Country Club Ret Center I I I

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Feb 13, 2026

  Based on observation and interviews, the facility failed to maintain a clean and sanitary kitchen. This had the potential to affect 70 of the 72 residents who received food from the facility kitchen. The facility identified two residents, Residents #14 and #70, who received no food from the kitchen. The facility census was 72.Findings include:Observations during the initial kitchen tour conducted on 02/10/26 between 8:31 A.M. and 8:53 A.M. with Assistant Dietary Manager (ADM) #223 revealed one opened and undated bag tortilla chips and three loaves of outdated bread. The ice machine had pink growth on the rims that came off when wiped with a paper towel. The oven knobs had accumulated grease and dirt. The shelf above the oven had a layer of grease and dust. […]

• No harm, potential for more than minimal, widespreadF882Feb 13, 2026

  Based on observation, interview, record review, facility assessment review, and review of infection-Antibiotic (ATB) Surveillance logs and facility policy, the facility failed to have a designated infection preventionist (IP) who effectively monitored and implemented the facility's Infection Prevention and Control Program (IPCP). This had the potential to affect all 72 residents residing in the facility.Findings include: 1. Review of the medical record for Resident #69 revealed an admission date of 07/15/24 and a diagnosis of COVID-19 (Coronavirus, an infectious respiratory disease) dated 02/09/26. […]

• No harm, potential for more than minimal, patternF880Feb 13, 2026

  Based on observation, interview and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to follow transmission-based precautions for infection control. This affected one resident (#69) and had the potential to affect 12 residents on Certified Nursing Assistant (CNA) #289's assignment (#4, #13, #18, #22, #33, #37, #40, #41, #47, #53, #69 and #73). The facility census was 72.Findings include:Review of the medical record for Resident #69 revealed an admission date of 07/15/24 and a diagnosis of COVID-19 (Coronavirus, an infectious respiratory disease) dated 02/09/26. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #69 had intact cognition. […]

• No harm, potential for more than minimal, patternF881Feb 13, 2026

  Based on record review, interview, and review of facility policy and the antibiotic surveillance infection logs, the facility failed to maintain an effective antibiotic stewardship program that monitored antibiotic use including reducing the risk of adverse effects of the development of antibiotic-resistant organisms from unnecessary or inappropriate antibiotic use. This affected 25 residents (#1, #2, #3, #5, #10, #14, #15, #19, #28, #29, #32, #33, #34, #36, #37, #45, #46, #47, #48, #49, #50, #55, #56, #65 and #72) who were ordered antibiotics but did not meet McGeer's criteria (infection surveillance definitions for long term facilities for antibiotic use) during the months of December 2025, January 2026 and February 2026. The facility census was 72.Findings include: 1. […]

• No harm, potential for more than minimal, patternF689Nov 6, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure the environment remained free of accident hazards for residents who used the designated outdoor smoking area. The facility did not provide a safe environment for the disposal of smoking materials, resulting in potential fire hazard. This had the potential to affect all residents, employees, and visitors who use the facility smoking areas. The facility census was 72.Findings include:Observation of facility smoking areas on 11/05/25 at 10:45 A.M. revealed two large steel cigarette butt receptacles with the label butt cans that were overfilled and overflowing onto the pavement smoking area by the kitchen exit door. […]