Safety Report: Country Club Rehab and Healthcare Center
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
13Requirements cited on more than one inspection
G
Government finding: Provide safe, appropriate dialysis care/services for a resident who requires such services.
Quality of Life and Care Deficiencies · Tag F698
Citations by topic
2Abuse, neglect & exploitation
4Infection control
4Medications & pharmacy
3Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (11) than in the cycle before (21).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Provide and implement an infection prevention and control program. (F880) | 4 | March 14, 2025; April 4, 2024; August 11, 2023; February 16, 2022 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 3 | March 14, 2025; August 11, 2023; February 16, 2022 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 3 | March 14, 2025; August 11, 2023; February 16, 2022 |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. (F686) | 3 | October 8, 2024; August 11, 2023; February 16, 2022 |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. (F804) | 2 | March 14, 2025; October 30, 2023 |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (F802) | 2 | March 14, 2025; October 30, 2023 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | March 14, 2025; August 11, 2023 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 2 | October 8, 2024; August 11, 2023 |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. (F806) | 2 | October 30, 2023; August 11, 2023 |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (F925) | 2 | August 11, 2023; February 16, 2022 |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. (F607) | 2 | August 11, 2023; February 16, 2022 |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. (F568) | 2 | August 11, 2023; February 16, 2022 |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F690) | 2 | August 11, 2023; February 16, 2022 |
Fines and enforcement
No federal fines or payment denials in the last three years.
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
March 14, 2025 — 11 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · complaint · corrected April 22, 2025
F
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F804 · complaint · corrected April 22, 2025
F
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.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F803 · complaint · corrected April 22, 2025
F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F802 · corrected April 22, 2025
F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F801 · corrected April 22, 2025
F
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F727 · corrected April 22, 2025
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected April 22, 2025
E
Have a plan that describes the process for conducting QAPI and QAA activities.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F865 · corrected April 22, 2025
E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F689 · corrected April 22, 2025
E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F550 · corrected April 22, 2025
D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F921 · corrected April 22, 2025
October 8, 2024 — 2 citations · complaint investigation
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F686 · complaint · corrected July 30, 2024
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected July 30, 2024
April 4, 2024 — 1 citation · complaint investigation
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · complaint · corrected May 1, 2024
October 30, 2023 — 3 citations · complaint investigation
F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F802 · complaint · corrected December 14, 2023
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · complaint · corrected December 14, 2023
D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F806 · complaint · corrected December 14, 2023
August 11, 2023 — 19 citations (includes serious)
G
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F698 · corrected September 15, 2023
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected September 15, 2023
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected September 15, 2023
F
Post nurse staffing information every day.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F732 · corrected September 15, 2023
E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F925 · corrected September 15, 2023
E
Have enough outside ventilation via a window or mechanical ventilation, or both.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F923 · corrected September 15, 2023
E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F806 · corrected September 15, 2023
E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected September 15, 2023
E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · corrected September 15, 2023
E
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F568 · corrected September 15, 2023
D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F740 · corrected September 15, 2023
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected September 15, 2023
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · corrected September 15, 2023
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected September 15, 2023
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected September 15, 2023
D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F686 · corrected September 15, 2023
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected September 15, 2023
D
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F569 · corrected September 15, 2023
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected September 15, 2023
February 16, 2022 — 20 citations
F
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Widespread · Infection Control Deficiencies · F880 · corrected March 31, 2022
F
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F838 · corrected March 31, 2022
E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
No actual harm, but potential for more than minimal harm · Pattern · Environmental Deficiencies · F925 · corrected March 31, 2022
E
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
No actual harm, but potential for more than minimal harm · Pattern · Administration Deficiencies · F840 · corrected March 31, 2022
E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected March 31, 2022
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected March 31, 2022
E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F690 · corrected March 31, 2022
E
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F686 · corrected March 31, 2022
E
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F677 · corrected March 31, 2022
E
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F607 · corrected March 31, 2022
E
Assure the security of all personal funds of residents deposited with the facility.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F570 · corrected March 31, 2022
E
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F568 · corrected March 31, 2022
E
Honor the resident's right to manage his or her financial affairs.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F567 · corrected March 31, 2022
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · corrected April 15, 2022
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected April 15, 2022
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected March 31, 2022
D
Plan the resident's discharge to meet the resident's goals and needs.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F660 · corrected March 31, 2022
D
Assess the resident when there is a significant change in condition
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F637 · corrected March 31, 2022
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · corrected March 31, 2022
D
Allow residents to self-administer drugs if determined clinically appropriate.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F554 · corrected March 31, 2022
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare