A list of the most recent deficiencies for Country Club Ret Center I I 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2023-05-16 | 2023-05-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-04-03 | 2023-04-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-03 | 2023-04-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-03 | 2023-04-21 | Y |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-03-27 | 2023-04-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-03-27 | 2023-04-21 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-03-27 | 2023-04-21 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-02-27 | 2020-04-17 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2020-02-24 | 2020-04-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-02-24 | 2020-04-17 | 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 | 2020-02-24 | 2020-04-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-02-24 | 2020-04-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-24 | 2020-04-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-02-24 | 2020-04-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-02-24 | 2020-04-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-02-24 | 2020-04-17 | N |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2020-02-24 | 2020-04-17 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-02-24 | 2020-04-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-02-24 | 2020-04-17 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-13 | 2019-01-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-12-13 | 2019-01-28 | 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 | 2018-12-13 | 2019-01-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-12-10 | 2019-01-28 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-12-10 | 2019-01-28 | 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 | 2018-12-10 | 2019-01-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-10 | 2019-01-28 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-12-10 | 2019-01-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-10 | 2019-01-28 | N |
