Country Club Retirement CTR IV

In the surveyor’s words

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

• Actual harm, isolatedF684Jun 9, 2026

  Based on review of medical records, review of hospital and pharmacy records, and interviews with resident and staff, the facility failed to provide timely medical intervention when a resident experienced an acute change in condition. This affected one resident (#6) of two residents reviewed for hospitalization. In addition, the facility failed to provide treatment to a resident's skin tear. This affected one resident (#53) of four residents reviewed for skin conditions. The facility census was 45.Actual harm occurred on 10/02/25 when Resident #6, with a known history of gastric reflux with esophagitis, two recent emergency room visits for duodenitis and gastritis, and was taking routine ibuprofen (non-steroidal anti- inflammatory medication) and a routine Plavix (anti-platelet medication),… […]

• Actual harm, isolatedF684Mar 17, 2026

  Based on closed medical record review, review of hospice notes, review of photos, review of pharmacy records, policy review, and interviews, the facility failed to ensure Resident #40 received adequate and necessary care and services for end-of-life care. This affected one resident (#40) of three residents reviewed for quality care and services.Actual harm was identified on 11/26/25 involving Resident #40, who was admitted to the facility for end of life care and hospice services. The facility failed to ensure the resident received comprehensive assessments and adequate monitoring of his condition, including evaluation and management of ongoing pain and anxiety associated with his terminal illnesses. […]

• Actual harm, isolatedF697Mar 17, 2026

  Based on closed medical record review, review of hospital records, policy review and interview, the facility failed to implement a comprehensive, individualized and effective pain management program for Resident #41, who had a diagnosis of migraines. Actual harm occurred on 11/29/25 (three days after admission) when Resident #41, who was diagnosed with severe intractable migraines prior to admission to the facility, did not receive ordered anti-migraine medication resulting in the resident's transfer to the hospital for intractable headaches with vomiting and hypertension. The resident was hospitalized from [DATE] until 12/06/25 for management of intractable migraines. […]

• Actual harm, isolatedF692Aug 27, 2025

  Based on record review, facility policy review, and interview, the facility failed to ensure dietary recommendations were timely implemented and the physician was updated timely on a resident's severe weight loss. Actual harm occurred to Resident #1 when nutrition recommendations were not implemented, and the physician was not updated resulting in the resident sustaining an avoidable 16.6% severe weight loss in one month. This affected one (Resident #1) of three residents reviewed for nutrition.Findings include:Review of the medical record for Resident #1 revealed an admission date of 05/02/25 with diagnoses including atherosclerotic heart disease, dementia, ventricular tachycardia, chronic kidney disease, congestive heart failure (CHF), and depression. […]

• No harm, potential for more than minimal, widespreadF919Jun 9, 2026

  Based on observation, interview, and record review, the facility failed to have an adequately equipped call system which relayed the call directly to a staff member or centralized staff work area from each resident's bedside or toilet and bathing facility. During a call system outage, there was a delay providing hand bells and a monitoring system to monitor resident needs. There also was not a way for residents to call for assistance from a toilet or bathing area. This affected all 45 residents residing in the facility. The facility census was 45.Findings include: On 06/02/26 at 8:20 A.M., during a facility tour, observation revealed there was no functioning electronic call light system in the facility. […]