A list of the most recent deficiencies for Country Club Center I. 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? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-28 | 2024-01-13 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-28 | 2024-01-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-28 | 2024-01-13 | Y |
| 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 | 2023-12-28 | 2024-01-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-28 | 2024-01-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-28 | 2024-01-13 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-08-16 | 2023-09-01 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-08-16 | 2023-09-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-08-16 | 2023-09-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-16 | 2023-09-01 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-28 | 2023-07-10 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-05-17 | 2023-06-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-17 | 2023-06-08 | Y |
| 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 | 2023-05-17 | 2023-06-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-17 | 2023-06-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-05-17 | 2023-06-08 | Y |
| 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 | 2022-09-21 | 2022-10-18 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-09-21 | 2022-10-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-09-21 | 2022-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-21 | 2022-10-18 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-21 | 2022-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-21 | 2022-10-18 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-21 | 2022-10-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-21 | 2022-10-18 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-01 | 2022-10-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-11 | 2022-07-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-04 | 2021-10-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-04 | 2021-10-20 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-10-04 | 2021-10-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-07-22 | 2021-08-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-22 | 2021-08-03 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-07-08 | 2021-08-03 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-06-24 | 2021-08-03 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-26 | 2019-12-19 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-26 | 2019-12-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-26 | 2019-12-19 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-26 | 2019-12-19 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-11-26 | 2019-12-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-26 | 2019-12-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-26 | 2019-12-19 | 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 | 2019-11-26 | 2019-12-19 | 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 | 2019-11-26 | 2019-12-19 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-26 | 2019-12-19 | 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 | 2019-11-26 | 2019-12-19 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2019-11-26 | 2019-12-19 | N |
| Provide or obtain dental services for each resident. | Health | 2019-11-26 | 2019-12-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-26 | 2019-12-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-26 | 2019-12-19 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-11-26 | 2019-12-19 | 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 | 2019-11-27 | 2019-12-19 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-12-12 | 2019-01-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-12-12 | 2019-01-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-12-12 | 2019-01-16 | N |
| Respond appropriately to all alleged violations. | Health | 2018-12-12 | 2019-01-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-12 | 2019-01-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-12-12 | 2019-01-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-12-12 | 2019-01-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-12-12 | 2019-01-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-12-12 | 2019-01-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-12-12 | 2019-01-16 | 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 | 2018-12-12 | 2019-01-16 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2018-12-12 | 2019-01-16 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-12-12 | 2019-01-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-12-12 | 2019-01-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-12-12 | 2019-01-16 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2018-12-12 | 2019-01-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-12 | 2019-01-16 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-12 | 2019-01-16 | N |
