Health inspection·April 3, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the hospital documentation dated 12/09/22 at 11:49 A.M. revealed left eighth and ninth rib fractures. Treatment instructions were provided to the son which included monitoring closely for signs of pneumonia and administering acetaminophen (analgesic) as needed for pain. Review of the printed text message dated December 9th (year not printed), at 2:30 P.M. to RN #537 from the Director of Nursing revealed questioning for forgotten documentation of a fall on the previous night for Resident #50 as the resident was sent out with a fractured rib. RN #537 responded with Ok. Review of the progress note dated 12/10/22 at 4:01 A.M. by RN #537 for Resident #50 revealed an entry of . Interview on 03/30/23 at 8:55 A.M. with Assistant Director of Nursing (ADON) #532 confirmed RN #537 and State Tested Nursing Assistant (STNA) #529 reported Resident #50 fell but verified there was no documentation including an incident report and an investigation related to the fall. ADON #532 was the manager on duty the weekend of the incident and talked with Resident #50's family and recalled the incident on 12/08/22 around 6:30 P.M. ADON #532 indicated Licensed Practical Nurse (LPN) #578 who was assigned on 12/09/22 stated receiving in report from RN #537 that Resident #50 fell and then Resident #50's son called and reported Resident #50 was having rib pain so LPN #578 transferred her to the local emergency room for evaluation. ADON #532 verified nurses were required to document all falls, including filling out a report. Telephone interview on 03/30/23 at 11:24 A.M. with RN #537 stated on 12/08/22 between 7:30 P.M. and 8:00 P.M. Resident #50 fell while attempting to get out of a recliner chair and was sitting on its leg rest. An assessment revealed no injury or pain so both RN #537 and STNA #529, one on each side and arm in arm, assisted Resident #50 in scooting back onto the chair seat, then to a standing position, and then to ambulate to the bed using a walker. Resident #50 did not complain throughout the night or during personal care. RN #537 indicated a belief the documentation was completed but now all that could be found was an entry with a period in it. RN #537 confirmed the physician and family were not contacted and informed of the fall, investigation forms were not completed, and interventions were not put into place. Interview on 03/30/23 at 11:42 A.M. with ADON #532, Regional Nurse #582, and the Director of Nursing verified there was no fall investigation completed or fall interventions put into place by RN #537 after Resident #50's fall on 12/08/22. Interview on 03/30/23 at 1:44 P.M. with LPN #578 verified Resident #50 was transferred to the local emergency room because of complaint of rib pain. LPN #578 denied remembering what was received in report from RN #537 but knew Resident #50 fell because the nursing assistants talked to her about the fall the night before. LPN #578 denied remembering talking with Resident #50's family but stated the physician was aware which was how Resident #50 was able to be transferred. Review of the documented statement by RN #537, dated 03/31/23, revealed on 12/08/22 around 8:00 P.M. Resident #50 was observed sitting upright on the mechanical reclining chair footrest with her legs out in front of her and arms down at her sides. Resident #50 stated she was trying to get out of the recliner and the remote control did not work to lower the leg rest so she scooted down to get out of the chair which resulted in tipping the recliner and the footrest to the floor with Resident #50 sitting on top of it. Resident #50 denied pain and hitting her head. After assessment of the upper and lower extremities all were within normal limits. Resident #50 with assistance of STNA (unnamed) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365642 If continuation sheet Page 2 of 9 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 365642 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Ret Center I I I 925 E 26th St Ashtabula, OH 44004 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was raised to the seat of the recliner. The power chord of the recliner was found to be unplugged and the remote began to work again. Resident #50 was raised to a standing positioning using the mechanical recliner and with two staff assistance and a walker ambulated to bed. Resident #50 was educated to use the call bell for assistance with transfers. The physician was not notified due to no significant abnormal findings and Resident #50 had no complaints of pain. Resident #50 was alert and in a good mood, and there were no other incidents for the remainder of the shift. Review of the documented statement by STNA #529 dated 04/03/23 revealed on 12/08/23 Resident #50 was observed sitting on the footrest of the lift recliner. The nurse (unnamed) was informed and assessed Resident #50 who stated the chair remote did not work so she scooted down onto the footrest to get out of the chair, causing the chair to tilt. The footrest landed on the floor with Resident #50 sitting on top with legs out in front of her, and with the assistance of Resident #50 and the nurse, lifted her back into the chair. Resident #50 had no complaints of pain. After inspecting the chair, it was found to be unplugged so it was plugged back in, and Resident #50 was ambulated to the bed with assistance. Interview on 04/03/23 at 1:01 P.M. with ADON #532 verified RN #537 should have called the physician and family after Resident #50 fell on [DATE] regardless of injury because it was the facility's policy. ADON #532 stated there were some families who had designated not to receive phone calls during night hours which were designated on the medical chart but Resident #50 was not one of them. Review of the facility policy, Falls Policy and Procedures, revised 05/21/18, revealed when a fall occurs the licensed nurse shall assess the resident's condition, complete the incident report, the falls investigation, implement immediate safety approaches if identifiable until the interdisciplinary team (falls committee) can meet to review the fall and implement interventions to the plan of care, document the incident in the medical record and post fall assessment, and notification of physician and responsible party. Review of the facility policy, Resident Condition Changes/COVID Notification, revised 05/20/20, revealed the nurse will contact the resident's physician immediately when any resident has a perceived change in condition, an assessment will be made by the nurse prior to the phone call so that nurse is prepared to discuss condition change, a condition change includes an accident, the nurse will also notify resident' responsible party of condition change, if resident is responsible for self that is the person who should be notified documentation will be completed in nurses notes, the nurse will implement all new physician's order immediately, the nurse will document condition change and physician/responsible party contact information in nurses notes, the nurse will report resident changes and new orders to oncoming nurse. This deficiency represents non-compliance investigated under Complaint Number OH00141550. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365642 If continuation sheet Page 3 of 9 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 365642 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Ret Center I I I 925 E 26th St Ashtabula, OH 44004 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, documented staff statements, and facility policy review, the facility failed to ensure a fall was documented, investigated, fall interventions were implemented, and the care plan was updated for Resident #50. This affected one resident (#50) of three residents reviewed for falls. The census was 62. Findings include: Review of the medical record for Resident #50 revealed an admission date of 08/19/22. Diagnoses included difficulty walking, abnormalities of gait, muscle weakness, cognitive communication deficit, need for assistance with personal care, pain in right knee, arthritis, overactive bladder, history of falling, and dizziness and giddiness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had moderately impaired cognition. Resident #50 required extensive one staff assistance for bed mobility, transfers, and toileting. The assessment indicated Resident #50 was frequently incontinent of urine and occasionally incontinent of bowel. Review of the progress note dated 12/09/22 at 10:14 A.M. revealed Resident #50 complained of left rib pain and all over pain to her son and was transferred to the local emergency room for evaluation. Review of the physician progress note dated 12/14/22 revealed Resident #50 was diagnosed with post left multiple rib fractures with pain of the eighth and ninth ribs. Interview on 03/29/23 at 5:10 P.M. with Regional Nurse #582 verified there was no incident report or investigation completed for Resident #50's rib fractures, and the only documentation in the medical record was the progress notes. Regional Nurse #582 stated Resident #50 reported that the evening before going to the hospital she was trying to put her nightgown on and fell forward out of her wheelchair. When asked if anyone helped her off the floor she did not respond or indicate reporting it to any staff. Regional Nurse #582 confirmed an investigation was started. Interview on 03/30/23 at 8:06 A.M. with Regional Nurse #582 revealed staff was aware Resident #50 fell prior to the resulting fractures on 12/09/23, and the facility was collecting documents to complete the fall investigation. Regional Nurse #582 identified Registered Nurse (RN) #537 who was on assignment when the fall occurred and despite being confronted by administrative staff through a text message to complete the necessary documentation, failed to do so and ultimately it was not again addressed. Review of the hospital documentation dated 12/09/22 at 11:49 A.M. revealed left eighth and ninth rib fractures. Treatment instructions were provided to the son which included monitoring closely for signs of pneumonia and administering acetaminophen (analgesic) as needed for pain. Review of the printed text message dated December 9th (year not printed), at 2:30 P.M. to RN #537 from the Director of Nursing revealed questioning for forgotten documentation of a fall on the previous night for Resident #50 as the resident was sent out with a fractured rib. RN #537 responded with Ok. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365642 If continuation sheet Page 4 of 9 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 365642 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Ret Center I I I 925 E 26th St Ashtabula, OH 44004 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress note dated 12/10/22 at 4:01 A.M. by RN #537 for Resident #50 revealed an entry of . Interview on 03/30/23 at 8:55 A.M. with Assistant Director of Nursing (ADON) #532 confirmed RN #537 and State Tested Nursing Assistant (STNA) #529 reported Resident #50 fell but verified there was no documentation including an incident report and an investigation related to the fall. ADON #532 was the manager on duty the weekend of the incident and talked with Resident #50's family and recalled the incident on 12/08/22 around 6:30 P.M. ADON #532 indicated Licensed Practical Nurse (LPN) #578 who was assigned on 12/09/22 stated receiving in report from RN #537 that Resident #50 fell and then Resident #50's son called and reported Resident #50 was having rib pain so LPN #578 transferred her to the local emergency room for evaluation. ADON #532 verified nurses were required to document all falls, including filling out a report, and initiate interventions. ADON #532 stated if nurses did not complete the necessary paperwork it might fall through the cracks as in this case. Review of the plan of care for falls last revised on 09/14/22 revealed Resident #50 was at risk for falls and injury related to a history of falls, weakness, arthritis, macular degeneration, dizziness, pain in the right knee, muscle weakness, difficulty walking and other abnormalities of gait. Interventions included one person assistance with transfers and gait with walker; increase assistance as needed; keep bed in low position; staff to anticipate needs; therapy to evaluate and treat as ordered; put call light within resident reach; encourage resident to come to the multipurpose room for closer supervision; and encourage non-skid, gripper socks when shoes are off. There were no additional interventions added or revisions made after Resident #50's fall with resulting fracture on 12/08/22. Review of the plan of care for pain last revised on 08/23/22 revealed Resident #50 had potential for alteration in comfort related to arthritis, right knee pain, a history of falls, and an overactive bladder. Interventions included to administer medications as ordered and per resident preference or request; assist resident with repositioning as needed; attempt alternate relief measures, i.e., a back rub, relaxation, reposition, exercise, or music prior to medications; encourage resident to report pain early prior to becoming severe; and observe for any signs or symptoms of pain. There were no additional interventions added or revisions made after Resident #50's fall with resulting fracture on 12/08/22. Interview on 03/30/23 at 10:28 A.M. with MDS Nurse #530 stated being unaware of Resident #50's fall with rib fractures on 12/08/22 and confirmed Resident #50's care plan for falls and pain was not revised or updated after 12/08/22. Telephone interview on 03/30/23 at 11:24 A.M. with RN #537 stated on 12/08/22 between 7:30 P.M. and 8:00 P.M. Resident #50 fell while attempting to get out of a recliner chair and was sitting on its leg rest. An assessment revealed no injury or pain so both RN #537 and STNA #529, one on each side and arm in arm, assisted Resident #50 in scooting back onto the chair seat, then to a standing position, and then to ambulate to the bed using a walker. Resident #50 did not complain throughout the night or during personal care. RN #537 indicated a belief the documentation was completed but now all that could be found was an entry with a period in it. RN #537 confirmed the physician and family were not contacted and informed of the fall, investigation forms were not completed, and interventions were not put in place. Interview on 03/30/23 at 11:42 A.M. with ADON #532, Regional Nurse #582, and the Director of Nursing verified there was no fall investigation completed or fall interventions put into place by RN #537 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365642 If continuation sheet Page 5 of 9 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 365642 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Ret Center I I I 925 E 26th St Ashtabula, OH 44004 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 0689 after Resident #50's fall on 12/08/22. Level of Harm - Minimal harm or potential for actual harm Interview on 03/30/23 at 1:44 P.M. with LPN #578 verified Resident #50 was transferred to the local emergency room because of complaint of rib pain. LPN #578 denied remembering what was received in report from RN #537 but knew Resident #50 fell because the nursing assistants talked to her about the fall the night before. LPN #578 denied remembering talking with Resident #50's family but stated the physician was aware which was how Resident #50 was able to be transferred. Residents Affected - Few Review of the documented statement by RN #537, dated 03/31/23, revealed on 12/08/22 around 8:00 P.M. Resident #50 was observed sitting upright on the mechanical reclining chair footrest with her legs out in front of her and arms down at her sides. Resident #50 stated she was trying to get out of the recliner and the remote control did not work to lower the leg rest so she scooted down to get out of the chair which resulted in tipping the recliner and the footrest to the floor with Resident #50 sitting on top of it. Resident #50 denied pain and hitting her head. After assessment of the upper and lower extremities all were within normal limits. Resident #50 with assistance of STNA (unnamed) was raised to the seat of the recliner. The power chord of the recliner was found to be unplugged and the remote began to work again. Resident #50 was raised to a standing positioning using the mechanical recliner and with two staff assistance and a walker ambulated to bed. Resident #50 was educated to use the call bell for assistance with transfers. The physician was not notified due to no significant abnormal findings and Resident #50 had no complaints of pain. Resident #50 was alert and in a good mood, and there were no other incidents for the remainder of the shift. Review of the documented statement by STNA #529 dated 04/03/23 revealed on 12/08/23 Resident #50 was observed sitting on the footrest of the lift recliner. The nurse (unnamed) was informed and assessed Resident #50 who stated the chair remote did not work so she scooted down onto the footrest to get out of the chair, causing the chair to tilt. The footrest landed on the floor with Resident #50 sitting on top with legs out in front of her, and with the assistance of Resident #50 and the nurse, lifted her back into the chair. Resident #50 had no complaints of pain. After inspecting the chair, it was found to be unplugged so it was plugged back in, and Resident #50 was ambulated to the bed with assistance. Interview on 04/03/23 at 1:01 P.M. with ADON #532 verified RN #537 should have called the physician and family after Resident #50 fell on [DATE] regardless of injury because it was the facility's policy. ADON #532 stated there were some families who had designated not to receive phone calls during night hours which were designated on the medical chart but Resident #50 was not one of them. Review of the facility policy, Falls Policy and Procedures, revised 05/21/18, revealed the falls care plan will be reviewed at least quarterly and as needed by the interdisciplinary team/falls committee and updated; when a fall occurs the licensed nurse shall assess the resident's condition, complete the incident report, the falls investigation, implement immediate safety approaches if identifiable until the interdisciplinary team (falls committee) can meet to review the fall and implement interventions to the plan of care, document the incident in the medical record and post fall assessment, and notification of physician and responsible party. Review of the facility policy, Resident Condition Changes/COVID Notification, revised 05/20/20, revealed the nurse will contact the resident's physician immediately when any resident has a perceived change in condition, an assessment will be made by the nurse prior to the phone call so that nurse is prepared to discuss condition change, a condition change includes an accident, the nurse will also notify resident' responsible party of condition change, if resident is responsible for self that is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365642 If continuation sheet Page 6 of 9 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 365642 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Ret Center I I I 925 E 26th St Ashtabula, OH 44004 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 0689 Level of Harm - Minimal harm or potential for actual harm the person who should be notified documentation will be completed in nurses notes, the nurse will implement all new physician's order immediately, the nurse will document condition change and physician/responsible party contact information in nurses notes, the nurse will report resident changes and new orders to oncoming nurse. Residents Affected - Few This deficiency represents non-compliance investigated under Complaint Number OH00141550. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365642 If continuation sheet Page 7 of 9 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 365642 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Ret Center I I I 925 E 26th St Ashtabula, OH 44004 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 0921 Level of Harm - Potential for minimal harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on interview, record review, and facility policy review the facility failed to ensure facility temperatures of common areas and resident rooms were monitored and documented during a power outage. This had the potential to affect all residents residing in the facility. The census was 62. Findings include: Interview on 03/29/23 at 11:53 A.M. of Licensed Practical Nurse (LPN) #509 revealed she was working at the facility when the power went out on 03/25/23. LPN #509 stated the power flickered on and off a couple times before going out, and the generator turned on, flickered and then the power went out. LPN #509 stated Maintenance Director (MD) #517 was called, he lived close to the facility, arrived timely and was able to get the generator to work. LPN #509 stated she thought from the time the generator went out until it came back on was approximately a half hour. LPN #509 indicated when the power was out oxygen concentrators, air mattresses, computers were all plugged into the emergency outlets, and portable oxygen tanks were used. LPN #509 stated residents were on every 15-minute checks while the power was out. LPN #509 indicated she left the facility around 7:00 P.M. and she did not work again until 03/27/23 and the power was restored. Interview on 03/29/23 at 12:00 P.M. of Registered Nurse (RN) #556 revealed the facility had a power outage on 03/25/23 due to severe weather. RN #556 stated the power was out for about 16 hours from around 3:00 P.M. on 03/25/23 through 03/26/23 at around 9:00 A.M. RN #556 stated the call light system and facility phones did not work and no management staff were in the facility during the outage. RN #556 stated on 03/25/23 at 3:00 P.M. the emergency generator did not work for about a half hour when the power went out. RN #556 stated on 03/26/23 at around 6:30 or 7:00 A.M. it was 65 degrees in the facility when he looked at the indoor thermometer in the common area, and residents were complaining they were very cold, especially on the skilled nursing unit. RN #556 stated he started calling families to let them know the facility was not sure when the power would come back on and asked them if they wanted to take residents home until the power was restored. RN #556 indicated residents were checked at least every half hour, and oxygen and air mattresses were plugged into the emergency outlets in the halls. RN #556 stated the emergency generator did not work for about a half hour when the power first went out on 03/25/23 at 3:00 P.M. Interview on 03/29/23 at 12:35 P.M. of MD #517 revealed the weather got bad very quickly, and the power was out throughout the entire area the facility was in. MD #517 stated the power flickered on and off for about ten minutes, then went out entirely. MD #517 stated the generator started but because the power flickered multiple times the generator had an issue and did not work for a few minutes. MD #517 indicated he arrived at the facility in about ten minutes because he lived close and had the generator running within minutes of his arrival. MD #517 stated he walked around to make sure everything was alright, and the staff had enough extension cords and batteries. MD #517 stated he checked the water, and it was ok, and the corridor lights were working. MD #517 indicated the extension cords were plugged into emergency outlets in the hallway and were used for air mattresses and oxygen concentrators. MD #517 stated heat was supplied to the residents during the power outage through a central duct located in the ceilings of the halls of each nursing unit and branches from the central duct led into each resident room and supplied some heat. MD #517 stated on 03/25/23 at 8:00 P.M. the temperature was 71 degrees Fahrenheit. MD #517 stated RN #556 told him the temperature was around 66 degrees Fahrenheit in the skilled nursing unit and around 70 degrees Fahrenheit in the long-term nursing unit on the morning of 03/26/23. MD #517 stated there was no log with temperatures documented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365642 If continuation sheet Page 8 of 9 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 365642 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Ret Center I I I 925 E 26th St Ashtabula, OH 44004 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 0921 Level of Harm - Potential for minimal harm Residents Affected - Many throughout the power outage of the common areas and resident rooms. MD #517 stated if the facility phones were not working, he was not aware of it, and his communication with the staff was via his cell phone. Interview on 03/29/23 at 3:42 P.M. of the Administrator revealed severe weather on 03/25/23 caused the facility to have a power outage. The Administrator stated MD #517 was in the facility timely and supplied flashlights, extension cords, and assisted with plugging oxygen concentrators into emergency outlets. The Administrator indicated the electric company was contacted and the facility was told power would not be restored until 03/27/23, but power was restored on 03/26/23 around 8:30 A.M. The Administrator stated he did not come to the facility to assist staff during the power outage because he was out of town. The Administrator stated the furnaces were working, just not at full power, and he was told by RN #556 the temperature in the facility was 69 degrees Fahrenheit. The Administrator stated residents liked their rooms very warm and a temperature of 69 was freezing for them. The Administrator stated residents were given blankets and hot tea. The Administrator confirmed temperatures were not monitored during the power outage in resident rooms and the common areas. The Administrator stated monitoring the temperatures was a good idea if there was enough staff and resources, and it was a matter of priority. Interviews on 03/29/23 between 2:50 P.M. and 3:05 P.M. of Resident's #20, #41 and #50 revealed it was very cold in the facility when the power was out. Interview on 03/30/23 at 3:46 P.M. with the Director of Nursing (DON) revealed she worked on 03/24/23 from 10:00 P.M. until 03/25/23 around 3:00 P.M. and was home sleeping when the power went out in the facility. When she learned about the power outage, she returned to work on 03/26/23 around 7:45 A.M. and assisted staff to provide care for the residents. Record review did not reveal evidence temperatures in the facility common areas and resident rooms were monitored during the power outage on 03/25/23 at 3:00 P.M. through 03/26/23 at 8:30 A.M. Review of the undated facility policy titled Exceeding Maximum and Minimum Temperature included the policy of the facility was to provide comfortable and safe temperature levels. The temperature of the facility should be maintained between 71- and 81-degrees Fahrenheit. Any temperature outside of this range required specific interventions to avoid potential negative impact on the resident's wellbeing. Should the air conditioning or heating system fail, specific monitoring and safety measures should be activated. Environmental temperatures were monitored by the assigned person every one to four hours throughout the facility. This deficiency represents non-compliance investigated under Complaint Number OH00141475 and OH00141550. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365642 If continuation sheet Page 9 of 9