Health inspection·August 9, 2024

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the SRI tracking number 248910 dated 06/22/24 revealed on 06/20/24 facility staff identified a supply of six tablets was missing from the medication supply indicated for Resident #40. The tablets in question were the remaining amount of an initial 30 tablet supply. A suspected perpetrator was identified and suspended pending investigation. Resident #40's physician was notified. The investigation consisted of interview of Resident #40, interview of the suspected perpetrator, interviews of residents with potential to be affected, audits of medication quantities, audits of medication availability and interviews of staff with potential knowledge. During interview of Resident #40 denied experiencing any recent change in health or symptom management as well as any knowledge of the missing medication. Interviews of residents with potential to be affected did not identify any reports of failed symptom management. The audit conducted of medication quantities and availability according to receipt did not identify any abnormalities. During interview the suspected perpetrator denied any knowledge of the missing medication but failed to cooperate further with the investigation. Interviews of facility staff did not identify any knowledge of the missing medication. During the investigation the expense of the medication was ensured to have been provided for by the facility. Local law enforcement was notified as well as the Board of Pharmacy through the facility's pharmacy provider and the Board of Nursing. Through investigation the facility concluded misappropriation had occurred. The suspected perpetrator's employment was terminated as well as initial contact to report made with the Ohio Board of Nursing (OBN). Education regarding controlled substance receipt, securement, documentation of administration, exhaustion, and misappropriation to be initiated for all licensed nursing staff. As well as further auditing of current controlled substance records. Once completed on-going audits of controlled substance receipt, shift to shift count, securement, documentation and exhaustion to be initiated with results reviewed by the Quality Assurance and Performance Improvement (QAPI) committee weekly. Review of the signed typed statement from Licensed Practical Nurse (LPN) #415 dated 06/20/24 revealed he was looking for another medication for a resident and was searching the narcotic book for the sheet when he found a narcotic sheet in the back of the narcotic book. He stated he tried to find the card of medication that went with the sheet and could not find it, so he went to the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #410 to inform them. He stated the sheet indicated there were six tablets left in the card. He stated he thought maybe it had been discontinued and they gave the card of narcotic to the DON but not the sheet. Review of the signed typed statement from Registered Nurse (RN) #416 dated 06/21/24 revealed she spoke to Resident #40, who had intact cognition, regarding the last time he received his Norco. He reported that the last time he received any Norco was serval months ago maybe March or early April and he did not know he even still had it available. Review pf the undated unsigned typed statement from the DON revealed the Administrator, DON and ADON #410 conducted a phone interview with RN #300 on 06/20/24 in regard to the missing narcotic. When the DON questioned RN #300 if he knew where the medication could be he just sighed with no proper response. He was then educated on the importance of the situation, RN #300 only stated yeah. RN #300 was unable to give proper response to the question regarding the missing narcotic or count sheet found in the back of the narcotic binder. He was instructed to get a drug screen and would be ineligible to return to work until completed. RN #300 stated he was watching his father and was not able to go get tested. He was reminded of the importance to the investigation and his employment. He stated his understanding and that he would text his siter to come help with his father. Upon ending the phone call RN #300 texted the ADON #410 and stated he was not planning on getting a drug screen. Review of the police report dated 06/21/24 revealed they were called to the facility because a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365417 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Center I 860 Iron Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 nurse was falsely signing out medication to residents and reported missing pills from March until present. Level of Harm - Minimal harm or potential for actual harm On 08/08/24 at 1:40 P.M. an interview with Director of Clinical Services #400 revealed LPN #415 found a narcotic count sheet for Norco for Resident #40 folded up and stuck in between several blank shift to shift narcotic count sheets. He stated they never found the card of Norco. He stated the identified RN #300 as the perpetrator because he was the only nurse that had signed out any Norco. He stated Resident #40 was interviewed and he stated he was never given the Norco. He stated RN #300 was interviewed but never confessed to taking the Norco, but he would not cooperate, and he refused to be drug tested. He stated the facility paid for the medication, so they do not believe it was misappropriation; however, they do believe it was diversion. He stated they reported it to the Ohio Board of Nursing and the local police department. He stated the Attorney General's office has also been out to investigate. Residents Affected - Few Review of the facility policy titled, Abuse, dated 01/31/20, revealed the residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident's property. This included but not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraints that was not required to treat the resident's medical symptoms. Misappropriation of resident's property was the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. The deficient practice was corrected on 06/27/24 when the facility implemented the following corrective actions: • On 06/22/24 the local authorities were notified by the Administrator, report number 24-04962. • On 06/24/24 at 9:00 A.M. a QAPI meeting was held with the DON, ADON #410, RN #416, Director of Clinical Services #400, and Administrator. • On 06/24/24 an audit of all current residents with controlled substance quantities was completed by the DON, ADON #410, and RN #416 with no discrepancies identified. • On 06/24/24 an audit of all controlled substance administration records (cards, count sheets, MAR) were completed by the DON, ADON #410 and RN #416 for evidence of diversion with no discrepancies identified. • On 06/26/24 education for all licensed nurses regarding management, securement and administration of controlled substances was done by the DON, ADON #410, and RN #416 and completed on 07/01/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365417 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365417 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Center I 860 Iron Avenue Dover, OH 44622 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 • Level of Harm - Minimal harm or potential for actual harm On 06/26/24 the Director of Clinical Services #400 was notified of suspicion and investigation findings. • Residents Affected - Few On 06/27/24 an audit was completed by the DON and ADON #410 of receipt of controlled substances for prior 30 days with no discrepancies identified. • On 06/27/24 all residents with narcotic pain medications were interviewed by the DON, ADON #410, and RN #416 for effectiveness of pain management with no concerns identified. • Ongoing Actions included the DON, ADON #410 and RN #416 would perform randomized audits of the shift-to-shift controlled substance count process, receipt and removal of controlled substances from active supply, reconciliation of count sheet to MAR process, and interviews of residents to verify administration/effective pain management three times a week for four weeks. Findings would be presented to the QAPI committee weekly for evaluation and recommendations. Audits were completed on 07/25/24 with no further concerns identified. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365417 If continuation sheet Page 4 of 4