Country Club Center V, Inc

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF727Jan 4, 2023

  Based on record review and facility staff interview the facility failed to have eight hours of Registered Nurse (RN) coverage daily. This had the potential to affect all 50 residents who live in the facility. Findings Include: Review of the daily staffing punch detail for 12/31/22 revealed there were four Licensed Practical Nurses who worked 12/31/22 and eight State tested Nursing Assistants who worked on 12/31/22. There were no Registered Nursing hours accounted for on 12/31/22. During an interview with the Director of Nursing (DON) on 01/04/23 at 2:44 P.M. it was confirmed there was no Registered Nurse (RN) who worked in the facility on 12/31/22. […]

• No harm, potential for more than minimal, patternF761Apr 21, 2026

  Based on observation, interview, and record review, the facility failed to ensure medications, the medication cart, and the treatment cart were secured properly. This had the potential to affect 10 residents (Residents #11, #15, #20, #22, #25, #27, #36, #37, #41, and #34) who were identified as cognitively impaired and independently mobile. The facility census was 46.Findings include:Observation on 04/20/26 at 10:41 A.M. revealed the medication cart and treatment cart located near the main nurses' station were unlocked and unattended.Interview on 04/20/26 at 10:42 A.M. with Licensed Practical Nurse (LPN) #115 confirmed the medication and treatment carts were unlocked and unattended.Observation on 04/21/26 at 6:12 A.M. […]

• No harm, potential for more than minimal, patternF688Jan 4, 2023

  Based on record review and facility staff interview, the facility failed to provide restorative nursing services to three (#10, #20 and #40) of three reviewed for restorative services. The facility census was 50. Findings Include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included but are not limited to multiple sclerosis, paraplegia, trigeminal neuralgia, weakness, acute cystitis depression, neuromuscular dysfunction of the bladder, and anxiety. Review of the admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed the resident is cognitively intact. Resident #10 had no delusions, hallucinations or behaviors coded. […]

• No harm, potential for more than minimal, isolatedF609Apr 21, 2026

  Based on record review and interview the facility failed to report alleged abuse concerns to the state agency timely. This affected one (Resident #8) out of one residents review for abuse. The facility census was 46. Findings include:Review of the medical record for Resident #8 revealed an admission date of 08/25/24 with diagnoses including Type II Diabetes Mellitus, need for assistance with personal care, muscle weakness, chronic pain syndrome, legal blindness and low back pain.Review of care plan dated 01/07/25 revealed Resident #8 required assistance from staff to meet activities of daily living, interventions include assist with hair, oral, transfers, toileting and bed mobility as needed. […]

• No harm, potential for more than minimal, isolatedF692Apr 21, 2026

  Based on medical record review, staff interview, and facility policy review, the facility failed to monitor weights for a resident that experienced a significant weight loss. This affected one (Resident #3) of one resident reviewed for nutrition. The census was 46.Findings Include:Resident #3 was admitted to the facility on [DATE]. His diagnoses were chronic respiratory failure with hypoxia, acute respiratory failure, dependence on respirator, neuromuscular dysfunction of bladder, hypertension, Type II Diabetes, hyperlipidemia, chronic kidney disease, colostomy status, cerebral infarction, tracheostomy status, morbid obesity, anoxic brain damage, obstructive and reflux uropathy, and muscle weakness. […]