Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Retirement Center during CMS and state inspections, most recent first.
The facility failed to maintain a pest-free environment in the kitchen dishwashing area, where staff repeatedly observed cockroaches under and around the dishwasher and on the floor, and multiple glue traps contained live and dead cockroaches. Maintenance staff documented ongoing cockroach activity and performed repeated extra insect treatments, and an external pest control company later identified live cockroaches and cockroach eggs in the dishwashing room, requiring ongoing weekly treatments and trap replacement. A local health department inspection also observed a live cockroach on the dishwasher and additional cockroaches in traps beneath the dishwasher and drying racks, confirming persistent infestation despite the facility’s stated pest control policy.
Surveyors found that the facility failed to maintain an up-to-date daily nurse staffing posting, with the form at the main nurse's desk still dated several days earlier. The Administrator confirmed the form had not been updated as required, noting that a nurse is expected to change it daily but it had not been done that morning. The DON stated they are responsible for updating the form each morning and had not done so because they were covering nursing shifts. This issue was identified as an incidental finding during a complaint investigation and had the potential to affect all 68 residents.
A cognitively impaired resident with a history of elopement risk was able to remove a Wanderguard safety device and leave the facility without staff knowledge. The resident was later found at a family member's home after walking through the community, and the incident was only discovered during a routine check. The facility failed to maintain a safe environment and provide adequate supervision, allowing the resident to elope undetected.
A resident identified as a high fall risk experienced multiple falls without effective individualized interventions being implemented. Despite having a care plan with interventions like a personal alarm and room relocation, the facility failed to consistently review and update these measures following each fall. This oversight led to a significant incident where the resident sustained fractures, highlighting deficiencies in the facility's fall prevention program.
A resident with severe cognitive impairment and incontinence was physically abused by an STNA during care. The STNA slapped the resident's hand after the resident grabbed her, which was witnessed by another staff member. The resident's care plan included interventions for resistive behavior due to dementia. The facility's policy prohibits abuse, and the STNA's actions were inconsistent with these standards.
A resident's narcotic medication was misappropriated in an LTC facility. The resident, who required assistance with medication administration, had a prescription for Percocet. Eight tablets were found missing during a narcotic count, and an LPN was identified as a suspect but denied involvement. The facility's investigation revealed discrepancies in the narcotic count sheet and medication card, leading to the conclusion of misappropriation.
The facility failed to ensure that food was served at a palatable and warm temperature, affecting all residents who received meals from the kitchen. Observations revealed that trays were being passed out of an open-air cart, leading to significant temperature drops in the food items. The facility did not have a tray delivery policy, contributing to the deficiency.
The facility failed to provide scheduled bathing for five residents who were dependent on staff for their ADLs. Residents with cognitive impairments and physical dependencies did not receive showers or bed baths as scheduled, despite their preferences and needs. Corporate Nurse #100 and the DON confirmed the discrepancies in the bathing schedules.
The facility failed to implement enhanced barrier precautions for six residents with indwelling medical devices due to supply shortages and delays. Despite completing education on these precautions in April 2024, the necessary measures were not in place during an observation period, affecting infection control efforts.
The facility failed to maintain the correct advance directives in a resident's medical record. Despite a change in code status to DNRCC-Arrest, the medical record at the nurse's station showed no evidence of advance directives. An LPN confirmed the absence of these directives, although the electronic record indicated the correct status. This issue affected one resident and had the potential to impact all 60 residents.
The facility failed to protect a resident from physical abuse by an STNA and another resident from verbal abuse by an STNA. The incidents were not thoroughly documented or reported to the state agency as required, affecting the safety and well-being of all 60 residents.
The facility failed to report an allegation of staff-to-resident verbal abuse to the state agency as required. A resident reported that an STNA threatened to break her other leg and yelled at her in front of a family member. Despite multiple staff members being aware of the incident, it was not reported, and no documentation of an investigation was found.
The facility failed to thoroughly investigate abuse allegations for two residents, involving incidents of physical and verbal abuse by STNAs. The investigations were incomplete, lacked proper documentation, and were not reported to the state agency as required.
The facility failed to follow its bowel policy for two residents, leading to prolonged periods without bowel movements and lack of appropriate medical intervention. Additionally, the facility did not have the required Hospice communication records onsite for a resident receiving Hospice services, violating the facility and Hospice agreement.
A resident with multiple medical conditions developed stage III and stage II pressure ulcers on the buttocks due to the facility's failure to comprehensively assess and provide adequate interventions and treatment. The resident's declining condition and refusal of care were not addressed, and there were no documented weekly skin assessments or new interventions after the pressure ulcers were discovered.
A resident with dementia and other health issues was not offered additional food or nutritional shakes when consuming less than 50% of meals, despite a care plan requiring it. Interviews confirmed the deficiency.
The facility failed to ensure that dialysis communication forms were completed and returned post dialysis treatment for a resident with acute kidney failure and dependence on renal dialysis. The resident's plan of care required monitoring and communication regarding dialysis treatments, but forms for several dates were not completed by the dialysis center. This issue was confirmed by a nurse, who acknowledged difficulties in obtaining completed forms from the dialysis company.
The facility failed to address pharmacy recommendations in a timely manner for two residents. One resident's PRN order for Hydroxyzine lacked a stop date, and another resident's Seroquel dose reduction was delayed by 30 days. These deficiencies were confirmed through medical record reviews and staff interviews.
Failure to Maintain Pest-Free Dishwashing Area in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen dishwashing area, affecting all 68 residents who received food from the kitchen. Maintenance work orders documented that staff observed cockroaches under the dishwasher on 11/22/25 and a large number of cockroaches scattering on the floor in the dishwashing room when the lights were turned on on 03/03/26. Pest control service logs showed that facility maintenance staff performed multiple extra insect treatments with spray and dust applications in the kitchen and dishwashing room over several months. Invoices from an external pest control company documented initial treatment for live cockroaches and cockroach eggs in the dishwashing room, followed by weekly treatments and replacement of monitoring traps due to continued live cockroach activity. A local health department kitchen/food inspection noted a live cockroach running across the top of the dishwasher and back under its components, as well as live and dead cockroaches in several glue traps under the dishwasher and drying racks. During a survey observation of the dishwashing room, multiple insect glue traps were seen along the baseboards and under the dishwasher and drying rack, with several dead cockroaches visible in the traps. Interviews with the dietary supervisor and maintenance supervisor confirmed that cockroaches had been present in the dishwashing room for several months, that maintenance staff had been treating the area, and that there continued to be cockroaches in the dishwashing room despite these efforts. The facility’s written pest control policy stated that it was the facility’s policy to prevent infestation of pests and rodents to protect residents’ quality of life.
Failure to Maintain Updated Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to post an updated daily nursing staff form as required, affecting the accuracy of posted nurse staffing information for all 68 residents. On the morning of 04/14/26 at 7:50 A.M., surveyors observed that the daily nursing staff form displayed in a plastic stand-up frame at the main nurse's desk was dated 04/10/26, indicating it had not been updated for several days. In an interview at 7:55 A.M., the Administrator confirmed that the form had not been updated since 04/10/26 and stated that a nurse is supposed to update the form daily, but it had not yet been changed that morning. Later, at 1:32 P.M., the DON reported being responsible for updating the daily nursing staff form each morning and explained that they had been covering nursing shifts and had not updated the form. This deficiency was identified incidentally during a complaint investigation. No specific residents, their medical histories, or conditions at the time of the deficiency were described in the report, only that all 68 residents in the facility had the potential to be affected by the failure to maintain current posted staffing information.
Resident Elopement Due to Inadequate Supervision and Wanderguard Removal
Penalty
Summary
A cognitively impaired resident with a history of Wernicke's encephalopathy, chronic alcohol use disorder, seizure disorder, urinary tract infection, and hypertension was admitted to the facility and identified as being at risk for elopement. The resident was assessed as mildly cognitively impaired and was independent with activities of daily living, but required cueing and assistance at times. The care plan included the use of a Wanderguard safety bracelet to prevent unsupervised exit from the facility. Despite these interventions, the resident was able to remove the Wanderguard without staff knowledge. Staff discovered the device was missing and conducted a search of the resident's room and belongings, but could not determine how the device was removed. Subsequently, the resident was found to be missing during a routine check, prompting an elopement drill, notification of the DON, and involvement of local police. The resident's guardian later reported that the resident had arrived at her home, approximately two miles from the facility, after leaving the premises without staff awareness. Interviews with the resident and family confirmed that the resident had intentionally left the facility after removing the Wanderguard, walked through the community, and arrived at his guardian's home. The guardian was not concerned about the incident and did not notify the facility upon the resident's arrival. The facility's failure to maintain a safe environment and provide adequate supervision allowed the resident to elope undetected, despite being identified as at risk for such behavior.
Failure to Implement Comprehensive Fall Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized fall prevention program for Resident #60, who was identified as a high fall risk. Despite having a history of falls and being at risk due to cognitive impairment, dizziness, and other medical conditions, the facility did not implement effective fall prevention interventions. Resident #60 experienced multiple falls, including a significant incident on 09/04/24, where she was lowered to the floor by a State tested Nursing Assistant after becoming unsteady. Following this incident, the resident was found to have sustained acute fractures, which required emergency room evaluation. Resident #60's medical record indicated a history of heart failure, muscle weakness, depression, dementia, osteoporosis, osteopenia, and syncope. She was receiving hospice services for end-stage heart failure. The care plan included interventions such as encouraging slow position changes, moving her room to a higher traffic area, and using a personal alarm bed/chair. However, these interventions were not consistently reviewed or updated following each fall, and there was no evidence of a root cause analysis or trend identification to prevent further falls. The facility's incident logs and interviews with staff revealed that falls on 07/21/24, 07/28/24, 08/26/24, and 09/04/24 did not result in new fall interventions being implemented. The Director of Nursing acknowledged that interventions should have been implemented for each fall, but due to workload and staffing issues, this was not consistently done. The facility's policy on accident/incident reporting emphasized the need for prompt and thorough investigation and implementation of corrective actions, which was not adhered to in this case.
Resident Abuse by STNA During Care
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member. The incident involved a State Tested Nursing Assistant (STNA) who slapped a resident's hand during care. The resident, who had severe cognitive impairment and required total care for incontinence, was unable to recall the incident. The facility's investigation revealed that the STNA reacted to the resident grabbing her by smacking the resident's hand, which was witnessed by another staff member. The resident involved had a history of dementia, high blood pressure, asthma, and muscle weakness, and was always incontinent of bowel and bladder. The facility's records indicated that the resident required assistance with activities of daily living and had a care plan addressing resistive behavior due to dementia. The care plan included interventions such as reassuring the resident and attempting care at a later time if the resident was resistive. The facility's policy on abuse clearly stated that residents have the right to be free from abuse, including physical abuse. The policy defined abuse as the willful infliction of injury or punishment resulting in harm or mental anguish. Despite the STNA's training on abuse and dementia care, her actions were deemed inconsistent with the facility's standards, leading to her termination.
Misappropriation of Resident's Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication belonging to a resident, identified as Resident #12. The resident, who was cognitively intact, had a prescription for Percocet to manage pain associated with conditions such as rheumatoid arthritis and osteoporosis. The medication was to be administered as needed, and records indicated it was given daily at bedtime throughout August. However, on August 17, facility staff discovered that eight tablets were missing from the resident's medication supply. A suspected perpetrator was identified, and the resident's physician and responsible party were notified. The resident reported no changes in health or awareness of the missing medication. During the investigation, it was found that the narcotic count sheet for Resident #12 was improperly handled, with a comment of completion and a signature from an LPN who had worked the previous night shift. The count sheet indicated eight tablets remained, but these were not accounted for in the medication card, which was found empty in a shred box. The LPN denied knowledge of the missing medication and was suspended pending investigation. The facility's Director of Nursing (DON) initiated an investigation and filed a police report when the LPN could not be reached for further questioning. The facility's policy on abuse and misappropriation of resident property was reviewed, highlighting the residents' right to be free from such incidents. The investigation revealed that the narcotic medication card and count sheet did not match, leading to the conclusion that the medication was misappropriated. The facility took immediate steps to address the issue, including notifying the pharmacy and ensuring the resident's medication needs were met, although these actions are not detailed in this summary.
Failure to Maintain Appropriate Food Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a palatable and warm temperature, affecting all residents who received meals from the kitchen. During an interview, a resident mentioned that the food was sometimes not very warm. Observations revealed that trays were being passed out of an open-air cart during the first lunch dining service. A test tray was prepared, and the temperatures of the food items were measured before and after delivery. Initially, the corn measured 139 degrees Fahrenheit, Spanish rice 142 degrees Fahrenheit, and tacos 160 degrees Fahrenheit. However, after being served from the open-air delivery cart, the temperatures dropped significantly to 109 degrees Fahrenheit for the corn, 118 degrees Fahrenheit for the Spanish rice, and 115 degrees Fahrenheit for the taco. The Dietary Supervisor confirmed that the food was lukewarm and/or cold upon serving, and the tortilla used for the taco was cold. Further interviews and observations revealed that the facility did not have a tray delivery policy. The Food Preparation policy dated 06/20/17 stated that dietary staff would ensure all foods are held at appropriate temperatures: greater than 135 degrees Fahrenheit for hot foods and under 41 degrees Fahrenheit for cold foods. The lack of an insulated delivery cart and the absence of a tray delivery policy contributed to the failure to maintain appropriate food temperatures, leading to the deficiency.
Failure to Provide Scheduled Bathing for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled bathing for five residents who were dependent on staff for their activities of daily living (ADL). Resident #12, who had cognitive impairment and required substantial assistance for bathing, did not receive a shower or bed bath on multiple occasions over a 30-day period. Resident #12 expressed a preference for showers at least twice a week, which was not met. Corporate Nurse #100 confirmed the resident was not bathed as scheduled or preferred. Resident #22, who also had cognitive impairment and required physical assistance with showers and was totally dependent for bed baths, did not receive scheduled showers on several dates. The resident had a sign in their room indicating showers were scheduled for Mondays and Thursdays but reported not always receiving them twice a week. Corporate Nurse #100 verified the resident was not bathed as scheduled or preferred. Other residents, including Resident #28, Resident #30, and Resident #43, also did not receive their scheduled baths or showers. Resident #28, who required supervision or touching assistance for bathing, only received one shower in the 30-day period. Resident #30, who required partial to moderate assistance, missed multiple scheduled showers. Resident #43, who had severe cognitive impairment and required substantial to maximal assistance, did not receive baths or showers as per their schedule and preference. The Director of Nursing confirmed the discrepancies in the bathing schedule for these residents.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement enhanced barrier precautions in a timely manner for six residents who had indwelling medical devices. Observations revealed that five residents with Foley catheters and one resident with a peritoneal dialysis site did not have the necessary enhanced barrier precautions in place. This deficiency was noted during an observation period from 8:00 A.M. to 4:30 P.M. on 05/13/24. The facility's policy mandates the use of enhanced barrier precautions to prevent the transmission of multidrug-resistant organisms (MDROs), but these precautions were not implemented for the affected residents during the observed period. Interviews with facility staff revealed that education on enhanced barrier precautions was completed in April 2024, but the official roll-out was delayed due to supply shortages. The facility's commonly used supply company experienced delays and low stock of essential isolation supplies, including gowns and masks. Despite receiving some supplies from the Ohio Department of Health in late April, the facility had not yet implemented the necessary precautions as of 05/15/24. The supply company confirmed that they had to switch manufacturers due to back orders, which contributed to the delay in delivering the required supplies. The facility's failure to implement these precautions in a timely manner directly affected the six residents reviewed for infection control.
Failure to Maintain Correct Advance Directives in Medical Record
Penalty
Summary
The facility failed to have the correct advance directives in Resident #22's medical record. Resident #22, who was admitted with diagnoses including dementia, hypertension, mood disorder, and anxiety disorder, had advance directives documented as a full code on 06/15/23. However, an order was signed on 09/15/23 to change the code status to Do Not Resuscitate Comfort Care (DNRCC)-Arrest. Despite this change, a review of the medical record at the nurse's station on 05/14/24 revealed no evidence of advance directives. An LPN verified that Resident #22 did not have advance directives in the medical record at the nurse's station, although the electronic record indicated a DNRCC-Arrest status. This deficiency affected one resident out of three reviewed for advance directives and had the potential to affect all 60 residents in the facility.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect Resident #4 from staff-to-resident physical abuse and Resident #17 from staff-to-resident verbal abuse. Resident #4, who had severe cognitive impairment and was dependent on staff for toileting, was slapped on the back of the hand by STNA #102 during incontinence care. This incident was witnessed by STNA #5, who reported it to the Director of Nursing (DON). Despite conflicting accounts from STNA #102 and STNA #5, the facility's investigation confirmed that Resident #4 stated the slap hurt. STNA #102 was terminated following the incident, but there was no detailed documentation of the circumstances surrounding the termination in the Employee Change of Status Notification. The facility's abuse policy mandates thorough documentation and investigation of such incidents, which was not fully adhered to in this case. Resident #17, who was cognitively intact and required assistance for various activities of daily living, reported being verbally threatened by STNA #40. Resident #17 stated that STNA #40 threatened to break her other leg and yelled at her in front of a family member. This incident was reported to a housekeeper, who then informed the Social Service Director (SSD) #9. Despite Resident #17's complaints, the DON and other staff members did not have clear documentation or recall of the investigation's outcome. Interviews with various staff members, including STNA #40, revealed inconsistencies in the accounts of the incident, and there was no evidence that the incident was reported to the state agency as required. The facility's failure to document and thoroughly investigate these incidents of abuse, as well as the lack of proper reporting to the state agency, highlights significant deficiencies in their handling of abuse allegations. The facility's abuse policy requires comprehensive documentation and investigation, which was not adequately followed in these cases. This deficiency had the potential to affect all 60 residents in the facility, as it undermines the overall safety and well-being of the residents.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident verbal abuse against a resident to the state agency as required. The incident involved a resident who was cognitively intact and had various medical conditions, including polyneuropathy and morbid obesity. The resident reported that an STNA threatened to break her other leg and yelled at her in front of a family member. The resident initially reported the incident to a housekeeper, who then informed the Social Service Director (SSD). Despite these reports, the incident was not reported to the state agency, and the facility did not have documentation of the investigation or its results. Interviews with various staff members, including the SSD, DON, and ADON, revealed inconsistencies and a lack of clear documentation regarding the incident. The SSD mentioned that the resident had issues with an STNA but did not specify which one. The DON and ADON both indicated that they were aware of the incident but did not have any documentation to support that an investigation was conducted. The STNA involved in the incident admitted to having issues with the resident but denied any mistreatment. The DON and ADON both stated that the previous Administrator had decided the incident was not reportable. Further review of the facility's self-reported incidents to the state agency showed no evidence that this particular incident was reported. The facility's abuse policy requires that all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of property, and injuries of unknown origin be reported to the state agency within 24 hours. The failure to report this incident as required constitutes a deficiency in the facility's compliance with state regulations.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse for two residents, which had the potential to affect all 60 residents. For Resident #4, the incident involved an STNA allegedly slapping the back of the resident's hand during incontinence care. Despite the resident's severe cognitive impairment, the incident was reported by another STNA, and the resident indicated that the slap caused pain. However, the incident was not documented in the resident's medical record, and the investigation lacked a signed statement from the accused STNA. Additionally, there were no details provided regarding the STNA's termination, and the facility's abuse policy was not followed as required documentation and thorough investigation were missing. For Resident #17, the resident reported being threatened with bodily harm by an STNA. The resident stated that the STNA threatened to break her other leg and yelled at her in front of a family member. The incident was reported to a housekeeper and the Social Service Director, but the investigation was incomplete and lacked proper documentation. The DON and ADON were aware of the situation but did not have records of the investigation or statements from the involved parties. The facility also failed to report the incident to the state agency as required by their abuse policy. Both incidents highlight significant lapses in the facility's handling of abuse allegations, including inadequate documentation, incomplete investigations, and failure to follow established abuse policies. These deficiencies indicate a systemic issue in the facility's approach to ensuring resident safety and compliance with regulatory requirements.
Failure to Follow Bowel Policy and Maintain Hospice Communication Records
Penalty
Summary
The facility failed to follow its bowel policy for two residents, leading to prolonged periods without bowel movements and lack of appropriate medical intervention. Resident #22, who has cognitive impairment and is always continent of bowel, did not have a bowel movement for seven consecutive days. Despite the facility's policy requiring documentation of bowel movements each shift and intervention after three days without a bowel movement, there was no evidence that the physician was notified or that any stool softeners or laxatives were administered. Similarly, Resident #39, who also has cognitive impairment, did not have a bowel movement for four consecutive days without any documented intervention or physician notification, contrary to the facility's bowel policy. These failures were verified by Corporate Nurse #100 during an interview on 05/16/24. Additionally, the facility failed to ensure that Hospice communication was onsite for Resident #9, who has severe cognitive impairment and is receiving Hospice services for congestive heart failure. When requested, the Hospice notes for Resident #9 were not available on-site. Registered Nurse #45 was unable to locate the Hospice communications in the resident's medical record or the Hospice binder. The Director of Nursing confirmed that the facility did not have the Hospice communication form on-site and had to contact the Hospice company to send over the notes for the last 30 days. This is in violation of the facility and Hospice agreement, which requires complete, accurate, and detailed clinical records to be readily available on request by authorized agencies.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to comprehensively assess and provide adequate interventions and treatment for a resident who developed stage III and stage II pressure ulcers on the buttocks. The resident, who had a history of type II diabetes, convulsions, traumatic brain injury, Parkinson's disease, and chronic kidney disease, was admitted on a specific date and later expired. The plan of care included interventions such as administering medications, applying treatments, encouraging repositioning, and notifying the physician or wound nurse practitioner as needed. However, there were no documented weekly skin assessments, and the pressure ulcers were not identified until they had progressed to stage II and stage III. The medical record revealed that the resident was admitted to hospice care, and the only skin assessments conducted in 2024 were on two specific dates, which showed no new skin areas. The wound nurse note indicated that the resident had new wounds to the buttocks, including a stage III pressure ulcer on the right buttock and a stage II pressure ulcer on the left buttock. The treatment ordered was barrier cream, but there was no documented evidence of the pressure ulcers until they were discovered by the nurse practitioner. Additionally, the order by the nurse practitioner was not implemented, and no new interventions were put in place after the development of the pressure ulcers. Interviews with the Assistant Director of Nursing (ADON) and the nurse practitioner revealed that the resident had been declining and often refused care, but no interventions were put in place for the resident's declining condition or refusal of care. The ADON confirmed that there were no weekly skin assessments and no documentation of skin impairment until the wounds were stage II and stage III. The facility's wound and skin care policy required documentation of pressure ulcers, including measurements and descriptions, but this was not followed. The hospice nurse confirmed that the hospice staff did not assess or provide treatment for the resident's pressure ulcers, and the facility nurses were responsible for the treatment.
Failure to Provide Nutritional Support
Penalty
Summary
The facility failed to offer an alternative meal choice or nutritional shake for a resident when less than 50% of the meal was consumed. This deficiency affected one resident who had diagnoses including dementia, muscle weakness, and venous insufficiency. The resident's medical record indicated a severely impaired cognition for daily decision-making abilities and required supervision or assistance for eating. Despite a care plan that included offering food preferences and substitutions as needed, the resident's meal intake records showed that additional food or nutritional shakes were not offered when less than 51% of meals were consumed over a specified period. The resident's meal intakes from two separate time frames revealed that the resident often consumed less than 50% of meals. Despite this, there was no documented evidence that additional food or nutritional shakes were offered as required by the care plan. Interviews with the Cooperate Nurse and the Director of Nursing confirmed that the resident did consume less than 50% of meals and that supplements were not offered. This failure to follow the care plan resulted in a deficiency in providing adequate nutritional support for the resident.
Failure to Ensure Completion of Dialysis Communication Forms
Penalty
Summary
The facility failed to ensure that dialysis communication forms were completed and returned post dialysis treatment for a resident who required such services. Specifically, Resident #267, who had diagnoses including acute kidney failure, dependence on renal dialysis, and hypertension, did not have completed dialysis communication forms for several dates. The resident's plan of care required monitoring and communication regarding dialysis treatments, but forms dated 05/04/24, 05/07/24, and 05/14/24 were not completed by the dialysis center. This issue was confirmed by Cooperation Nurse #100, who acknowledged difficulties in obtaining completed forms from the dialysis company. The facility's policy required the review of documentation sent with the resident upon return from dialysis and the implementation of new orders based on this documentation. However, the facility did not adhere to this policy, as evidenced by the incomplete or missing dialysis communication forms for Resident #267. This deficiency affected the resident's care and monitoring related to their dialysis treatments, as the necessary communication and documentation were not consistently provided or reviewed.
Failure to Address Pharmacy Recommendations in a Timely Manner
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for two residents. Resident #32, who has diagnoses including anxiety, heart disease, and a fracture of the left arm, was noted to receive antianxiety medication daily. Pharmacy recommendations dated 03/13/24 and 04/21/24 indicated that the PRN order for Hydroxyzine 25 mg every eight hours for anxiety/agitation required a stop date if continued beyond 14 days. There was no evidence that the physician reviewed or addressed these recommendations. This was confirmed during an interview with Cooperate Nurse #100 on 05/16/24. Resident #22, diagnosed with dementia, mood disorder, and anxiety disorder, received a pharmacy recommendation on 12/17/23 for a dose reduction of Seroquel (antipsychotic) from 200 mg daily to 150 mg daily. The physician did not address this recommendation until 01/17/24, resulting in a 30-day delay. This was verified by the Assistant Director of Nursing (ADON) #47 during an interview on 05/16/24. Both instances demonstrate the facility's failure to address pharmacy recommendations promptly, affecting the care of the residents involved.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 150 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Court | 0.3 mi | ★★★★★ | 9 | 1 |
| Ohio Eastern Star Hlth Care Ctr The | 0.7 mi | ★★★★★ | 16 | 0 |
| Als Mount Vernon Inc | 1 mi | ★★★★★ | 15 | 0 |
| Laurels Of Mt Vernon The | 1.3 mi | ★★★★★ | 1 | 0 |
| Whispering Hills Rehabilitation And Nursing Center | 1.4 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Country Club Retirement Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.