Country Club Retirement Center

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 3, 2024

  Based on observation, medical record review, review of emergency room records, review of the facility incident and accident logs, interview and facility policy review, the facility failed to develop and implement a comprehensive and individualized fall prevention program to prevent falls including a fall with major injury for Resident #60. Actual Harm occurred on 09/04/24 at 7:45 P.M. when Resident #60, who was identified as a high fall risk and experienced recent falls without individualized fall prevention interventions implemented to prevent further falls, climbed out of bed, unassisted and had to be lowered to the floor by State tested Nursing Assistant (STNA) #222 when she became unsteady and began to fall. […]

• Actual harm, isolatedF686Aug 29, 2023

  Based on observation, record review, policy review and staff interview the facility failed to implement adequate skin risk interventions and treatment for Resident #5, who was cognitively impaired, at risk for pressure ulcer development and dependent on staff for turning and repositioning, to prevent the development of a pressure ulcer to the resident's left heel. Actual harm occurred on 05/21/23 when an order for skin prep was obtained for Resident #5's heels with no corresponding assessment or information related to why. On 05/24/23 the wound Certified Nurse Practitioner (CNP) assessed Resident #5 to have a Stage III (full-thickness loss of skin, in which adipose (fat) is visible in the ulcer. Slough and/or eschar may be visible) pressure ulcer to the left heel. […]

• Actual harm, isolatedF697May 20, 2021

  Based on record review, review of hospital records, review of a fall investigation, facility policy review and resident and staff interview the facility failed to provide timely and effective pain management for Resident #35 following a fall with injury. Actual harm occurred on 09/15/20 at 2:15 P.M. when Resident #35, who exhibited moderate cognitive impairment and required extensive staff assistance for activities of daily living, sustained a fall with verbalization of pain, guarding to the right hip and an inability to bear weight following the incident. The facility failed to provide effective pain management/pain medication to the resident following the incident or notify the physician of the pain level. […]

• No harm, potential for more than minimal, widespreadF812Jun 25, 2026

  Based on observation and staff interview, the facility failed to clean dishes in a safe and sanitary manner. This affected all 68 residents residing at the facility.Findings include:Observation of breakfast dishes being washed on 06/22/26 at 8:15 A.M. with the high temperature sanitizing machine with Dietary Supervisor (DS) #215 revealed the machine rinse temperature reached approximately 148 degrees Fahrenheit (F) to rinse and sanitize the dishes. Digital temperature reading at the time of observation was 156. Review of June 2026 Main Kitchen Dish Machine Temperature Log on 06/22/26 at 8:18 A.M. revealed daily temperature checks were completed daily at breakfast, lunch and dinner. […]

• No harm, potential for more than minimal, widespreadF925Apr 14, 2026

  Based on observation, review of pest control work orders and invoices, interviews and facility policy review, the facility failed to maintain a pest-free environment. This deficient practice had the potential to affect all 68 residents receiving food from the kitchen. The facility census was 68.Findings include:Review of the facility's maintenance work order request dated 11/22/25 revealed cockroaches were observed under the dishwasher machine by staff. Further review of the maintenance work order request revealed on 03/03/26 staff observed a large number of cockroaches scattering on the floor in the dishwashing room when the lights were turned on.Review of the facility's pest control service logs revealed extra insect treatments were completed in the kitchen and dishwasher room including… […]