Country Club Retirement Center I I I

Total Number of Beds: 65	Percent of Occupied Beds: 97%
Total Number of Residents: 63	Located Within a Hospital: No
Type of Ownership: For profit - Corporation	Multiple Nursing Homes by Same Owner: No
Councils the Nursing Home Participates in: Family & Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 05/22/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.58

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.57

Number of CNA Hours per Nursing Home Resident per Day: 2.2

Number of Staff Hours per Nursing Home Resident per Day: 3.35

Nursing Home Resident Information**:

Percent of Short-Stay Residents With Pressure Sores: 19%
Percent of High-Risk Residents Who Have Pressure Sores: 5%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 24%
Percent of Residents Who Have Moderate to Severe Pain: 5%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 13%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 0%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 12%
Percent of Residents Who are More Depressed or Anxious: 5%
Percent of Short-Stay Residents With Delirium: 10%
Percent of Residents Who Were Physically Restrained: 4%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 2%
Percent of Residents With a Urinary Tract Infection: 4%
** Details Last Reported on: 5/22/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-05-02	2001-06-20	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
2001-05-02	2001-06-20	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
2002-03-29	2002-04-04	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
2002-03-29	2002-04-04	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
2002-03-29	2002-04-04	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
2002-03-29	2002-04-04	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
2002-03-29	2002-04-04	Quality Care Deficiencies	Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.	Isolated	Minimal harm or potential for actual harm
2002-03-29	2002-04-04	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Actual harm
2002-03-29	2002-04-04	Pharmacy Service Deficiencies	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
2002-03-29	2002-04-04	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
2002-03-29	2002-04-04	Environmental Deficiencies	Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
2003-05-22	2003-06-30	Resident Rights Deficiencies	Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
2003-05-22	2003-06-30	Mistreatment Deficiencies	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
2003-05-22	2003-06-30	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Minimal harm or potential for actual harm
2003-05-22	2003-06-30	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.