, review of the menu and dietary spreadsheet, and facility policy review, the facility failed to follow the pre-planned menu and provide pureed bread to five residents (Residents #1, #16, #28, #33, and #154) who received a pureed diet. The deficient practice affected all five residents (Residents #1, #16, #28, #33, and #154) who received a pureed diet. The facility census was 51. Findings Include: Review of the list of resident diets provided by the facility revealed there were five residents who received a pureed diet, Residents #1, #16, #28, #33, and #154. Review of the pre-planned lunch menu dated 12/14/22 revealed country fried steak, garlic mashed potatoes, sunshine carrots, choice of roll, cinnamon maple apple cake, country gravy, margarine, and coffee or tea was to be served to residents. [...]

Inspectors wroteBased on observation, medical record review, staff interview, resident interview, and facility policy and procedure review, the facility failed to ensure call lights were in working order. This affected one Resident (#103) out of four residents reviewed for accidents, and had the potential to affect 27 residents (#1, #3, #4, #7, #8, #9, #10, #11, #14, #16, #18, #20, #21, #28, #31, #32, #33, #35, #37, #38, #41, #45, #103, #153, #154, #204, #301) who utilized the station #3 shower room. The census was 51. Findings Include: [...]

Inspectors wroteBased on medical record review, observation and staff interview the facility failed to ensure Resident #42 had her call light within reach. This affected one resident (Resident #42) of five reviewed for accidents.

Inspectors wroteBased on medical record review, resident interview, staff interview, and facility policy and procedure review, the facility failed to honor residents shower preferences. This affected three residents (#22, #38, and #103) of six residents reviewed for activities of daily living. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #103 revealed an admission date of 11/22/22 and a discharge date of 12/13/22 with the diagnoses of encounter for orthopedic aftercare, osteomyelitis right ankle and foot, atrial fibrillation, dementia, peripheral autonomic neuropathy, gait abnormalities, muscle weakness, need for assist with personal care, arthritis, low back pain, benign prostatic hyperplasia and cataracts. [...]

Inspectors wroteBased on review of the medical record, review of the Self-Reported Incident (SRI), resident interview and staff interview the facility failed to ensure misappropriation of funds did not occur for Resident #13. This affected one resident (Resident #13) of two reviewed for misappropriation of property.

Inspectors wroteBased on medical record review, review of the facility's investigation, staff interview, and facility policy review, the facility failed to report an allegation of verbal abuse for one resident (Resident #102). This affected one (Resident #102) of two residents reviewed for abuse/misappropriation. The facility census was 51. Findings Include: Review of the closed medical record for former Resident #102 revealed an admission date on 04/05/22 and a discharge date on 04/08/22. Medical diagnoses included paroxysmal atrial fibrillation, type II diabetes mellitus, and weakness. Review of the admission assessment dated [DATE] revealed Resident #102 was alert to person, place, and time and was verbally appropriate. Review of the Five-Day Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #102 required limited assistance from one staff to complete Activities of Daily Living. [...]

Inspectors wroteBased on medical record review, review of facility Self-Reported Incident (SRI), policy review, resident interview and staff interviews the facility failed to thoroughly investigate allegation of misappropriation for Resident #13 and verbal abuse for Resident #102. This affected two residents (Resident #13 and #102) of 17 reviewed for abuse.

Inspectors wroteBased on medical record review, staff interview, review of Pre-admission Screening and Resident Reviews (PASARRs), and facility policy review, the facility failed to update PASARR screenings when two residents (Resident #31 and #34) had additional mental health diagnoses added. This affected two (Residents #31 and #34) of two residents reviewed for PASARR screenings. The facility census was 51. Findings Include: 1. Review of the medical record for Resident #34 revealed an admission date on 02/25/19. Medical diagnoses included unspecified dementia with agitation (10/01/22), Major Depressive Disorder-recurrent (02/25/19), delusional disorders (08/21/19), anxiety disorder (03/29/20), hallucinations (08/21/19), and cognitive communication deficit (02/25/19). [...]

Inspectors wroteBased on interview and record review the facility failed to provide quarterly care conferences for Resident#17 and failed to invite Resident #5 to her care conference. This affected two (#5 and #17) of two residents reviewed for care conferences. The facility census was 51.

Inspectors wroteBased on observation, interview, and record review the facility failed to assist Resident #38 and Resident #154 with nail care. This affected two (#38, #154) of two residents reviewed for nail care. The facility census was 51.

Inspectors wroteBased on observation, medical record review, staff interview and facility policy and procedure, the facility failed to ensure pressure ulcer interventions were in place. This affected one resident (#37) out of one resident reviewed for pressure. The facility identified one resident (#37) with pressure ulcers. The census was 51. Findings Include: Review of the medical record for Resident #37 revealed an admission date of 04/10/19 and the diagnoses of paraplegia, colostomy, protein calorie malnutrition, diabetes type two, spinal stenosis, and reflex neuropathic bladder. Review of the Braden pressure ulcer risk assessment dated [DATE], revealed Resident #37 was at low risk for developing a pressure ulcer. Review of the care plan dated 04/22/19 and updated 11/23/22 revealed Resident #37 had a history of wounds with multiple dates and stages of differing wounds. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident #35's splinting program was initiated per therapy recommendations. This affected one (#35) of two residents reviewed for therapy recommendations. The facility census was 51.

Inspectors wroteBased on observation, medical record review, staff interview, resident interview, family interview, and facility policy and procedure review, the facility failed to ensure residents were not left unattended while unresponsive, resulting in a fall for Resident #103, and failed to thoroughly investigate a fall for Resident #38. This affected two residents (#38 and #103) out of four Residents reviewed for accidents. The census was 51. Findings Include: 1. Review of the medical record for Resident #103 revealed an admission date of 11/22/22 and a discharge date of 12/13/22 with the diagnoses of encounter for orthopedic aftercare, osteomyelitis right ankle and foot, atrial fibrillation, dementia, peripheral autonomic neuropathy, gait abnormalities, muscle weakness, need for assist with personal care, arthritis, low back pain, benign prostatic hyperplasia and cataracts. [...]

Inspectors wroteBased on observation, review of the medical record and staff interview the facility failed to ensure Resident #42 received her nutritional supplements as ordered. This affected one resident (Resident #42) of four revealed for nutrition.

Inspectors wroteBased on interview, and record review the facility failed to put in place an end date for Resident #31's as needed anxiety medication, and failed to implement a recommendation to reduce an antidepressant for Residents #4 and #34. This affected three out of six residents reviewed for unnecessary medications (Resident #4, #31, and #34). The facility census was 51.

Inspectors wroteBased on medical record review, policy review, and staff interview the facility failed to ensure Resident #5 was offered a pneumonia vaccine. This affected one resident (Resident #5) out of five reviewed for immunizations.

Inspectors wroteBased on review of the medical record, resident interviews and staff interviews the facility failed to ensure Resident #153, Resident #201, and Resident #204 received COVID-19 vaccine education. This affected three residents (Resident #153, #201 and #204) of five reviewed for COVID-19 vaccinations.

Inspectors wroteBased on observation, staff interview and policy and procedure review the facility failed to follow infection control guidelines in regards to cleaning a glucometer. This had the potential to affect four residents (Residents #21, #42, #67 and #273) who were ordered to have blood sugar checks by fingerstick on Station II. The facility census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to follow physician orders in regards to notification of weight gain. This affected one (Resident #67) of three residents reviewed for hospitalization. The census was 68.

Inspectors wroteBased on record review and staff interview, the facility failed to provide an estimated cost for services for one (Resident #56) who was discharged from Medicare part A services and remained in the facility. The deficient practice affected one (Resident #56) of three residents reviewed for Beneficiary Notices. The facility census was 68.

Inspectors wroteBased on clinical record review, observation, staff interview and policy review, the facility failed to provide an accurate smoking assessment with smoking materials secured safely for one (Resident #25) of one resident reviewed for safe smoking. The facility census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure care plans included all components of care in regards to respiratory care and urinary tract infections. This affected two (Residents #15 and #16) of 19 residents whose care plans were reviewed. The facility census was 68.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to maintain accurate care plans related to alarms and the use of pain medications. This affected two (Resident #15 and Resident #1) of 19 residents reviewed for care plans. The facility census was 68.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure residents received necessary assistance with activities of daily living. This affected two (Resident #9 and #15) of two residents review for activities of daily living. The facility census was 68.

Inspectors wroteBased on record review and staff interview the facility failed to follow physician orders in regards to obtaining daily weights. This affected one (Resident #67) of three residents reviewed for hospitalization. The facility census was 68.

Inspectors wroteBased on record review, observation, staff interview and policy review the facility failed ensure smoking materials were safely secured for one (Resident #25) of one resident reviewed for safe smoking. The affected one (Resident #25) and had the potential to affect two additional residents (#36 and #7). The facility census was 68.

Inspectors wroteBased on record review, observation, staff interview and policy review the facility failed to provide physician ordered respiratory care for Resident #7. This affected one of two residents reviewed for respiratory care. The facility census was 68.

Inspectors wroteBased on staff interview and record review, the facility failed to stop administering blood pressure medication prior to dialysis at the dialysis center's request. This affected one (Resident #49) of one resident reviewed for dialysis treatment. The facility census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the pharmacy identified perimeters for opioid medications. This affected one (Resident #15) of five residents reviewed for unnecessary medications. The census was 68.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure non-pharmacological interventions were attempted and blood pressures monitored prior to administration of medications. This affected one (Resident #15) of five residents reviewed for unnecessary medications. The census was 68.

Inspectors wroteBased on record review, observations, staff interviews and policy review, the facility failed to support the use of psychoactive medications for two (Residents #41 and #45) of five residents reviewed for unnecessary medications. The census was 68.