Country Club Center V, Inc

Review of the Power of Attorney (POA) documents dated 2017 revealed Resident #51 had named her three daughters as her healthcare POA's.

Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #51 had a Brief Interview of Mental Status (BIMS) of 14 indicating intact cognition and required dependence upon staff and maximum assistance for mobility.

Review of Resident #51's physician letter dated 07/07/25 revealed the resident had cognitive impairment and required assistance with decision making.

The letter also mentioned possible financial abuse.

Review of progress notes dated 07/07/25 revealed Resident #51 had worked with an elder care attorney and was trying to change POA paperwork.

The progress note dated 07/08/25 stated the resident requested facility representation anytime her daughter was in the facility.

The progress note dated 07/09/25 revealed the facility informed the residents daughter that the resident requested a facility representative when she was present in the facility. Resident #51's daughter explained the resident was angry that they stopped the resident's sister from accessing the resident's money. Resident #51's daughter stated they were considering moving her to Tennessee to get her away from her sister and closer to her two daughters.

Facility staff explained the facility would follow POA paperwork and the residents wishes.

Review of the note dated 07/15/25 revealed Resident #51 stated I don't want those two here.

Staff asked who she had referred to and she stated two of her daughters.

The resident also stated, they did this to her, (implying causing her sisters suicide attempt). Resident #51 requested a court appointed guardian.

Staff then called the resident's daughter to let her know what was said.

The note dated 07/16/25 revealed Resident #51's daughter called the facility and requested a referral be sent to Capri Gardens, as she worked there.

The note dated 07/25/25 revealed Resident #51 transferred to Capri Gardens and the facility was not to tell the resident's sister where the resident went.

Interviews on 08/27/25 from 11:00 A.M. to 4:20 P.M. with the Director of Nursing (DON) and Social Services (SS) #150 confirmed the facility had no documented evidence that Resident #51 had a say in her discharge plan and did not have evidence Resident #51 was agreeable to her discharge plan.

They acknowledged a concern related to the documentation of Resident #51 wanting a different decision maker and after each attempt, the resident's daughter(s) put barriers in place. SS #150 confirmed the timing of the letter was suspicious and reported it was odd that it included information about the financial concerns between family members and no cognitive assessment was completed. SS #150 also acknowledged odd timing of family requesting resident transfer the day after she requested a court appointed guardian.

She reported no conversations with Resident #51 were documented regarding if she took part in the discharge process or if she was agreeable.

This deficiency represents non-compliance investigated under Master Complaint Number 2575389.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Country Club Center V, Inc

478 S Sandusky St Delaware, OH 43015

SUMMARY STATEMENT OF DEFICIENCIES

Ensure each resident’s drug regimen must be free from unnecessary drugs.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure staff implemented physician orders and monitored vital signs as required.

This affected one resident (Resident #24) out of three records reviewed for following physician orders.

The facility census was 44.Findings include:

Review of the medical record for Resident #24 revealed an admission date of 10/29/24 with diagnoses including peripheral vascular disease, edema, muscle weakness, depression, paroxysmal atrial fibrillation (a fib), anxiety and essential hypertension.

Review of the care plan dated 11/11/24 revealed Resident #24 had the potential for symptoms of cardiac impairment related to a fib and hypertension.

Interventions included administering medication as ordered, following up with the cardiologist as ordered and observe for side effects.Review of a physician order dated 12/20/24 revealed orders for Amiodarone hydrochloride (HCl) oral tablet 200 milligrams (mg) to be given by mouth once daily for a fib.

Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] showed Resident #24 was severely cognitively impaired.Review of a progress note dated 08/09/25 showed the nurse spoke with the on-call physician regarding Resident #24's amiodarone.

The physician gave parameters to hold the medication if the residents heart rate was less than 60 beats per minute (bpm) and to check blood pressure and heart rate twice daily for 14 days.Review of physician orders dated 08/10/25 revealed orders for blood pressure checks twice daily for 14 days.Review of a progress note dated 08/13/25 showed a new order for Amiodarone 100 mg by mouth daily with instructions to hold if heart rate was less than 50 beats per minute and to notify cardiology if the medication was held.Review of a physician order dated 08/14/25 showed Amiodarone HCL oral tablet 100 mg to be given by mouth once daily for paroxysmal atrial fibrillation with instructions to hold if heart rate was less than 50 beats per minute.

Review of the medication administration record (MAR) and treatment administration records (TAR) from 08/10/25 through 08/24/25 showed the residents blood pressure and heart rate vital signs were not monitored twice daily as ordered.

Review of the blood pressure summary from 08/10/25 through 08/28/25 showed the residents blood pressure was only monitored once daily.

Review of the pulse summary from 08/10/25 through 08/28/25 showed the residents heart rate was only monitored once daily.

Review of the MAR from 08/01/25 through 08/31/25 showed Amiodarone HCL oral tablet 100 mg was given by mouth once daily for a fib with instructions to hold the medication if the heart rate was less than 50 bpm and to notify the cardiologist if the medication was held. On 08/20/25 the resident's heart rate was documented at 49 bpm and on 08/23/25 it was 45 bpm.

The medication was documented as held on both dates.Review of progress notes dated 08/20/25 and 08/23/25 showed no documentation the cardiologist was notified of the low heart rates requiring the medication to be held per the physician orders.Interview on 08/27/25 at 2:42 P.M. with the Director of Nursing (DON) confirmed the medical record did not contain evidence the physician was notified that the Amiodarone was held on 08/20/25 and 08/23/25.

The record also did not contain blood pressure and heart rate measurements as ordered from 08/10/25 through 08/24/25.Interview on 08/27/25 at 3:53 P.M. with Licensed Practical Nurse (LPN) #139 confirmed the medical record did not show the cardiologist was notified that Resident #24's Amiodarone was held on 08/20/25 and 08/23/25. LPN #139 confirmed she received the order on 08/10/25 for staff to check blood pressure twice daily for 14 days.

Upon further review of the record she identified that under order type for Amiodarone she selected other orders no documentation required which resulted in the entry not appearing on the MAR or TAR. LPN #139 confirmed vital signs were not completed.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Country Club Center V, Inc

478 S Sandusky St Delaware, OH 43015

SUMMARY STATEMENT OF DEFICIENCIES

Based on record review, observations, staff interviews, review of the menu/meal spreadsheets, and review of facility policy, the facility failed to ensure residents received a nourishing meal per the facility menu and spreadsheets and failed to follow meal tickets for resident's choice.

This affected two residents (#5 and #12) of three reviewed for nutrition.

The facility identified two residents (#12 and #45) as receiving puree diets and seven residents (#4, #8, #9, #14, #19, #25, and #35) as receiving mechanical soft diets.

The facility census was 44.

Findings include: 1.

Review of the medical record for Resident #5 revealed an admission date of 01/13/21.

Diagnoses included hemiplegia and hemiparesis, vascular dementia, senile degeneration of the brain, mood disorder, muscle weakness and heart disease.

Review of the diet order dated 02/27/25 revealed orders for Resident #5 to receive a regular diet with mechanical texture.

Review of Resident #5's meal ticket dated 08/26/25 revealed the resident should receive mechanical (MM5) glazed ham, green beans, rice pudding and au gratin potatoes and a wheat dinner roll.

Review of the menu/spreadsheet for the meal on 08/26/25 revealed the mechanical diet included mechanical glazed ham, au gratin potatoes, brussels sprouts with bacon, a wheat dinner roll and a berry truffle, but the dessert was substituted for rice pudding.

Observation on 08/26/25 at 11:19 A.M. revealed [NAME] #145 took food temperatures for all food items to be served at lunch. No green beans were observed to be made.

Observation and interview on 08/26/25 at 11:47 A.M. with Certified Nursing Assistant (CNA) #165 revealed she brought Resident #5 her meal tray.

The resident received brussel sprouts on her tray.

The CNA confirmed green beans were not provided on the tray and she was unsure why.

The CNA confirmed the ticket stated green beans and had no mention of brussel sprouts.

Interview on 08/26/25 at 11:47 A.M. with Kitchen Manager (KM) #174 confirmed green beans were not made according to the menu/spreadsheet.

The KM confirmed she did not know why and stated, I am not the cook. 2.

Review of the medical record for Resident #12 revealed an admission date of 07/17/23.

Diagnoses included Alzheimer's disease, dementia without behaviors and dysphagia.

Review of the diet order dated 07/18/23 revealed orders for Resident #12 to receive a regular diet with puree texture.

Review of Resident #12's meal ticket dated 08/26/25 revealed the resident should receive puree glazed ham, puree brussels sprouts, puree rice pudding, puree au gratin potatoes and puree bread.

Review of the menu/spreadsheet for the meal on 08/26/25 revealed the puree diet meal included puree glazed ham, puree brussels sprouts, puree au gratin potatoes, puree bread and puree berry truffle, but the dessert was substituted for rice pudding.

Observation on 08/26/25 at 11:19 A.M. revealed [NAME] #145 took food temperatures for all food items to be served at lunch.

The only puree items observed were pureed ham and pureed brussel sprouts with bacon. No pureed au gratin potatoes, pureed rice pudding or pureed bread was made.

Observation on 08/26/25 at 12:00 P.M. with Resident #12 revealed she only received pureed meat and pureed brussel sprouts. Resident #12 did not receive any puree au gratin potatoes, pureed rice pudding or pureed bread.Observation and interview on 08/26/25 at 12:02 P.M. with Kitchen Manager #174 confirmed Resident #12 only received pureed meat and pureed brussel sprouts and the resident did not receive any puree au gratin potatoes, pureed rice pudding or pureed bread.

The KM stated she was waiting on the blender to dry before making the puree au gratin potatoes.

The KM reported she was unsure why the items were not provided at time of service.

After surveyor intervention, KM began making puree au gratin potatoes.Interview on 08/28/25 at 8:40 A.M. with Diet Tech #200 revealed residents should be served all items marked on the meal ticket.

Review of facility policy titled, Menu and Preferences dated 12/17/24, revealed a menu shall be provided for resident meals and shall meet resident's nutritional needs.

Menus shall be served as written unless changed for preference or unavailability.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Country Club Center V, Inc

478 S Sandusky St Delaware, OH 43015

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, staff interview, review of the facility menu and spreadsheet, and review of facility policy, the facility failed to ensure food was in a form to meet individual needs of the residents.

This affected one resident (#12) of three reviewed for nutrition.

The facility identified two residents (#12 and #45) who received a puree diet.

The facility census was 44.

Findings include:

Review of the medical record for Resident #12 revealed an admission date of 07/17/23.

Diagnoses included Alzheimer's disease, dementia without behaviors and dysphagia.

Review of the diet order dated 07/18/23 revealed an order for Resident #12 to receive a regular diet with puree texture.

Review of the meal spreadsheet dated 08/26/25 revealed the regular texture meal was to receive brussels sprouts with bacon and the puree meal was to receive puree glazed ham, puree brussels sprouts, and puree au gratin potatoes.

There was no mention that bacon was to be included within the puree vegetable on the nutrition spread sheet.

Observation on 08/26/25 at 11:15 A.M. revealed [NAME] #145 scooped several servings of brussels sprouts into a metal container.

The contents of the container were dumped into the blender without scraping the sides.

Brussels sprout leaves and pieces of bacon were left in the metal container.

After the food was blended, it was scooped back into the metal container with the full brussels sprout leaves and chunks of bacon bits.

The large unpureed pieces were visible in the container.

Interview on 08/26/25 at 11:47 A.M. with Kitchen Manager (KM) #174 confirmed the brussels sprouts had chunks of full leaves and bacon on the container.

The Kitchen Manager informed [NAME] #145 who started to remake them.

Observation and interview on 08/26/25 at 12:11 P.M. with the Kitchen Manager (KM) #174 confirmed puree food should be a smooth consistency without any chunks. A plate of puree food was made and observed with brussels sprouts with bacon and a serving of ham that was chunky in consistency.

The KM confirmed the ham was a chunky consistency (similar to ham salad) and bacon bits could visibly be picked out of the brussels sprouts.

She confirmed both were not the proper consistency.

The KM had also just made puree au gratin potatoes and was scooping the mixture into a metal container.

Several chunks were observed on the sides of the blender and were scooped out to be served.

The KM confirmed it was not a smooth consistency and placed the mixture back in the blender to continue mixing after surveyor intervention.

Interview on 08/28/25 at 8:40 A.M. with Diet Tech #200 revealed puree food should be a smooth consistency without chunks and should hold a shape.

She reported the bacon could not be pureed as it would not break down in the blender and would remain chunky.

Review of facility policy titled, Puree Food Production Procedure dated 12/11/14, revealed puree food shall be processed until they were a pudding like consistency.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/28/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Country Club Center V, Inc

478 S Sandusky St Delaware, OH 43015

SUMMARY STATEMENT OF DEFICIENCIES

Based on observation, record review, and interview, the facility failed to ensure proper infection control policies and procedures were maintained during resident personal care.

This affected one (Resident #31) out of three residents reviewed for incontinence care.

The facility census was 44.Findings include:Review of the medical record for Resident #31 revealed an admission date of 08/16/21 with diagnoses including constipation, neuromuscular dysfunction of the bladder, retention of urine, chronic pain syndrome, chronic obstructive pulmonary disease and age-related osteoporosis.

Review of the care plan dated 10/27/24 revealed Resident #31 was frequently to totally incontinent of bowel and bladder related to impaired mobility, with diagnoses of neurogenic bladder and urinary retention.

Interventions included to administer medication, apply barrier cream, assist the resident with pads/briefs/pull-ups, assist with toileting as needed and requested and provide privacy during incontinence care.

Review of the Minimum Data Set (MDS) 3.0 assessment completed on 07/10/25 revealed Resident #31 was cognitively intact, had no impairment of upper and lower extremities, was dependent on staff for toileting needs, and required substantial to maximal assistance with rolling left and right in bed.

Additionally, the resident was frequently incontinent of bowel and bladder.

Review of the bowel and bladder evaluation dated 08/19/25 revealed the resident was incontinent of stool daily, was immobile or required two-person assistance with toileting, was forgetful but followed commands, was sometimes aware of the need to toilet and had functional type incontinence.Observation of incontinence care on 08/26/25 from 11:31 A.M. to 11:53 A.M. involving Resident #31 and Certified Nurse Assistant (CNA) #144 revealed that hand hygiene was performed prior to entering the room.

Upon approach, the aide introduced herself, donned gloves, and removed the resident's blanket, revealing a soiled brief with noticeable urine and bowel movement odor.

The aide began wiping the resident's front area multiple times, each wipe visibly soiled, discarding used wipes into the bedside trash can.

After removing the soiled gloves, she reached into her pocket for a walkie-talkie, bringing it to her mouth to request additional supplies.

When the supplies arrived, she received them from another staff member, placed them on the bed, and donned a new pair of gloves from her pocket without performing hand hygiene.

She placed a clean pad and depends under the resident and continued cleaning, noting the need for additional wipes to reach the feces between the resident's crevices.

Bowel movement was again visible on the aide's gloves while assisting the resident in repositioning from side to side.

After completing care to the resident's backside, the aide moved back to the front peri-area without changing gloves or performing hand hygiene, and cleaned visible bowel movement from the front area.

Once care was completed, all soiled wipes and gloves were discarded, the clean brief was secured, and the resident was covered with personal blankets.

The aide then washed her hands with soap and water in the restroom.

Hand sanitizer was visibly available in the resident's room during the observation and at the exit.Interview on 08/26/25 at 11:55 A.M. with CNA #144 confirmed hand hygiene should have been performed after doffing soiled gloves and before donning new ones, which was not completed during Resident #31's incontinence care.Interview on 08/27/25 at 2:42 P.M. with the Director of Nursing (DON) confirmed hand hygiene should be conducted after taking off soiled gloves and/or prior to putting on clean gloves.Review of the undated incontinence care policy revealed residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections.

Review of the undated hand hygiene policy revealed employees shall wash their hands after handling potentially contaminated objects and after removing gloves.This deficiency represents non-compliance investigated under Complaint Number 2564567 and Complaint Number 2569231.

Facility ID: