Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Country Club Ret Center I I I during CMS and state inspections, most recent first.
Surveyors observed multiple sanitation issues in the kitchen, including an opened and undated bag of tortilla chips, outdated bread, pink growth on the ice machine rims, greasy and dirty oven knobs, a grease- and dust-covered shelf above the oven, sanitizer buckets that did not meet the required chemical level, and food splatters on the wall near the reach-in freezer. The ADM verified the findings and stated the ice machine was cleaned monthly.
Failure to designate and effectively use an IP led to breakdowns in infection control oversight, PPE use, antibiotic stewardship, and immunization tracking. A CNA entered a resident's COVID isolation room without the required gown, eye protection, or N95, the DON could not show consistent ATB surveillance documentation or physician notification when antibiotics did not meet McGeer's criteria, and a resident with multiple chronic conditions had no record of pneumococcal vaccination being offered or given.
Failure to follow COVID-19 transmission-based precautions. A resident with a COVID-19 diagnosis was on airborne/droplet isolation with PPE posted outside the room, but a CNA entered to deliver lunch wearing only a surgical mask and gloves, without a gown, eye protection, or an N95 respirator. The CNA confirmed the lapse, and the DON verified the findings.
Antibiotic stewardship monitoring was incomplete and inconsistent, with multiple residents receiving ATBs for UTI, cellulitis, respiratory symptoms, skin issues, and other conditions without clear McGeer criteria support or documentation that criteria were met. The DON stated she and the former ADON shared infection control duties, that she only placed nonqualifying ATB use on the log, and that she did not notify the physician for each resident; she also acknowledged that January surveillance forms were incomplete or blank and that she later learned the forms had been completed incorrectly.
A resident with quadriplegia and Stage 4 pressure ulcers on both ischial areas had incomplete wound documentation when required weekly wound assessments were not entered into the medical record over multiple multi‑day intervals. The care plan did not specify weekly wound assessment or documentation, and although an LPN assessed and measured the wounds weekly on a multi‑resident tracking log sent to corporate, these assessments were not transcribed into the resident’s chart. The resident, who was cognitively intact but totally dependent for ADLs, continued to have Stage 4 pressure ulcers confirmed by outside wound clinic providers and on-site observation, while facility policy required wound documentation at least every seven days with defined assessment elements.
Failure to document and offer pneumococcal vaccination. A resident admitted with diabetes, CHF, CKD stage 4, dysphagia, obesity, and cognitive communication deficit was not current on pneumococcal immunization, and there was no record that the vaccine was offered. The DON confirmed the facility had no documentation that the resident received or was offered the vaccine, despite facility policy requiring admission assessment and offering the vaccine per CDC guidance.
Surveyors observed that the facility's designated outdoor smoking area had overfilled cigarette butt receptacles and numerous cigarette butts scattered on dry leaves and debris, creating a fire hazard. The Director of Maintenance confirmed the unsafe conditions, which were not in accordance with the facility's smoking policy requiring proper disposal of smoking materials.
The facility failed to implement required enhanced barrier precautions (EBP) and proper glove use for five residents with medical devices, including gastrostomy tubes, tracheostomies, urinary catheters, and PICC lines. Staff did not follow EBP guidelines or adhere to appropriate standards of practice, such as changing soiled gloves and performing hand hygiene. Interviews confirmed that EBP training was completed, but implementation was delayed due to supply issues.
The facility failed to implement its abuse policy after an allegation that a resident's spouse smacked the resident in the face. Staff did not report the incident to the Administrator, and no abuse investigation was conducted, despite the facility's policy requiring immediate reporting and investigation of such incidents.
A resident with multiple chronic conditions experienced inadequate care for edema management due to the facility's failure to implement and maintain physician orders for diuretics. Despite the resident's complaints and visible signs of significant edema, the facility did not provide consistent monitoring or treatment.
A resident with a tracheostomy did not receive consistent tracheostomy care as ordered, with records showing a lack of documented care and the resident having to remind staff to perform necessary procedures. Issues with supply availability were noted but later resolved.
The facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days or had a stop date, affecting three residents. Medications were administered multiple times without proper documentation or adherence to guidelines.
The facility failed to document diagnoses to justify the use of ordered medications for a resident with multiple health conditions. Medications such as Atorvastatin, Amitiza, Levothyroxine, Tizanidine, Buspirone, and Lorazepam were prescribed without corresponding diagnoses. The ADON confirmed the lack of documentation.
Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen during an initial kitchen tour observed by surveyors with the Assistant Dietary Manager present. Findings included one opened and undated bag of tortilla chips, three loaves of outdated bread, pink growth on the rims of the ice machine that came off when wiped with a paper towel, oven knobs with accumulated grease and dirt, a shelf above the oven with a layer of grease and dust, sanitizer buckets that did not meet the required chemical level for sanitizing surfaces, and food splatters on the wall next to the reach-in freezer. The Assistant Dietary Manager verified these observations and stated that the kitchen cleaned the ice machine monthly.
Failure to Designate and Effectively Use Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist responsible for the infection prevention and control program, and the Director of Nursing was the only staff member documented as having infection preventionist training. The facility assessment identified infection prevention and control as including identification and containment of infections and prevention of infections, but it did not document the amount of time the infection preventionist was designated to work on infection control or any other specific responsibilities. The DON stated she and the former ADON had shared infection control duties, but after the former ADON left, she was also responsible for DON duties and restorative nursing while trying to spend two to three hours per day on infection control. During observation of a resident on airborne/droplet precautions for COVID-19, the required PPE was available outside the room, but a CNA entered the room wearing only a surgical mask and gloves. The CNA did not wear a gown, eye protection, or an N95 respirator as required by the signage for transmission-based precautions. The CNA confirmed after exiting the room that the required precautions were not followed. The resident had an admission date of 07/15/24 and a diagnosis of COVID-19 dated 02/09/26, with isolation ordered due to a positive COVID-19 test. The facility also had problems with its antibiotic surveillance process and immunization records. The December 2025 ATB surveillance log showed 14 occurrences where resident antibiotic use did not meet McGeer's criteria and one occurrence that was not marked either way. For January 2026, there was no log present, only individual McGeer checklist sheets for residents on antibiotics, and 13 sheets lacked the date the antibiotic was ordered, the reason, the name of the antibiotic, and whether criteria were met. The DON stated she had not notified physicians for each resident when antibiotics did not meet criteria and did not know she needed to. In addition, a resident admitted with diabetes, cognitive communication deficit, dysphagia, CHF, CKD stage four, and obesity had no record of being offered or receiving pneumococcal vaccination.
Failure to Follow COVID-19 Transmission-Based Precautions
Penalty
Summary
The facility failed to follow transmission-based precautions for infection control for a resident with COVID-19. Resident #69 had an admission date of 07/15/24, a diagnosis of COVID-19 dated 02/09/26, and a quarterly MDS assessment that indicated intact cognition. Physician orders for February 2026 included airborne/droplet isolation precautions due to the positive COVID-19 test, and observation on 02/10/26 showed signage on the resident’s door indicating isolation was in effect from 02/09/26 until 02/19/26, with required PPE available outside the room. On 02/11/26, CNA #289 delivered the resident’s lunch into the room but did not follow the required precautions. The CNA wore only a surgical mask and gloves and did not wear a gown, eye protection, or an N95 respirator. The CNA confirmed the precautions were not followed during the observation, and the DON verified the findings and stated the CNA was suspended for three days for not following the required COVID-19 precautions for the resident.
Antibiotic Stewardship Program Documentation and Monitoring Failure
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program that monitored antibiotic use and documented whether antibiotic therapy met McGeer criteria. During review of the antibiotic surveillance logs and infection checklists, surveyors found multiple residents who were ordered antibiotics even though the documentation indicated the antibiotics did not meet criteria or did not clearly show whether criteria were met. The affected residents included individuals treated for urinary tract infections, cellulitis, respiratory symptoms, skin issues, ear infection, and other reported infections. For December 2025, the antibiotic surveillance log showed 14 occurrences of antibiotic use that did not meet McGeer criteria and one occurrence where it was not marked whether criteria were met. Examples included residents ordered doxycycline for bilateral lower extremity cellulitis and cellulitis, Augmentin and ampicillin for UTI, amoxicillin for UTI, Augmentin for bacterial infection, Bactrim for UTI, Keflex for a foot issue, Macrobid and Levaquin for UTI, doxycycline for an upper respiratory infection, and Keflex for skin. The log also showed residents whose antibiotic use was not documented as meeting or not meeting criteria. For January 2026, there was no antibiotic surveillance log present, only individual McGeer Criteria for Infection Surveillance Checklists. Thirteen checklists lacked key information such as the date the antibiotic was ordered, the reason for the antibiotic, the name of the antibiotic, and whether the antibiotic met criteria. Several forms were blank or only partially completed, including residents with cough, congestion, pneumonia-related findings, drainage from an ear, and an ear infection. For February 2026, the surveillance log showed five occurrences where antibiotics did not meet McGeer criteria, including antibiotics ordered as preventative, for UTI, for cough, and for UTI with multiple antibiotics. The DON stated she and the former ADON shared infection control duties, that she had been placing nonqualifying antibiotic use on the log, that she did not contact the physician for each individual resident, and that there was no documentation the physician was notified when antibiotics did not meet criteria. She also stated she later learned she had been completing the forms incorrectly and redid the January and February documentation after speaking with Corporate Nurse #800.
Failure to Maintain Weekly Wound Documentation in Medical Record
Penalty
Summary
The facility failed to maintain accurate and thorough wound documentation in the medical record for Resident #2, who was admitted with diagnoses including quadriplegia, muscle weakness, contractures, and abnormal posture. The resident’s care plan identified Stage 4 pressure ulcers on the left ischium and right buttock, with interventions such as scheduling wound clinic appointments and providing treatment as ordered, but did not include interventions for at least weekly wound assessments or documentation. Review of the medical record showed weekly wound assessments documented on 12/03/25, 12/10/25, 12/18/25, 12/26/25, and 01/14/26, but there was no documentation of weekly wound assessments between 12/26/25 and 01/14/26 (18 days) and between 01/14/26 and 02/03/26 (19 days), despite the resident having ongoing Stage 4 pressure ulcers confirmed by an outside wound nurse practitioner and an after-visit summary. The resident, who had intact cognition but was totally dependent on staff for ADLs including turning, transfers, toileting, hygiene, and showers, continued to have two Stage 4 pressure ulcers not present on admission. Observation of wound care confirmed the presence of these Stage 4 ulcers. The LPN responsible for following the wounds acknowledged that weekly wound assessments were required and confirmed that no wound assessments were entered into the resident’s medical record during the identified gaps. She reported difficulty completing all wound responsibilities after the former ADON left and stated she was unable to get to all measurements. She later produced weekly wound tracking logs, submitted to corporate, that contained weekly measurements and assessments for multiple residents, including this resident, but verified that these logs were not part of the resident’s medical record and that she had not documented the weekly wound assessments into the record, contrary to the facility’s wound documentation policy requiring assessments every seven days with specific elements recorded.
Failure to Document and Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure Resident #32 was current with her pneumococcal vaccination and had no documentation that she was offered the vaccine. Resident #32 was admitted with diagnoses of diabetes, cognitive communication deficit, dysphagia, congestive heart failure, chronic kidney disease stage four, and obesity. Review of the Annual MDS showed the resident was cognitively intact. During interview, the DON confirmed the facility had no record that Resident #32 had received or been offered the pneumococcal vaccine. Review of facility policy showed residents were to be assessed for pneumococcal vaccine status upon admission and offered the vaccine in accordance with CDC guidelines.
Unsafe Smoking Area and Fire Hazard Due to Improper Disposal of Smoking Materials
Penalty
Summary
The facility failed to maintain a safe environment in the designated outdoor smoking area, as observed during a survey. Two large steel cigarette butt receptacles labeled as butt cans were found to be overfilled and overflowing onto the pavement near the kitchen exit door. Additionally, a significant number of cigarette butts were scattered on the ground, directly on top of a large accumulation of dry leaves and debris. The Director of Maintenance confirmed the presence of the overfilled receptacles and the cigarette butts on the dry leaves and debris, acknowledging the situation as a fire hazard. Review of the facility's Resident Smoking Policy indicated that residents who smoke are required to use the designated outdoor area and discard cigarette butts and matches in the appropriate receptacle. This deficiency was identified during a complaint investigation and had the potential to affect all residents, employees, and visitors who use the facility smoking areas.
Failure to Implement Enhanced Barrier Precautions and Proper Glove Use
Penalty
Summary
The facility failed to implement and utilize required enhanced barrier precautions (EBP) for five residents and did not adhere to appropriate standards of practice with the use of gloves during catheter and tracheostomy care. For Resident #35, who had a gastrostomy tube, there was no EBP posted and no personal protective equipment (PPE) available at the room entrance. Similarly, Resident #170, who had a tracheostomy, also lacked EBP postings and PPE. During tracheostomy care, the registered nurse did not wear a gown and used soiled gloves to handle sterile equipment, which was confirmed during an interview with the nurse. Resident #36, who had a urinary catheter, also did not have EBP postings or PPE available. During catheter care, the nursing assistant used soiled gloves to assist the resident with dressing and transferring, which was verified during an interview with the assistant director of nursing (ADON). Resident #172, who had a PICC line and wound drain, and Resident #163, who had a PICC line for antibiotic therapy, both lacked EBP postings and PPE at their room entrances. During intravenous medication administration for Resident #172, the registered nurse did not wear a gown as required, which was confirmed during an interview with the nurse. The same issue was observed for Resident #163, who also did not have EBP postings or PPE available at the room entrance. Interviews with the director of nursing (DON), ADON, and corporate nurse confirmed that EBP training was completed, but the implementation was delayed due to supply issues. The facility was aware of the memorandum from the Department of Health and Human Services for initiating EBPs but was uncertain about the required effective date. The facility policy for EBP involved gown and glove use during high-contact resident care activities for residents with wounds or indwelling medical devices, but this was not followed. The Centers for Disease Control and Prevention guidelines for glove use and hand hygiene were also not adhered to, as gloves were not changed and hand hygiene was not performed during patient care when moving from a soiled body site to a clean body site.
Failure to Implement Abuse Policy and Procedure
Penalty
Summary
The facility failed to implement its abuse policy and procedure after receiving an allegation of abuse involving a resident. The incident involved Resident #52, who had moderate cognitive impairment and several medical conditions, including chronic obstructive pulmonary disease and diabetes mellitus type 2. On the date of the incident, a staff member reported that Resident #52's spouse, who lived in an adjoining assisted living facility, smacked Resident #52 in the face. Despite this report, the incident was not communicated to the facility's Administrator or other appropriate staff members as required by the facility's abuse prevention policy. Interviews with various staff members revealed a lack of awareness and proper reporting of the incident. LPN #211, who was informed of the incident, assumed that the adjoining facility's staff had handled the situation and did not report it to the Administrator. Additionally, the Assistant Director of Nursing (ADON) #232, who was present at the time, received a report of the incident but did not notify the Administrator, believing it to be a resident-to-resident altercation despite the spouse living in a different facility. This miscommunication and misunderstanding led to the failure to conduct an abuse investigation as required. The facility's policy on abuse, revised in January 2020, mandates that all incidents or allegations of abuse be reported immediately to the Administrator or designee. The policy also requires the Administrator to notify the survey agency of all alleged violations within 24 hours. However, in this case, the policy was not followed, and the incident was not reported or investigated appropriately, potentially affecting the safety and well-being of all residents in the facility.
Failure to Manage Edema in Resident
Penalty
Summary
The facility failed to provide individualized and sufficient care to manage edema for a resident with multiple chronic conditions, including diabetes mellitus type 2, congestive heart failure, chronic severe kidney disease, and essential primary hypertension. Despite the resident's history of edema and previous use of diuretics, the facility did not continue or adjust the treatment plan to manage the edema effectively. The resident's medical records showed that an order for Bumex was discontinued upon admission, and subsequent physician orders for diuretics were either not implemented or not maintained. Interviews with the resident and nursing staff confirmed the presence of significant edema and the lack of consistent monitoring and treatment. The resident expressed frustration with the ongoing swelling in both legs, which made it difficult to wear shoes and walk. Observations during the interview confirmed gross edema in the lower legs and ankles. Nursing staff and the Assistant Director of Nursing acknowledged the resident's condition and the failure to implement physician orders. The facility's policy required immediate implementation of new physician orders, but this was not followed, leading to inadequate care for the resident's edema.
Failure to Provide Tracheostomy Care
Penalty
Summary
The facility failed to provide appropriate tracheostomy care for Resident #170, who was admitted with diagnoses including malignant neoplasm of supraglottis, emphysema, diabetes mellitus type 2, and tracheostomy status. Despite a physician's order for daily trach care and PRN starting on 05/05/24, the medical records revealed that no tracheostomy-related care, including oxygenation monitoring, suctioning, dressing changes, or cannula changes, was provided until 05/06/24. The medication and treatment administration records for May 2024 showed no evidence of tracheostomy care being completed, except for the care provided on 05/06/24. Additionally, the nursing progress notes lacked documentation of consistent tracheostomy care, with only one note indicating a dressing and tie change on 05/05/24. Resident #170, who had no cognitive impairment, reported having to remind staff to perform tracheostomy care, and noted that some nurses provided care while others did not. An interview with RN #258 revealed that there was an issue with the availability of supplies, which was later resolved. The DON and Corporate Nurse #289 verified these findings during an interview on 05/08/24.
Failure to Limit PRN Orders for Psychotropic Drugs
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days or had a determined stop date, affecting three residents. Resident #28, with severe cognitive impairment and multiple medical diagnoses, had an indefinite PRN order for Lorazepam for anxiety and agitation. The medication was administered multiple times over several months without a stop date, and the facility could not locate the pharmacist's note to the attending physician regarding this issue. Resident #51, with intact cognition and multiple medical diagnoses, had an indefinite PRN order for Hydroxyzine Pamoate for anxiety. Despite a pharmacist's recommendation to discontinue one of the two Hydroxyzine orders to avoid duplication, the Advanced Practitioner Registered Nurse declined to change the treatment. The medication was administered multiple times in April without a documented stop date. Resident #48, with impaired cognition and multiple medical diagnoses, had an indefinite PRN order for Lorazepam for anxiety and agitation. The pharmacist had informed the physician that PRN orders for such medications should be limited to 14 days, but the order remained without a stop date. The medication was administered multiple times in April and May. The Assistant Director of Nursing confirmed the lack of a stop date for the Lorazepam order.
Failure to Document Diagnoses for Medications
Penalty
Summary
The facility failed to accurately document the resident's diagnoses to justify the use of ordered medications for one resident. Resident #48, who had multiple diagnoses including diabetes, muscle weakness, and chronic kidney disease, was found to have several medication orders without corresponding diagnoses. These medications included Atorvastatin for cholesterol, Amitiza for irritable bowel syndrome, Levothyroxine for hypothyroidism, Tizanidine for spasms, Buspirone for anxiety, and Lorazepam for anxiety and agitation. The Assistant Director of Nursing confirmed that there were no diagnoses listed to justify all the medication orders during an interview.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ashtabula
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carington Park | 0.6 mi | ★★★★★ | 0 | 0 |
| Saybrook Landing | 3.5 mi | ★★★★★ | 0 | 0 |
| Ashtabula County Nursing Home | 4.7 mi | ★★★★★ | 1 | 0 |
| Austinburg Nsg And Rehab Ctr | 7.9 mi | ★★★★★ | 0 | 0 |
| Jefferson Healthcare Center | 9.6 mi | ★★★★★ | 0 | 0 |
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