A list of the most recent deficiencies for Country Club Retirement 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? |
|---|---|---|---|---|
| Ensure that residents are free from significant medication errors. | Health | 2023-11-07 | 2023-11-21 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-11-07 | 2023-11-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-11-07 | 2023-11-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-29 | 2023-09-18 | Y |
| 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 | 2023-04-20 | 2023-05-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-04-20 | 2023-05-05 | 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 | 2023-04-20 | 2023-05-05 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-04-20 | 2023-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-04-20 | 2023-05-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-20 | 2023-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-20 | 2023-05-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-20 | 2023-05-05 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-04-20 | 2023-05-05 | N |
| Provide or obtain dental services for each resident. | Health | 2023-04-20 | 2023-05-05 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-04-20 | 2023-05-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-20 | 2023-05-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-20 | 2023-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-20 | 2023-05-05 | N |
| Meet requirements for sections of health care facilities separated by fire resistive construction. | Fire Safety | 2023-04-18 | 2023-05-05 | 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 | 2023-04-18 | 2023-05-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-18 | 2023-05-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-18 | 2023-05-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-18 | 2023-05-05 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-18 | 2023-05-05 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-18 | 2023-05-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-18 | 2023-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-20 | 2021-06-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-05-20 | 2021-06-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-20 | 2021-06-10 | N |
| Meet other general requirements. | Fire Safety | 2021-05-25 | 2021-06-10 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-05-25 | 2021-06-10 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2021-05-25 | 2021-06-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-25 | 2021-06-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-25 | 2021-06-10 | 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 | 2019-02-13 | 2019-04-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-13 | 2019-04-22 | N |
| Use approved construction type or materials. | Fire Safety | 2019-02-13 | 2019-04-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-13 | 2019-04-22 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-02-13 | 2019-04-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-02-13 | 2019-04-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-13 | 2019-04-22 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-02-13 | 2019-04-22 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-02-13 | 2019-03-12 | N |
