Health inspection·December 18, 2019

F 0609 sustained by Resident #46 were not reported to the State agency as injuries of unknown origin. Level of Harm - Minimal harm or potential for actual harm Review of the abuse policy, reviewed 10/01/18, revealed injuries of unknown source were both when the injury was not observed by any person and the injury was suspicious because of the extent of the injury, the location of the injury and the number of injuries. All injuries of unknown source would be reported to the State agency as soon as possible but no later than two hours. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 2 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and interview the facility failed to implement a comprehensive and individualized restorative ambulation and transfer program for Resident #46 following the resident's discharge from therapy as recommended. This affected one resident (#46) of four residents reviewed for restorative nursing services. Residents Affected - Few Findings Include: Review of Resident #46's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA) with aphasia (inability to speak). The resident was admitted to the facility from an acute care hospital with a history of falls and inability to ambulate with recommendations for occupational therapy (OT) due to functional mobility, dressing and transfer decline. The resident was also noted to have deficits in strength, balance and coordination affecting his functional mobility and transfer ability requiring physical therapy (PT) at the time of admission. Record review revealed the resident was cognitively impaired. Review of the admission physician's orders, treatment administration orders and STNA task documentation, beginning 07/17/19 revealed there were no fall/safety interventions ordered or in place at the time of admission. Review of the STNA task documentation revealed on 07/17/19 the resident was to use a wheeled walker with two staff and a gait belt during ambulation. This directive remained in place for the duration of the resident's stay at the facility. Review of the admission fall risk assessment, dated 07/17/19 revealed Resident #46 had a history of falls in the past six months (prior to admission). The assessment revealed the resident was at moderate risk for falls. Review of an immediate plan of care, dated 07/17/19 revealed Resident #46 required assistance from one staff person for toileting, ambulation and transfers. The resident used both a walker and a wheelchair for mobility. The care plan indicated Resident #46 was at risk for falls with interventions that included reduce clutter, provide proper lighting and ensure the call light was within place. Resident #46 wore glasses. The immediate plan of care did not address the resident's cognition or ability to use the call light. Review of the initial OT evaluation, dated 07/18/19 revealed Resident #46 had a decline affecting his functional transfers requiring OT intervention. The resident was noted to have a decline in functional mobility, dressing and transfers due to physical, cognitive and/or psychosocial skills which resulted in activity limitations and/or participation restrictions. Minimal to moderate modifications of tasks, including modified visual cues, were needed to enable the resident to complete the evaluation. There were concerns related to engaging in daily life activities including balance and communication. Functional cognition revealed the resident needed some help from another person to complete activities. Transfers from chair and/or bed to chair, and sit to stand tasks needed contact guard assist due to unsteadiness. The resident needed cuing and/or redirection for safety on two occasions during the evaluation and the resident needed minimal assistance of one person for dressing. Review of the PT evaluation, dated 07/19/19 revealed Resident #46 had limitations and participation restrictions with strength, balance and coordination affecting functional mobility, transfer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 3 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ability and endurance. The resident had performance deficits in functional mobility, dressing and toilet transfers related to physical, cognitive or psychosocial skills including being a fall risk. Resident #46 required partial assistance of another person with ten percent visual cueing for safety for ambulation using a four wheeled walker which enabled him to ambulate 90 feet. Resident #46 also had a wheelchair for mobility. The resident needed minimal assistance of one person for toilet transfers and needed minimal to moderate assistance of one person for picking up objects. Resident #46's safety orientation was to person and place only. The therapy evaluation revealed Resident #46's safety was impaired by functional limitations as evidenced by need for assist with transfers, gait and bed mobility. Static standing balance was fair and he was able to maintain balance with occasional hand held support. The resident was at moderate fall risk (26-75%) due to balance issues and having kyphosis (forward rounding of the back). The resident had minimal impairment (up to 25%) for coordination of the right and left extremities. Review of the admission Minimum Data Set (MDS) 3.0, dated 07/24/19 revealed a Brief Interview for Mental Status (BIMS) was not completed due to the resident not being understood. The MDS assessment indicated Resident #46 required extensive assistance from one person for bed mobility, transfers and toileting, was not steady when ambulating and had impairment on one side of the lower extremities. The resident was mobile with both a walker and a wheelchair. Review of a PT Discharge summary, dated [DATE] revealed therapy goals were not met. Resident #46 continued to need assistance from one person for transfers and ambulation. The summary revealed the goals were not met due to the resident's limited cognition and hip fracture. The resident was referred to a restorative nursing program. Review of a therapy referral for restorative services, dated 10/02/19 revealed recommendations for restorative services for transfers on and off the toilet, in and out of bed and in and out of the chair with one person assistance. Review of the STNA task documentation revealed no evidence the restorative nursing program was implemented for the resident. On 12/11/19 at 10:00 A.M., interview with RN #94 and the Administrator verified a restorative transfer and ambulation program had not been initiated for Resident #46 following the resident's discharge from therapy, dated 10/02/19. On 12/11/19 at 11:00 A.M., interview with Physical Therapy Assistant (PTA) #94 revealed Resident #46's orientation varied. The resident had poor safety awareness including not remembering to use the call light for assistance or his walker when attempting to self-transfer. PTA #94 revealed Resident #46 required staff assistance with transfers because of his unsteadiness. PTA #94 revealed therapy staff had been told the resident could communicate by writing, but staff tried this method twice and it was unsuccessful. The resident was not able to write accurate information related to the questions asked. PTA #94 revealed Resident #46 was not safe to transfer, ambulate, toilet or dress himself. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 4 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure a wound specimen was obtained timely and antibiotic treatment was initiated timely for Resident #29. This affected one resident (#29) of two residents reviewed for non- pressure skin alterations. Residents Affected - Few Findings Include: Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including open wound of ankle, anemia, acute embolism and thrombosis of deep veins of right lower extremity, moderate protein-calorie malnutrition, and peripheral vascular disease. Review of Resident #29's wound center orders, dated 10/11/19 revealed new orders to obtain a wound aerobic and anaerobic positive gram stain (to be collected by the facility on 10/11/19). Review of Resident #29's progress notes dated 10/11/19 revealed at 4:00 P.M., the resident returned from the wound center with new orders to obtain a sample from the resident's right lateral ankle and send to the laboratory in the morning. At 4:07 P.M., the specimen was obtained from the right lateral ankle wound as ordered. At 11:25 P.M., the lab was advised the specimen needed to be picked up tomorrow morning. The lab advised the nurse that the specimen was not a STAT lab and the wound specimen needed to be picked up on regularly scheduled lab days Monday through Friday. Record review revealed the specimen was not sent to the lab until 10/14/19. Further review of Resident #29's progress notes revealed no evidence the physician or wound center were notified the wound specimen was not sent to the lab, until 10/14/19. On 10/14/19 at 10:35 A.M., the progress note indicated the specimen was not sent to the lab because it was not ordered as a STAT lab. The nurse made the physician aware. New orders to obtain specimen now and send with the lab when they arrive in the morning. Review of Resident #29's wound specimen results, dated 10/14/19 revealed the specimen was collected on 10/14/19 and the final report was completed on 10/16/19. The report indicated there was light growth gram positive cocci in clusters with no white blood cells. Further review revealed a hand written note from the physician, dated 10/18/19 that indicated if the resident was not allergic to penicillin start Amoxicillin 500 milligrams (mg) three times a day for seven days. Review of Resident #29's medication administration records (MAR) dated 10/2019 revealed the resident received one one dose of Amoxicillin 500 mg on 10/18/19, three doses from the 19th to the 24th, and two doses on 25th. Review of Resident #29's weekly skin assessments dated 10/08/19 and 10/15/19 revealed on 10/08/109 the right ankle vascular wound had moderate amount of thin serous non odorous drainage. The wound bed was pink. On 10/15/19 the wound had moderate amount of thin serous odorous drainage. The wound bed was pink with 25/5 slough adherent to the wound margins with no edema. Interview on 12/11/19 at 8:26 A.M., and 8:41 A.M., with Registered Nurse (RN) #94 reported the lab was at the facility earlier on 10/11/19 and had picked up Resident #29's blood work, however would not come back the following day to pick up the wound specimen because it was not ordered STAT. RN #94 reported staff had hand written a note on the resident's blood work results to let the physician (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 5 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0684 Level of Harm - Minimal harm or potential for actual harm know they were unable to do the wound specimen until next week due to lab issues, however never indicated the reason why it had to collected next week. There was no evidence the wound center was notified the specimen was not collected as ordered. RN #94 confirmed the wound specimen results were received on 10/16/19 at 12:13 P.M., however the physician did not address results until two days later delaying the resident's antibiotic treatment. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 6 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed Resident #38 was admitted to the facility on [DATE] with diagnoses which included brain cancer with caused seizures. Review of the current physician's order, initiated 11/25/19 revealed Resident #38 was to wear a splint at all times during the day to the left arm. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/05/19 revealed a Brief Interview for Mental Status (BIMS) score of 12. The assessment revealed the resident needed extensive assistance of of two or more staff for dressing. The resident had limitations to one side of her upper extremity. On 12/09/19 at 11:59 A.M., the resident was observed without a splint on his left arm. On 12/10/19 at 2:35 P.M. and 4:25 P.M. the resident was observed without a splint on his left arm. On 12/10/19 at 4:40 P.M., interview with the resident revealed he wore his left arm splint whenever staff put it on him but they had not put it on in the last few days. On 12/10/19 at 4:50 P.M., interview with STNA #12 verified she had not seen the resident today but when she worked with him last week he had on a splint to the left arm and did not refuse to wear. On 12/10/19 at 4:53 P.M., interview with Licensed Practical Nurse (LPN) #88 verified the resident was to have a splint on his left arm and was not aware the splint was not in place as ordered. On 12/10/19 at 4:57 P.M., interview with STNA #40 verified she was not aware the resident was to wear a splint on his left arm and had not put it on him 12/09/19 or today. Based on observation, record review and interview the facility failed to ensure restorative range of motion services and/or splints were implemented per the plan of care for Resident #3 and Resident #38 and failed to ensure restorative staff were knowledgeable of the types of range of motion exercises to be provided. This affected two residents (#3 and #38) of four residents reviewed for positioning and restorative/rehabilitation. Findings Include: 1. Record review revealed Resident #3 was admitted to the facility on [DATE] with diagnoses including muscle weakness, difficulty walking, and unsteadiness on feet. Review of Resident #3's physical therapy notes, dated 09/30/19 the revealed resident was discharged to skilled nursing facility with recommendations including restorative nursing. Review of Resident #3's occupational therapy notes dated 09/30/19 revealed the resident was discharged from therapy with recommendations for transfer and functional mobility including decrease balance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 7 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of Resident #3's therapy referral to restorative dated 10/02/19 revealed active range of motion to right upper and lower extremities, left upper and lower extremities two sets of 10 repetitions (reps) twice a day. Ambulate 50 feet with one assist with chair to follow and gait belt. Review of Resident #3's restorative program task revealed she would ambulate 50 feet twice a day, 6-7 days a week, for 15 minutes. Range of motion to upper extremities: shoulders flexion (arms over head) and back down times 10 repetitions (reps) times two, elbow, wrist, and finger flexion and extension times 10 reps times two 6-7 days a week for minimum of 15 minutes. Transfer: stand resident up from a sitting position for 10 reps, also throughout the day, during toileting, and all other surfaces to surface transfers. The recommended program was to be completed 6-7 days a week for a minimum of 15 minutes. Further review of Resident #3's restorative program documentation dated 11/10/19 to 12/09/19 revealed from 11/10/19 to 11/16/19 the resident received ROM one time a day for four days and refused one time. From 11/17/19 to 11/23/19 the resident only received ROM one time a day for five days and had no refusals. The weeks of 11/24/19 to 11/30/19 the resident received ROM one time a day for six days. The week of 12/01/19 to 12/07/19 the resident received ROM one time a day for three days, twice for two day, and one refusal. Review of Resident #3's mobility assessment dated [DATE] revealed the resident had full flexion, extension, and abduction of right and left shoulders. Record review revealed the resident had a plan of care related to a potential for decreased range of motion, due to decreased strength in upper extremities. Interventions included restorative program, range of motion for upper extremities: shoulders- flexion (arms over head) and back down 10 reps, 2 times. Elbow- Flexion and extension x 10 reps, 2 times. Wrist- flexion and extension, side to side x 10 reps, 2 times. Fingers-flexion and extension x 10 reps, 2 times. 6-7 days a week for a minimum of 15 minutes. Review of the undated therapy exercise program instruction revealed the instruction showed pictures and direction with each exercise. For active range of motion (AROM) shoulder abduction instruction the instruction included with your affected arm starting at your side with your thumb pointed upward, raise up your arm to the side. For AROM flexion while sitting or standing with your arm at your side, slowly raise it up and forward towards overhead. For AROM shoulder extension with your affected arm starting at your side, draw your arm back behind your waist. Keep your elbows straight. Interview and observation with Resident #3 on 12/09/19 at 9:50 A.M., revealed the resident reported she was not able to lift her left arm over her head because her left shoulder had been frozen for a couple years now. The resident demonstrated and she was only able to lift her left arm to shoulder level. The resident reported she had the same issue in the right should years ago, however it improved with therapy. She was able to extend the right arm above her head during the observation. The resident revealed she had not received any type of restorative nursing services including range of motion exercise or therapy to the left shoulder. She reported was in restorative for walking, but not range of motion. Interview with Restorative aide (RA) #34 on 12/10/19 at 10:00 A.M., revealed she had been doing restorative five days a week for about one and half years. RA #34 reported she was not sure what abduction ROM for shoulder would include. She reported for flexion she would lift the elbow to shoulder level and extension she would lift the resident and elbow straight out in front of them. She was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 8 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few aware of Resident #3 had any limited range of motion. RA #34 reported she was provided little training from the previous restorative aide and had received little training from therapy. She reported it was difficult to complete all the restorative programs at times because she also responsible for helping answering call lights. She indicated she tries to do the best she can with the time she had. Observation of Resident #3 on 12/10/19 at 10:05 A.M., with the Director of Nursing (DON) revealed the resident was not able to lift/extend her left arm/shoulder above her head. She was able to lift her arm to shoulder height. The resident reported to the DON that staff were not performing ROM exercise to the upper extremities, however they were walking her. Interview with Therapy manager/Physical therapy Assistant (TM) #95 on 12/10/19 at 11:43 A.M., verified therapy had recommended Resident #3's restorative therapy for supervision range of motion including flexion, extension, and abduction of all four extremities two sets of 10 reps twice a day. TM #95 reported she had not documented evidence the RA's were provided any type of training. Interview on 12/10/19 at 12:38 P.M, with Registered Nurse (RN) #94 confirmed Resident #3's restorative program was not performed per her plan of care or therapy recommendation and the mobility assessment completed on 10/31/19 indicating the resident had no limited range of motion was inaccurate if the resident reported she had decrease ROM in the left shoulder for years. The RN reported the issue was with the electronic medical reported because it automatic populates the task and was not individual towards the residents. The RN reported she was going to have therapy provide education to RA #34 on the types of ROM of motions since she was unable to demonstrate flexion and extensions correctly and did not know what abduction range of motion was. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 9 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 - Immediate jeopardy to resident health or safety 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 review of a closed medical record, hospital records, death certificate, facility investigation and staff interview the facility failed to develop and implement comprehensive and individualized fall/safety interventions and provide adequate supervision for one resident (Resident #46), who was assessed as cognitively impaired, at risk for falls and required extensive staff assistance for transfers and ambulation. Resident #46 sustained 18 falls while residing in the facility between [DATE] and [DATE]. This resulted in Actual Harm that was Immediate Jeopardy on [DATE] when Resident #46 sustained an unwitnessed fall in his room sustaining an intracranial bleed, multiple facial fractures, lacerations to his right forehead/scalp which required six sutures to control vascular bleeding, two cervical spine fractures and a right frontal skull fracture with a scalp hematoma. Resident #46 expired (in the hospital) on [DATE] as a result of the injuries sustained during the fall. The cause of death on the death certificate indicated blunt force injury due to a fall. This affected one resident (#46) of five residents reviewed for falls. The facility census was 51. On [DATE] at 2:59 P.M. the Administrator (LNHA) and Corporate Registered Nurse (RN) #94 were notified Immediate Jeopardy began on [DATE] when Resident #46, who was at high risk for falls, cognitively impaired and required extensive assistance from staff for transfers and ambulation sustained an unwitnessed fall in his room which resulted in multiple serious injuries including a skull fracture and cervical spine fractures. The resident was subsequently transported to the emergency room and admitted to the hospital where he later expired as a result of complications from the fall. The death certificate, dated [DATE] revealed Resident #46's cause of death was from blunt force injury due to the fall. The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective action: • On [DATE] at 7:22 P.M., Resident #46 was sent to the hospital and subsequently expired. • On [DATE] the facility initiated an investigation regarding Resident #46's injuries/fall on [DATE]. • On [DATE] the DON/designee completed fall risk assessments for all 52 residents residing in the facility as of [DATE]. Ten residents (Resident #9, #12, #18, #19, #21, #28, #37, #42, #43, and #297) were identified to be at risk for falls. On [DATE] at 10:30 P.M. RN #19, RN #94, RN #23, RN #96, Social Service Director (SSD) #6, Licensed Practical Nurse (LPN) # 38 and Physical Therapy Assistant (PTA) #95 observed fall risk safety interventions in place as planned for the ten current residents identified to be at risk for falls. A plan for the DON/designee to audit fall safety (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 10 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 interventions being in place three Level of Harm - Immediate jeopardy to resident health or safety times per week for an indefinite period of time was implemented. Residents Affected - Few On [DATE] at 6:30 P.M. nine residents (#9, #12, #19, #21, #28, #37, #42, #43, #297) identified by the facility to have • experienced falls from [DATE] through [DATE] were reviewed by the DON/designee to ensure a thorough investigation was completed to determine the root cause of the fall and to determine if interventions were implemented appropriately. The plan of care for all each resident was reviewed and revised on [DATE] by Corporate RN #94. • Beginning on [DATE] a plan for all residents to have a fall risk assessment completed on admission, quarterly, and as needed by the DON/ designee to ensure interventions were implemented that would decrease the number of falls and the risk for injury. The DON would ensure care plans were revised based on the risk assessment. In addition, a plan for a fall risk re-assessment to be completed after each fall was implemented. • On [DATE] a new fall intervention listing sheet for each resident was initiated by Corporate RN #94. The list is to be reviewed at the nurses' station by nursing staff during shift changes. The purpose of this fall intervention listing was to provide easily accessible, visual information to the direct care staff. A plan was implemented for the Assistant Director of Nursing (ADON) to review the listing three times per week. • Beginning [DATE] fall investigations were to be initiated immediately, at the time of a fall, by the licensed nurse on duty. A new fall investigation form was developed to be utilized to include what was the location of the resident prior to the fall, where was the resident last seen and by whom, what was the resident doing when last seen, does the resident wear glasses and if so, were the glasses on at the time of the fall, were all previous interventions in place and if so, what were those interventions, was the call light within reach, was the call light on at the time of the fall and was it working. • Beginning on [DATE] a plan for the interdisciplinary (IDT) team consisting of Corporate RN #94, the DON, ADON, Programs Nurse, Therapy Director, and the SSD to review all fall investigations to ensure a thorough investigation and a root cause analysis was done in order to ensure individualized (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 11 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 interventions and revision/review of fall care plans. Level of Harm - Immediate jeopardy to resident health or safety • Residents Affected - Few On [DATE] Corporate RN #94 provided education to all nurse managers which included the DON, ADON, MDS Nurse and Programs Nurse on the fall program, thorough investigation with root cause analysis and individualized interventions for residents at risk for falls or with actual falls. • On [DATE] beginning at 3:56 P.M. the DON/designee provided education to 27 STNAs either in person or via telephone related to fall interventions and the fall intervention listing sheet. As of [DATE] the facility identified only one STNA who had not received the education. A plan for this employee to receive the training prior to the next scheduled work shift was implemented. • On [DATE] the DON/designee provided education to 17 licensed nurses either in person or via telephone related to the all program, implementation of immediate interventions, fall intervention listing sheet and the investigation of falls. As of [DATE] the facility identified three licensed nurses who could not be reached and implemented a plan to ensure all three received the education prior to their next scheduled work shift. • On [DATE], audits were started by the DON/designee, to be conducted for four weeks, then monthly for two months, and then ongoing by the DON/designee to ensure falls have thorough investigations, individualized interventions based on the root cause analysis. • On [DATE], a Quality Assurance and Performance Improvement (QAPI) review included discussion of Resident #46's fall and the lack of a thorough fall investigation, lack of root cause analysis, and if fall/safety interventions were appropriate. A plan to review fall investigations to ensure they include a thorough investigation and a root cause analysis to implement interventions that are individualized was developed. • Observation on [DATE] between 1:45 P.M. and 4:25 P.M. revealed fall risk interventions were in place for Resident #21, #28, #42 and #43. No concerns were identified. • Interviews on [DATE] between 1:55 P.M. and 4:22 P.M. with RN #15, LPN #88 and State Tested Nursing Assistants STNAs) #11, #60, and #73 revealed the staff interviewed were knowledgeable of the facility fall policy, fall expectations and the fall intervention listing binder. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 12 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 - Immediate jeopardy to resident health or safety Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action including all staff education, audits and interdisciplinary team follow up. Findings Include: Residents Affected - Few Review of Resident #46's closed medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (CVA) with aphasia (inability to speak). The resident was admitted to the facility from an acute care hospital with a history of falls and inability to ambulate with recommendations for occupational therapy (OT) due to functional mobility, dressing and transfer decline. The resident was also noted to have deficits in strength, balance and coordination affecting his functional mobility and transfer ability requiring physical therapy (PT) at the time of admission. Record review revealed the resident was cognitively impaired. Review of the admission physician's orders, treatment administration orders and STNA task documentation, beginning [DATE] revealed there were no fall/safety interventions ordered or in place at the time of admission. Review of the STNA task documentation revealed on [DATE] the resident was to use a wheeled walker with two staff and a gait belt during ambulation. This directive remained in place for the duration of the resident's stay at the facility. Review of the admission fall risk assessment, dated [DATE] revealed Resident #46 had a history of falls in the past six months (prior to admission). The assessment revealed the resident was at moderate risk for falls. Review of an immediate plan of care, dated [DATE] revealed Resident #46 required assistance from one staff person for toileting, ambulation and transfers. The resident used both a walker and a wheelchair for mobility. The care plan indicated Resident #46 was at risk for falls with interventions that included reduce clutter, provide proper lighting and ensure the call light was within place. Resident #46 wore glasses. The immediate plan of care did not address the resident's cognition or ability to use the call light. Review of the initial OT evaluation, dated [DATE] revealed Resident #46 had a decline affecting his functional transfers requiring OT intervention. The resident was noted to have a decline in functional mobility, dressing and transfers due to physical, cognitive and/or psychosocial skills which resulted in activity limitations and/or participation restrictions. Minimal to moderate modifications of tasks, including modified visual cues, were needed to enable the resident to complete the evaluation. There were concerns related to engaging in daily life activities including balance and communication. Functional cognition revealed the resident needed some help from another person to complete activities. Transfers from chair and/or bed to chair, and sit to stand tasks needed contact guard assist due to unsteadiness. The resident needed cuing and/or redirection for safety on two occasions during the evaluation and the resident needed minimal assistance of one person for dressing. Review of the PT evaluation, dated [DATE] revealed Resident #46 had limitations and participation restrictions with strength, balance and coordination affecting functional mobility, transfer ability and endurance. The resident had performance deficits in functional mobility, dressing and toilet transfers related to physical, cognitive or psychosocial skills including being a fall risk. Resident #46 required partial assistance of another person with ten percent visual cueing for safety for ambulation using a four wheeled walker which enabled him to ambulate 90 feet. Resident #46 also had a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 13 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 - Immediate jeopardy to resident health or safety Residents Affected - Few wheelchair for mobility. The resident needed minimal assistance of one person for toilet transfers and needed minimal to moderate assistance of one person for picking up objects. Resident #46's safety orientation was to person and place only. The therapy evaluation revealed Resident #46's safety was impaired by functional limitations as evidenced by need for assist with transfers, gait and bed mobility. Static standing balance was fair and he was able to maintain balance with occasional hand held support. The resident was at moderate fall risk (26-75%) due to balance issues and having kyphosis (forward rounding of the back). The resident had minimal impairment (up to 25%) for coordination of the right and left extremities. Review of the admission Minimum Data Set (MDS) 3.0, dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not completed due to the resident not being understood. The MDS assessment indicated Resident #46 required extensive assistance from one person for bed mobility, transfers and toileting, was not steady when ambulating and had impairment on one side of the lower extremities. The resident was mobile with both a walker and a wheelchair. Review of the speech therapy initial evaluation, dated [DATE] for communication revealed the resident was having extreme difficulty communicating and following directions. The resident was confused, had profound impairment (with less than 10 percent comprehension) in auditory comprehension when answering yes/no questions. The resident had severe impairment requiring extensive cueing for following one step commands. Upon discharge from speech therapy ([DATE]) the staff were educated on compensatory communication strategies including use of a notebook, picture sheets, eye contact, limiting choices and repetition. Review of the signed [DATE] monthly physician orders revealed there were no fall interventions ordered. Further review of the treatment administration record (TAR) and the STNA tasks (each resident had their individual needs on tasks in the computer the STNAs were to sign as the task was completed) revealed there were no fall interventions documented as being completed for the resident. Record review revealed the resident sustained 18 falls, from [DATE] through [DATE] while residing in the facility: Review of the nurse's note, dated [DATE] revealed the STNA reported an area of discoloration to the resident ' s tailbone. Further review of the note revealed the resident informed the nurse he had a prior fall but was not able to give any details. The nurse observed bruising to the resident's tail bone, left hip, right shoulder blade and right lateral thigh. A raised toilet seat was initiated after the fall. Review of the nurse's note, dated [DATE] revealed the STNA found the resident sitting on the floor with two skin tears to the left hand and two to the left knee. Review of the fall investigation revealed the resident fell at 4:40 P.M. when getting up from the dining room table. The investigation was contradictory, one statement indicated the resident fell when he did not lock the wheels of the wheelchair and another statement indicated the resident did not lock the wheels of the walker. Record review revealed the resident's plan of care was updated on [DATE] for staff to anticipate the resident ' s needs, apply non-skid gripper socks when shoes were off and have therapy evaluate (which was already being done). The care plan interventions from the immediate care plan indicated the room be clutter free and provide adequate lighting as interventions. There were no interventions to ensure the wheels were locked of either the walker or the wheelchair. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 14 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 - Immediate jeopardy to resident health or safety Residents Affected - Few Review of the nurse's note, dated [DATE] revealed Resident #46 was guarded with his right lower quadrant and showed staff a bruise to his right lower quadrant. The resident pointed to the foot board of the bed and indicated he fell into it. Further review of the fall investigation revealed on [DATE] at 11:45 A.M., the resident fell into the foot board and sustained bruising (there was no further description of the bruising). The resident indicated he was walking in the room but was not able to say why or what he was trying to do. The intervention was a noodle covering the foot board to pad and protect from further harm. The care plan was updated [DATE] to reflect the use of the covering. Review of the nurse's note, dated [DATE] revealed Resident #46 had skin tears to the left lower hand, to the left upper hand/forearm, to the left upper knee and to the lower knee all with drainage needing treatments related to a fall. There was no additional information available related to these injuries and no investigation was completed. Review of the nurse's note, dated [DATE] at 10:44 P.M., revealed the STNA called the nurse to Resident #46 ' s room. The nurse observed the resident laying on his right side on the floor beside his bed and above his head was a trash can. The STNA stated she witnessed the resident fall and the resident did hit his head on the trash can. The nurse asked the resident if he had any injuries and he pointed to his right hip. The resident was observed with a large bruise on the front of his groin and his hip. The resident was sent to the hospital for evaluation. Review of the hospital x-ray dated [DATE] revealed the resident sustained a right hip (superior/inferior pubic ramus) fracture and a head contusion. The resident returned to the facility on [DATE]. Record review revealed no new fall or safety interventions were put in place and no investigation of the fall was completed. Review of the nurse's note, dated [DATE] at 5:47 P.M., revealed the STNA called the nurse to the room. The note revealed Resident #46 attempted to take himself to the restroom and fell to his knees, caught himself with the grab bar and lowered himself to his knees. Further review of the fall investigation indicated the fall occurred at 5:00 P.M. but did not include evidence the facility attempted to determine the root cause or if any prior interventions were in place at the time of the fall. No new interventions were implemented following the incident. Review of the [DATE] nurse's note revealed the resident was observed on his hands and knees in front of his recliner chair. The recliner chair was in the highest position and the resident had a skin tear to the left elbow. Further review of the fall investigation revealed the fall occurred at 1:15 P.M. and the resident was not able to provide any information related to the fall. There was no evidence any prior fall interventions were in place at the time of the fall. Following the incident, a Dycem (non-skid mat) was to placed to the seat of the recliner chair. Review of the nurse's note, dated [DATE] revealed the resident was found lying on the floor on his left side with no visible injuries. Further review of the fall investigation revealed the fall occurred at 5:30 A.M. Resident #46 was not able to provide any information related to the fall due to his confusion. An intervention for the resident's bed to be in the lowest position was added to the care plan on [DATE]. Review of the nurse's note, dated [DATE] reveled the nurse was called to the room by the STNA who reported the resident was on the floor. Resident #46 was observed to be in the doorway of the room on his knees with his arms resting on the wheelchair seat. The STNA reported he had been in his recliner the last time he was seen (by staff). The resident did have a skin tear to his right lateral knee requiring treatment. Further review of the fall investigation revealed the fall occurred at 7:45 P.M. There was no evidence the Dycem was in place as planned at the time of the fall. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 15 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 - Immediate jeopardy to resident health or safety investigation revealed a sign was placed in the room reminding the resident not to get up by himself despite his confusion. However, this was not added to the care plan until [DATE]. Review of the signed [DATE] monthly physician's orders revealed there were no fall interventions ordered by the physician. Further review of the TAR and the STNA tasks revealed none of the care planned fall interventions were documented as being in place or monitored. Residents Affected - Few Review of the nurse's note, dated [DATE] at 4:00 A.M. revealed the nurse was called to the room by the STNA who reported the resident had a skin tear to his right elbow and there was blood on the wheelchair. The resident was not able to say what happened or how he obtained the skin tear. The STNA stated the last time she observed the resident he was in bed. There was no investigation of the injuries completed in an attempt to determine the root cause and no interventions were put into place for what appeared to have been a fall for the resident. Review of the nurse's note dated [DATE] at 1:33 P.M., revealed the nurse was called to Resident #46's room by an STNA. The resident was observed sleeping on the floor next to the bed with a pillow and blanket with his eyes closed. Further review of a fall investigation revealed at 7:45 A.M. the resident was found sleeping on the floor. The resident was alert and oriented times two. Following the incident, a new intervention was initiated to keep the resident in high traffic areas. A defined perimeter mattress (DPM) was implemented. However, the use of the DPM was not noted on the care plan until [DATE]. Review of the physician's progress note, dated [DATE] revealed the resident had a history of a stroke, was not able to speak and had recurrent falls. There was no other information related to the resident's falls and/or safety needs or fall risk interventions. Review of the nurse's note, dated [DATE] revealed a note see the fall assessment. However, there was no fall assessment completed on this date. There was no further nurse's note in the medical record related to a fall occurring on this date. However, review of a fall investigation revealed on [DATE] at 10:39 A.M., Resident #46 sustained a fall when attempting to transfer himself to the recliner from the wheelchair. The initial intervention was to remind the resident to use the call light (which had been implemented on admission on the immediate care plan). Staff also placed bright tape to the foot rest of the recliner on [DATE]. Review of a fall investigation revealed Resident #46 sustained a fall on [DATE] at 9:00 P.M. The nurse entered the resident's room with his medications and the resident was sitting in his wheelchair with skin tears and blood running down both legs. The resident also had skin tears to the right upper back. The resident was not able to answer any questions. The resident was reminded to use his call light when needing help and this message was written on the resident's dry erase board. The investigation also revealed to keep the resident in high traffic areas. Review of the nurse's note, dated [DATE] at 5:01 A.M., revealed Resident #46 tipped his wheelchair over backwards in the hallway and struck the back of his head on the wall and wooden banister. There was a large abrasion noted to the back of his head and the resident complained of head and neck pain and wanted to be sent to the hospital for evaluation. The resident returned to the facility with no new orders. Anti-tippers to the rear of the wheelchair were added after the fall. The use of the anti-tippers were not added to the resident ' s plan of care until [DATE]. Review of the nurse's note, dated [DATE] at 1:10 P.M., revealed the nurse was called to Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 16 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 - Immediate jeopardy to resident health or safety Residents Affected - Few #46's room and upon arrival, the resident was sitting on the floor. The STNA witnessed the resident backing out of his room quickly into the hallway while in his wheelchair, running into another resident. This resulted in Resident #46's wheelchair flipping and the resident falling out of the wheelchair. Further review of the investigation revealed the resident ' s wheelchair flipped backwards. There was no evidence the rear anti-tippers were in place at the time of the fall. The investigation did not attempt to determine why the resident was in his wheelchair alone in his room and not in high traffic areas or how the resident got into his wheelchair. The investigation did not specify if previous planned interventions were in place prior to the fall. Following the incident, the resident was educated to wheel frontwards while in the wheelchair. Review of a PT Discharge summary, dated [DATE] revealed therapy goals were not met. Resident #46 continued to need assistance from one person for transfers and ambulation. The summary revealed the goals were not met due to the resident's limited cognition and hip fracture. The resident was referred to a restorative nursing program. Review of the signed [DATE] monthly physician's orders revealed there were no fall interventions ordered by the physician. Further review of the TAR and the STNA task documentation revealed no evidence the care planned fall interventions were being monitored to ensure they were in place. The resident's OT services were extended for neuromuscular re-education and gait training. Review of a therapy referral for restorative services, dated [DATE] revealed recommendations for restorative services for transfers on and off the toilet, in and out of bed and in and out of the chair with one person assistance. Review of the STNA task documentation revealed no evidence the restorative nursing program was implemented for the resident. Record review revealed on [DATE] a change in physician services occurred due to family request. Review of the signed clinical nurse practitioner progress note, for the new physician, dated [DATE] revealed the resident was up in the wheelchair, was alert and oriented times two with slurred speech from a prior stroke. The plan was to monitor the resident for neurological deficits. There was no mention of the resident having any falls including the fall with a fracture or safety needs. Review of a nurse's note, dated [DATE] revealed the STNA called the nurse to Resident #46's room. The resident was observed face down on the floor with his head and body under the bed and his body positioned at an angle. The resident was not able to respond to any questions due to aphasia. There were two raised areas noted to the mid spine area and both were surrounded by purplish blue bruising. The resident also had bruising to the left rib areas, a skin tear to the top of the left outer knee, abrasion to the top of left great toe and a skin tear to the left elbow with active bleeding. The resident was groaning. Emergency Medical Services (EMS) was called and the resident was sent to the emergency department of the local hospital. The resident returned to the facility with a diagnosis of pneumonia and orders for antibiotics. Further review of the fall investigation revealed the resident fell at 10:30 A.M. At the time of the fall he was barefoot and was not wearing his glasses. There was no additional information documented regarding the fall including a root cause analysis. Following the fall, staff were to complete a side rail assessment, an initial bowel and bladder tracker and provide aromatherapy at night. Review of the OT Discharge summary, dated [DATE] revealed the resident needed one person assistance with transfers to and from the wheelchair and recliner. The summary revealed Resident #46 did not meet his transfer goal of being independent due to balance and lack of safety awareness concerns. Staff were educated on balance precautions. The resident was occasionally able to respond to needs and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 17 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 - Immediate jeopardy to resident health or safety Residents Affected - Few occasionally able to follow direction and/or respond appropriately through gestures. The summary revealed OT discussed with staff the need for supervision during transfers. Record review revealed on [DATE] an order was obtained for a wanderguard (an alert bracelet that alarms if a person tries to leave an area unsupervised) due to the resident's impaired cognition. Review of the nurse's note, dated [DATE] revealed the nurse was called to Resident #46's room by the housekeeper. The resident was observed on his knees on the floor. The housekeeper revealed the resident was trying to transfer himself to the chair and did not make it. Review of the fall investigation revealed the fall occurred at 10:00 A.M. There was no evidence any fall safety interventions were in place at the time of the fall. The investigation did not contain a root cause analysis and did not address why the resident was not in a high traffic area as previously planned. No new fall interventions were implemented following this fall. Review of the [DATE] physician progress note revealed no information related to the resident's increased falls, fall risk and/or safety needs or fall risk interventions. Review of the nurse's note, dated [DATE] at 6:45 P.M. and authored by RN #16 revealed the nurse was called to Resident #46's room. The note indicated upon arrival to the room, the resident was observed standing naked, walking away from the doorway with copious amounts of blood noted to the floor surrounding the resident. The resident had facial injuries with excessive amounts of blood on his head, face and chest. Pressure was applied to a large laceration above the resident's right eye and the resident was assisted to a seated position on his bed. The nurse was not able to assess the resident's facial wounds because of the need to keep continuous pressure to control active bleeding from his laceration and his nose. EMS was called and the resident was transported to the hospital. The resident left the facility at 7:15 P.M. and did not return. Review of a fall investigation, dated [DATE] revealed Resident #46 was found standing in his doorway holding onto his wheelchair bloody from head to toe at 6:45 P.M. when an STNA was walking down the hall assisting another resident. The STNA paged the nurse to the resident's room. Upon entering the resident's room, the nurse observed large puddles of blood on the carpet on the right side of bed (the side closest to the window). Blood spats were found throughout the entire traffic areas of the carpet. Blood was found on the toilet and the sink and blood spots were observed throughout the bathroom floor. The investigation revealed it appeared Resident #46 either fell head first when getting out of bed or fell head first on the right side of the bed while ambulating, then got himself up and ambulated to the bathroom and then towards the doorway. (The investigation did not fully determine how the resident fell as the fall was unwitnessed). The water was running in the bathroom sink but there was no water on the floor. The investigation revealed the resident had last been seen at the nurse's station at 6:30 P.M. when the nurse changed the resident's dressing. The nurse then walked by the resident as he propelled himself back to his room and was seen messing with items on his bed. The resident was not kept in a high traffic area and there was no evidence of any other fall/safety interventions being in place at the time of the fall. The resident was in his bare feet. Review of the EMS run sheet, dated [DATE] at 7:06 P.M., revealed when EMS personnel arrived to the facility, they found Resident #46 sitting on the bed surrounded by staff. Two staff members were holding pressure to the resident's face. There was a substantial amount of blood found on the floor, bed and in the bathroom. The resident had a one inch laceration above the right eye with a large goose egg and an abrasion on the top of his head. The resident was bleeding from both nostrils with blood clots, he was bleeding from the lip and mouth and had abrasions on the left shoulder and both (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 18 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 knees. The bleeding from all locations was uncontrolled. The resident's right eye was purple and swollen shut. The resident's airway needed suctioned on the way to the hospital Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 19 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0791 Provide or obtain dental services for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure Resident #9 received timely dental services. This affected one resident (#9) of one resident reviewed for dental care. Residents Affected - Few Findings Include: Medical record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, muscle weakness and a history of falling. Review of Resident #9's dental health notes revealed Resident #9 was seen by the dentist on 05/24/19 and a new lower partial was recommended so the resident could chew better. Review of Resident #9's oral status, dated 10/02/19 failed to identify the resident had a broken or loosely fitting partial denture. Review of Resident #9's oral cavity assessment, dated 10/07/19 revealed the resident had some teeth loss, but failed to identify she had a lower partial or the condition of the lower partial. Review of Resident #9's care plan, dated 12/10/19 revealed the resident was at risk for oral complications. The resident had her own teeth on top with several caries and a lower partial dental plate. The resident also had an intervention to observe her partial dental plate for proper fit. Observation on 12/09/19 at 10:26 A.M. revealed Resident #9 had several teeth missing from the front bottom part of her gums. Interview on 12/09/19 at 10:26 A.M. Resident #9 revealed she had a partial dental plate, but it was only for two missing teeth and had three. She further revealed her partial dental plate did not fit right, and she had not been able to wear it in at least six months. Interview on 12/11/19 at 11:30 A.M. with an employee at Resident #9's dentist office revealed on 05/24/19 the resident was seen and a partial dental plate was recommended. On 05/30/19 treatment authorization was sent to the resident's daughter. On 09/05/19 the dentist office received the authorization back. On 09/18/19 the dentist office received a plan of care from the facility. On 09/25/19 x-Rays with the plan of care and authorization were sent to Medicaid. A denial was receive within two weeks of the previous paperwork being sent due to the x-rays not being clear. On 11/01/19 the dentist re-did the x-rays. On 11/13/19 the dental office resubmitted to Medicaid. On 12/10/19 the dentist office checked on the progress and saw it was denied once again due to not submitting the information in a timely manner. On 12/10/19 the dentist office resubmitted everything to Medicaid. Interview on 12/11/19 at 11:40 AM with Registered Nurse #94 verified Resident #9 still had not reviewed her partial dental plate that was recommenced on 05/24/19 to help the resident chew better due to delays with the submission process. Interview on 12/12/19 at 10:06 A.M. with State Tested Nursing Assistant #76 revealed that Resident #9 rarely wore her partial dental plate, and that it was loose fitting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 20 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, record review and interview the facility failed to maintain adequate infection control practices during a pressure ulcer dressing change for Resident #27 to prevent the spread of infection. This affected one resident (#27) of one resident observed for wound care. Residents Affected - Few Findings Include: Record review revealed Resident #27 was admitted to the facility 05/18/19 with diagnoses including Stage III pressure ulcer to right shoulder and amyotrophic lateral sclerosis. Observation on 12/10/19 from 8:46 A.M. to 9:02 A.M., revealed Registered Nurse (RN) #19 placed supplies (clear trash bag, two alcohol wipes, gauze package, alginate (AG) package, and a foam dressing package) on an uncleaned bedside table. She wiped half of the bedside table with a wet paper towel and placed the clear trash bag over the half of the bedside table. She removed scissors from her pocket and cleansed them with one of the alcohol wipes and then placed them down on the clear plastic bag. The nurse removed the old dressing and performed hand hygiene with soap and water and applied new non-sterile gloves. She cleansed the wound with normal saline and gauze. She removed her gloves; however, she did not perform hand hygiene. She then opened the AG and cut a corner piece out of the AG with the scissors that were lying on the plastic bag. She placed her scissors back into her pocket without first cleaning them. She washed her hands with soap and water and applied new non-sterile gloves. She opened the foam dressing package and then reached into her smock pocket with the same gloved hands and removed a contaminated marker to date the foam dressing. She placed the marker back into her pocket which also contained tape and extra trash bags. With the same gloved hands, she picked up the AG touching both sides of the AG and placed the AG onto the wound bed. She applied the foam dressing over the wound. Interview on 12/10/19 at 9:02 A.M., with RN #19 confirmed the above findings. Review of clean dressing policy, dated 06/10/19 revealed to create a clean field, remove dressing and assess wound. Remove disposable gloves and discard. Immediately wash your hands and apply new gloves. Cleanse wound and apply prescribed medication and clean dressing. Remove gloves and wash and dry hands. Thoroughly clean all equipment used and return to appropriate storage area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 21 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on record review and interview the facility failed to implement a comprehensive and effective antibiotic stewardship program to ensure the appropriate use of antibiotics. This affected 19 residents (#18, #14, #17, #28, #149, #29, #46, #150, #3, #40, #45, #299, #35, #39, #20, #196, #12, #5 and #151) and had the potential to affect all 51 residents residing in the facility: Residents Affected - Many Findings Include: Review of the antibiotic stewardship program/infection control log dated 10/2019 to 12/2019 with Licensed Practical Nurse (LPN) #20 revealed: a. In October 2019 there were ten infections. Resident #18 was started on Cipro for a urinary tract infection (UTI) before the culture had returned. The culture indicated the resident was resistance against Cipro and she was switched to Amoxicillin. Resident #14 was treated with Keflex for and unidentified source and did not meet criteria. Resident #17 received Keflex for a UTI without evidence of urine culture. There was no form completed to ensure the resident met criteria. Resident #28 was treated with Daptomycin antibiotic and the culture indicated the wound sample was contaminated. There was no evidence another wound culture was collected or a form was completed to ensure the resident met criteria. Resident #149 was treated with antibiotics for an unidentified infection. There was no evidence a form was completed to ensure the resident met criteria for treatment. Resident #29 was treated with Almecillin for a wound infection. There was no evidence a form was completed to ensure the resident met criteria for treatment. Resident #46 was treated with Zithromax for a lower respiratory tract infection. There was no evidence a form was completed to ensure the resident met criteria for treatment. Resident #150 was treated with Aztreonam intravenously for a UTI. There was no evidence a form was completed to ensure the resident met criteria for treatment. b. In November 2019 there was 16 infection noted on the log. Resident #29 was treated with Tetracycline for Methicillin Resistant in a wound. There was no culture completed or a form completed to ensure the resident met criteria for treatment. Resident #3 was treated with Macrobid for a UTI. The culture indicated the urine was contaminated the form was completed and indicated the resident did not met criteria for treatment. Resident #40 Cefepime intravenously for a lower respiratory infection. There was no form completed to ensure the resident met criteria for treatment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 22 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0881 Level of Harm - Minimal harm or potential for actual harm Resident #45 was treated with Ceftin intravenously for an unidentified organism. There was no form completed to ensure the resident met criteria for treatment or the organism identified. Resident #299 was treated with Keflex prophylactic. The organism and source were unidentified and there was no form completed to ensure the resident met criteria for treatment. Residents Affected - Many Resident #28 was treated with Daptomycin intravenously and by mouth for a wound infection. There was no evidence a form was completed to ensure the resident met criteria for treatment. Resident #35 was treated with Doxycycline, Ampicillin, and Cipro for wound/skin infection. The wound culture did not include Doxycycline was resistant to the organism. Resident #39 was treated with Bactrim for a UTI. There was no evidence of a urine culture or a form completed to ensure the resident met criteria for treatment. Resident #20 was treated with Zipfian for a UTI. There was no evidence of a urine culture or a form completed to ensure the resident met criteria for treatment. Resident #12 was treated with Cipro for wound infection. There was no evidence of a wound culture or a form completed to ensure the resident met criteria for treatment. Resident #45 was treated with Augmentin for an unidentified organism or source. There was no evidence of a culture or a form completed to ensure the resident met criteria for treatment. Resident #196 was treated with Aztreomen intravenously and Vancomycin by mouth for lower respiratory infection. There was no evidence of x-ray/culture or a form completed to ensure the resident met criteria for treatment. Resident #5 was treated with Augmentin for an upper respiratory infection. There was no evidence of x-ray /culture or a form completed to ensure the resident met criteria for treatment. c. In December 2019 there were two infections noted on the log. Resident #151 returned from the hospital on Augmentin for a lower respiratory infection. There was no criteria form completed to indicate if the resident met criteria. The hospital chest x-ray completed on 12/03/19 indicated the resident had increased density at the right lung base that could represent acute infiltrate. There was no pleural effusion or pneumothorax. During an interview on 12/12/19 from 10:56 A.M. to 11:23 A.M., LPN #20 verified the above findings. She confirmed antibiotics were administered prior to culture results and there was no evidence residents meet the criteria for antibiotics, however received them anyways. She reported if she did not complete a criteria form that indicated the resident did not met criteria for treatment. Review of the antibiotic stewardship program policy, dated 11/14/19 revealed all residents with newly diagnosed infections utilizing antibiotics would be reviewed for appropriate utilization. Residents without proof of review of infection symptoms prior to the initiation of an antibiotic would be reviewed for antibiotic holiday, culture and sensitivity results would include recommendation for treatment and be discussed with the provider to ensure antibiotics were utilized in a responsible effective manner. Prescribers would be required to document dose, duration, and indications for all (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 23 of 24 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 365699 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/18/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Ctr IV 55801 Conno-Mara Drive Bellaire, OH 43906 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 0881 antibiotic use. Facility would track and monitor antibiotic prescribing and utilization. Level of Harm - Minimal harm or potential for actual harm Review of infection control protocol and tracking policy, dated 10/19/19 revealed when a resident was admitted to the facility with an infection or when a resident acquired an infection, the infection report would be completed by the infection control nurse/designee. Antibiotic orders would be obtained from the physician and implemented upon proper microorganism identification, if necessary. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 24 of 24