Country Court

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Apr 23, 2026

  Based on record review, interviews, and facility policy review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call emergency medical services (EMS) for a resident with advance directives for a Full Code (indication for healthcare providers to perform all possible life-saving measures in the event of a cardiac or respiratory arrest). This resulted in Immediate Jeopardy and Actual Harm/Subsequent Death on [DATE] at 5:30 A.M. when Resident #50 was found unresponsive without vital signs and Licensed Practical Nurse (LPN) #79 and Registered Nurse (RN) #75 failed to initiate CPR or contact EMS. LPN #79 and RN #75 did not review Resident #50's code status and determined Resident #50 was deceased at 5:30 A.M. […]

• Immediate jeopardy, isolatedF689Dec 5, 2023

  Based on observation, medical record review, facility investigation review, Emergency Medical Services report review, hospital record review, staff interview and policy review, the facility failed to provide Resident #50, who was identified to have intermittent confusion, adequate supervision, and assistance to prevent a fall with injury. Immediate Jeopardy and serious harm and injury occurred on 11/07/23 when staff assisted Resident #50 to the facility front porch to be transported to an outside appointment. The resident was left unattended in a wheelchair thought to not have properly functioning brakes. After being left unattended, the resident moved her wheelchair from the facility porch/portico and began to roll approximately 50 feet across the parking lot toward six concrete steps. […]

• Actual harm, isolatedF684Aug 10, 2023

  Based on closed record review and interview the facility failed to adequately monitor Resident #50 related to non-pressure skin ulcers and failed to ensure wound care was completed as ordered. Actual harm occurred on 07/04/23 when staff identified a decline in the resident's non-pressure skin ulcer to the left foot with an increase in drainage, necrosis (dead tissue) and slough (dead tissue, usually cream or yellow in color that impeded healing and increases the potential for infection) to the wound without evidence the physician or wound clinic were notified of the decline. The facility also had no evidence of wound monitoring, especially after the identified decline in the status of the wound. […]

• Actual harm, isolatedF689Feb 24, 2021

  Based on record review, review of incident and accident documentation, review of hospital documentation, review of the facility policy and procedure for Elopement and Falls and staff interview the facility failed to provide adequate supervision for Resident #5, who was cognitively impaired and at risk for falls and elopement to prevent the resident from sustaining a fall with injury outside the facility. The facility also failed to conduct a complete and thorough investigation of the fall incident. This affected one resident (#5) of three residents reviewed for falls. Actual harm occurred on 06/30/20 when Resident #5 exited an unlocked door from the main kitchen to the outside of the facility without staff knowledge. […]

• No harm, potential for more than minimal, widespreadF921May 27, 2026

  Based on observation and interviews with staff, the facility failed to ensure the washcloths used for resident care were not stained or discolored. This had the potential to affect all 48 residents in the facility.Findings Include: Observations conducted during the initial tour on 05/26/26 from 9:05 A.M. through 9:11 A.M. revealed all of the washcloths, 70 in total, in three of the linen closets were completely discolored/stained gray to dark brown.On 05/26/26 at 9:20 A.M. an interview with Certified Nursing Assistant (CNA) #106 revealed she did not know why all the washcloths in the linen closets were discolored and stained.Interview and observation of the laundry room on 05/26/26 at 9:35 A.M. […]