Country Club Center I

In the surveyor’s words

From the most serious findings on record at Country Club Center I, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Apr 17, 2026

  Based on medical record review, review of hospital records, review of medical education provided by The University of Pittsburgh Medical Center, facility policy review, and interview, the facility failed to timely and accurately assess Resident #24 and failed to respond to an acute change in condition. This resulted in Immediate Jeopardy and Actual Harm beginning on [DATE] at 7:30 A.M. when Resident #24 was noted to have an oxygen saturation (SpO2) of 83% (normal SpO2 95-100%), a heart rate of 138 ((tachycardic) normal heart rate 60-100), was febrile (elevated body temperature) with a temperature of 102.1 degrees Fahrenheit (normal temperature 97.5 to 98.9 degree Fahrenheit) and rhonchus lung sounds bilaterally (abnormal lung sounds in both lungs occurring when air moves through partially… […]

• Actual harm, patternF686Sep 21, 2022

  Based on observation, record review, facility policy and procedure review and interview, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of avoidable pressure ulcers, timely identify areas of new skin impairment, ensure pressure ulcer dressings were provided as ordered and/or prevent the risk of pressure ulcer infection for Residents #12, #38, #43, #47, #51 and #53. Actual Harm occurred on 08/11/22 when Resident #47, who was cognitively impaired, at moderate risk for pressure ulcer development, and dependent on staff for bed mobility, was found to have a deep tissue injury (persistent non-blanchable deep red, maroon or purple discoloration) pressure ulcer to the left heel and Stage III… […]

• Actual harm, isolatedF600Apr 17, 2026

  Based on observation, record review, interview, and policy review the facility failed to ensure residents were free from physical abuse.Actual harm occurred on 03/20/26 when the facility failed to implement appropriate interventions to prevent a resident-to-resident physical altercation despite staff knowledge of Resident #52's known history of aggression and verbal threats to kill his roommate, Resident #15. Resident #15 sustained bruising and psychosocial harm of fear and self-isolation because of the altercation. This affected two residents (Resident #15 and #52) of two residents reviewed for abuse. The facility census was 52. […]

• Actual harm, isolatedF697Apr 17, 2026

  Based on observation, record review, interview, national library of medicine review, drug manufacturer review, and policy review, the facility failed to ensure effective pain management interventions were implemented to adequately control resident pain. This affected three (Residents #1, #10 and #30) of three residents reviewed for pain.Actual Harm occurred to Resident #10 on 03/28/26 at 9:30 A.M. when the facility failed to administer the ordered dosage of Lyrica (an anticonvulsant medication and gabapentin used to treat neuropathic pain, fibromyalgia, and partial-onset seizures) and failed to provide any pharmacological or non-pharmacological interventions. This resulted in Resident #10 suffering excruciating pain and extreme nausea. […]

• Actual harm, isolatedF686Feb 2, 2026

  Based on observation, record review, and policy review, the facility failed to ensure a pressure ulcer was comprehensively assessed and treatment orders were obtained timely for Resident #28 to prevent the further decline of an identified in-house obtained pressure ulcer.Actual Harm occurred on 12/12/25 when Resident #28, who had moderately impaired cognition, and was at risk for pressure ulcer development, developed a new, in-house acquired left buttock pressure ulcer. The ulcer was first assessed as an open area without proper prevention, treatment, and interventions implemented. This affected one resident (Resident #28) of three residents reviewed for pressure ulcers. […]