Deficiency Records for Country Club Rehab and Healthcare Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Country Club Rehab and Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-10-30 | 2023-12-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-30 | 2023-12-14 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-10-30 | 2023-12-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-11 | 2023-09-15 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-08-11 | 2023-09-15 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-08-11 | 2023-09-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-11 | 2023-09-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-11 | 2023-09-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-11 | 2023-09-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-11 | 2023-09-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-08-11 | 2023-09-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-11 | 2023-09-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-11 | 2023-09-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-11 | 2023-09-15 | N |
| Post nurse staffing information every day. | Health | 2023-08-11 | 2023-09-15 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-08-11 | 2023-09-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-11 | 2023-09-15 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-08-11 | 2023-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-11 | 2023-09-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-11 | 2023-09-15 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2023-08-11 | 2023-09-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-11 | 2023-09-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-11 | 2023-09-15 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-11 | 2023-09-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-11 | 2023-09-15 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-08-11 | 2023-09-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-11 | 2023-09-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-11 | 2023-09-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-08-11 | 2023-09-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-08-11 | 2023-09-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-08 | 2023-07-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-18 | 2023-06-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-27 | 2023-02-27 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-16 | 2022-04-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-16 | 2022-04-15 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-16 | 2022-03-31 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-02-16 | 2022-03-31 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-02-16 | 2022-03-31 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-02-16 | 2022-03-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-16 | 2022-03-31 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-16 | 2022-03-31 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-02-16 | 2022-03-31 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-02-16 | 2022-03-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-16 | 2022-03-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-16 | 2022-03-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-16 | 2022-03-31 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-02-16 | 2022-03-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-16 | 2022-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-16 | 2022-03-31 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-02-16 | 2022-03-31 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2022-02-16 | 2022-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-02-16 | 2022-03-31 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-02-16 | 2022-03-31 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-02-16 | 2022-03-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-16 | 2022-03-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-16 | 2022-03-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-16 | 2022-03-31 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-02-16 | 2022-03-31 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-05-14 | 2021-06-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-14 | 2021-06-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-14 | 2021-06-25 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-05-14 | 2021-06-25 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-14 | 2021-06-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-14 | 2021-06-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-14 | 2021-06-25 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-14 | 2021-06-25 | N |
