Country Club Retirement Center IV

Total Number of Beds: 62	Percent of Occupied Beds: 97%
Total Number of Residents: 60	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: 09/25/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.42

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.78

Number of CNA Hours per Nursing Home Resident per Day: 2.77

Number of Staff Hours per Nursing Home Resident per Day: 3.97

Nursing Home Resident Information**:

Percent of Short-Stay Residents With Pressure Sores: 30%
Percent of High-Risk Residents Who Have Pressure Sores: 15%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 14%
Percent of Residents Who Have Moderate to Severe Pain: 6%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 5%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 4%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 7%
Percent of Residents Who are More Depressed or Anxious: 25%
Percent of Short-Stay Residents With Delirium: 0%
Percent of Residents Who Were Physically Restrained: 16%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 4%
Percent of Residents With a Urinary Tract Infection: 5%
** Details Last Reported on: 9/25/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-09-20	2001-11-09	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
2001-09-20	2001-11-09	Resident Rights Deficiencies	Make sure each resident has the right to choose activities, schedules and health care according to his or her interests, assessment, and plan of care.	Pattern	Minimal harm or potential for actual harm
2001-09-20	2001-11-09	Resident Rights Deficiencies	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
2002-12-12	2003-01-03	Mistreatment Deficiencies	1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
2002-12-12	2003-01-03	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
2002-12-12	2003-01-03	Pharmacy Service Deficiencies	1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
2002-12-12	2003-01-03	Administration Deficiencies	Get proof that a nurse aide has the training and skills that the State requires.	Widespread	Minimal harm or potential for actual harm
2003-09-25	0000-00-00	Administration Deficiencies	Keep accurate and appropriate medical records.	Widespread	Potential for minimal harm

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