Inspection·November 9, 2022

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review and interview the facility failed to ensure Resident #4 and Resident #96, who required staff assistance with activities of daily living received timely and adequate assistance with personal care, including facial hair removal. This affected two residents (#4 and #96) of four residents reviewed for activities of daily living. Residents Affected - Few Findings include: 1. Review of Resident #4's medical record revealed diagnoses including congestive heart failure, psychosis, type 2 diabetes mellitus, chronic atrial fibrillation, atherosclerotic heart disease, depression, schizophrenia, chronic obstructive pulmonary disease, pain, auditory and visual hallucinations, heart failure, macular degeneration, osteoarthritis, and generalized muscle weakness. A care plan initiated 05/30/22 indicated Resident #4 needed assistance from staff to meet activities of daily living needs. Interventions included assisting with meals, ambulation, hair care, incontinence care, oral care, toileting, transfers, bed mobility, dressing, and bathing as needed. The care plan did not specifically address monitoring for or removal of facial hair. The care plan did not reveal rejection of care. A quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/07/22 revealed Resident #4 required extensive assistance from staff for hygiene and grooming. Resident #4 was assessed to be severely cognitively impaired. On 11/07/22 at 9:28 A.M. Resident #4 was observed to have facial hair on her chin. Resident #4 indicated she had poor vision. Subsequent observations on 11/07/22 at 3:20 P.M., 11/08/22 at 10:55 A.M., 12:55 P.M., 3:50 P.M. and 4:10 P.M. revealed Resident #4 continued to have hair protruding from her chin with three hairs noted to be a minimum of an inch long. On 11/08/22 at 4:21 P.M. the facial hair was brought to the attention of Registered Nurse (RN) #404 who inquired of Resident #4 if she would like the hairs cut from her chin after supper and Resident #4 agreed. On 11/09/22 at 11:33 A.M. Resident #4 was noted to continue to have long chin hairs present. On 11/09/22 at 9:08 A.M. State Tested Nursing Assistant (STNA) #450 and STNA #475 verified neither of them had asked Resident #4 if she preferred or needed assistance with removal of chin hair. 2. Review of Resident #96's medical record revealed an admission date of 10/31/22 with diagnoses including ischemic cardiomyopathy (a condition of weakened heart muscles due to heart attack or coronary heart disease which might cause fatigue and shortness of breath), hypertension, pneumonia, and congestive heart failure. An intermediate care plan, dated 10/31/22 indicated Resident #96 might need help with activities of daily living with assist of one for grooming. On 11/07/22 at 10:01 A.M. Resident #96 was observed with facial hair on his cheeks, chin, under and above his lip, and on his neck. Resident #96 stated he was receiving blood thinners so staff did not want to shave him. Resident #96 reported he had never had a beard in his life and it was driving (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 2 of 7 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 11/09/2022 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 0677 him crazy. Level of Harm - Minimal harm or potential for actual harm On 11/07/22 at 1:02 P.M. interview with RN #212 revealed she did not know if staff shaved residents receiving blood thinners. Residents Affected - Few On 11/07/22 at 1:06 P.M. interview with STNA #467 verified she had noticed Resident #96 had facial hair growth and stated she could shave residents, even if they were receiving blood thinners. Another unidentified staff member standing nearby indicated STNA #467 should consult with the nurse prior to shaving a resident receiving blood thinners. On 11/07/22 at 3:25 P.M. interview with Resident #96 revealed staff tried to shave him but the razor they used was not very good. Resident #96 was noted to have less facial hair but patchy areas of hair remained, heavier above the lips. On 11/08/22 at 9:04 A.M. Resident #96 was observed to continue to have some patches of facial hair which was more prominent than other remaining facial hair. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 3 of 7 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 11/09/2022 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 Based on medical record review and interview the facility failed to ensure adequate monitoring and care for Resident #28 related a diagnosis of diabetes mellitus including clarification of a physician's order for administration of sliding scale insulin. This affected one resident (#28) of five residents reviewed for medication use. Residents Affected - Few Findings include: Review of Resident #28's medical record revealed diagnoses including Alzheimer's disease and diabetes mellitus. Record review revealed on 06/13/22 Resident #28 had a physician order for enteral (tube) feeding at night between 8:00 P.M. and 6:00 A.M., Novolog insulin 15 milliliters to be administered three times a day, and Novolin R insulin four times a day per sliding scale. On 06/13/22, the Novolin R was discontinued and an order was written for Novolog insulin to be administered four times a day per a sliding scale two hours after Resident #28 ate to see if blood glucose levels had gone down with the regular dose administered. The times were listed as 6:30 A.M., 10:30 A.M., 3:30 P.M. and 8:00 P.M. The routine Novolog insulin was discontinued 07/13/22 but the order remained to provide insulin coverage with Novolog per a sliding scale four times a day two hours after Resident #28 ate to see if blood glucose levels had gone down with the regular dose administered. No new orders were received for routine administration of insulin. On 11/09/22 at 3:54 P.M. interview with the Director of Nursing (DON) revealed residents ate at 7:00 A.M., 11:00 A.M., and 4:00 P.M. The order for administration of the Novolog after meals was discussed. At 3:57 P.M., the DON and Regional DON #444 were interviewed and Regional DON #444 revealed the order did not make sense because one would normally obtain blood glucose levels before meals. Both the DON and Regional DON #444 agreed staff administering the insulin should have questioned the order. The DON stated they just spoke to the physician and he wanted the blood glucose levels checked before meals as the staff were doing. At 4:08 P.M., the orders and order changes from June and July 2022 were discussed with the DON and Regional DON #444 and they agreed the order for monitoring blood glucose levels after meals made sense at that time. However, they were unable to provide an explanation as to why the order for administration of the sliding scale scale insulin after meals had the same times ordered as the routine insulin. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 4 of 7 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 11/09/2022 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on observation, medical record review, and interview the facility failed to ensure Resident #10, who had an indwelling urinary catheter received appropriate services to prevent urinary tract infections. This affected one resident (#10) of two residents reviewed for urinary catheters. The facility identified four residents with urinary catheters. Findings include: Review of Resident #10's medical record revealed diagnoses including obstructive and reflux uropathy (blockage in the urinary tract), Parkinson's disease, and osteoarthritis. A care plan, initiated 09/06/22 indicated Resident #10 had an indwelling urinary catheter related to urinary retention with hydronephrosis (excess urine accumulation in kidney(s) that caused swelling of kidneys) and obstructive and reflux uropathy. The goal was for Resident #10 to be free of infection. Review of physician's antibiotic orders and progress notes revealed Resident #10 was treated for a urinary tract infection beginning 07/29/22 and started treatment for a possible urinary tract infection on 10/04/22 related to (urinary tract infection) symptoms. On 11/07/22 at 10:20 A.M. Resident #10 was observed sitting in a wheelchair with her catheter bag and tubing touching the floor. On 11/07/22 at 1:07 P.M. Resident #10 was observed being propelled through the hall with the catheter bag dragging on the carpeted floor. On 11/07/22 at 3:17 P.M. Resident #10 was observed sitting in a wheelchair in her room with the bottom of the catheter bag resting on a fall mat on the floor beside Resident #10's bed. On 11/09/22 at 10:15 A.M. Resident #10 was observed sitting in a wheelchair in her room with the bottom of the catheter bag resting on the floor. The observation was verified by State Tested Nursing Assistant (STNA) #450. Review of guidance from the Centers for Disease Control (CDC) for Indwelling Urinary Catheter Insertion and Maintenance revealed the urinary catheter bag should be kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 5 of 7 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 11/09/2022 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on observation, review of the facility's concern log, record review, and interview the facility failed to maintain sufficient levels of staffing to ensure call lights were responded to in a timely manner and to meet the total care needs of all residents. This had the potential to affect all 45 residents residing in the facility. Findings include: 1. Review of the facility's concern log dated 11/01/21 to 10/27/22 revealed a concern, dated 07/28/22 indicating call lights needed to be answered more quickly. The facility response included the Director of Nursing (DON) re-educated staff on call lights and the facility's expectations. During the survey, the following resident concerns related to staffing were voiced: a. On 11/07/22 at 9:45 A.M. interview with Resident #7 revealed a concern that it took a while to receive staff assistance after activating the call light. The resident was unable to provide any specifics or quantify the time. b. On 11/07/22 at 10:06 A.M. interview with Resident #20 revealed concerns there were times she was unable to participate in activities because staff did not provide assistance to get her out of bed in accordance with her requests. Resident #20 indicated her showers had been moved to afternoon shift (due to staffing issues) but stated she preferred to be up for meals. On 11/07/22 at 10:21 A.M., while discussing Resident #20's request to be up for lunch so she could go to the dining room with an unidentified nurse, the nurse indicated she was aware Resident #20 wanted to be out of bed for lunch but needed her dressings changed. The nurse was unaware who was doing the dressing changes or when they would be performed. On 11/07/22 at 10:23 A.M. interview with State Tested Nursing Assistant (STNA) #440 verified Resident #20 preferred to be out of bed for meals and activities and preferred to get showers on day shift. c. On 11/07/22 at 8:57 A.M. interview with Resident #25 and his family member revealed concerns it took a while to receive care, especially on weekends. The family member stated there were times he was on the phone with Resident #25 and it would take one to 1.5 hours to receiving assistance with incontinence care or repositioning as the resident could not reposition himself. d. On 11/07/22 at 9:25 A.M. interview with Resident #4 revealed a concern that it took a long time to get call lights answered. The resident was unable to provide specific information or quantify the time. e. On 11/07/22 at 10:16 A.M. interview with Resident #10 revealed a concern that sometimes she waited a half hour to 40 minutes for staff assistance after activated it. 2. Review of Resident #96's medical record revealed diagnoses including ischemic cardiomyopathy (weakened heart muscles which can cause fatigue and shortness of breath), hypertension, pneumonia, and congestive heart failure. An admission Minimum Data Set (MDS) 3.0 assessment, dated 11/07/22 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 6 of 7 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 11/09/2022 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 0725 indicated Resident #96 was cognitively intact. Level of Harm - Minimal harm or potential for actual harm On 11/07/22 at 3:53 P.M. Resident #96 was observed lying in bed stating he was waiting for his brief to be changed. The call light had been activated. At 4:30 P.M., Resident #96 stated he had still not received assistance with incontinence care. At 4:33 P.M., the call light was responded to. When the unidentified staff member asked what Resident #96 needed he responded he needed changed and repositioned in bed. The staff member closed the door to provide the requested assistance. Residents Affected - Many On 11/08/22 at 4:06 P.M., Resident #96 was observed lying in bed and he stated he had been waiting as he needed pulled up in bed. Resident #96 stated the pad under him had bunched up and was causing discomfort due to his pressure injury. At 4:09 P.M., an unidentified staff member's walkie talkie in the hall announced alarm and identified Resident #96's room and bed number. The staff member was passing supper trays. At 4:10 P.M., Resident #96 remained down in the bed with his feet past the foot of the bed. At 4:12 P.M., an unidentified staff member in gray scrubs walked past Resident #96's room without stopping to inquire what he needed. At 4:15 P.M., RN #404 entered the room of the resident next to Resident #96 and asked what the resident wanted and stated somebody else must have turned the call light off. After exiting the other room, RN #404 was informed it might have been Resident #96 whose call light she intended to respond to. It was only at that time that RN #404 went to Resident #96's room to inquire if he needed something. RN #404 called over the walkie talkie for assistance. RN #404 stated she might have looked at the screen wrong prior to answering the adjoining room's call light. At 4:17 P.M. (an hour after the call light was activated), Resident #96 was assisted to reposition in the bed. 3. The following staff interviews were obtained related to staffing: a. On 11/08/22 at 10:57 A.M. interview with State Tested Nursing Assistant (STNA) #439 revealed when call lights were activated, staff received a notice over walkie talkies. STNA #439 indicated she did not have her walkie talkie on her at the time, having given it to somebody else to use. STNA #439 stated she had worked the day before and was there for supper, and stated around meal time it was harder to get to call lights timely as staff were transporting residents to and from the dining room and serving drinks and meals. The STNA indicated the facility attempted to try to have somebody to monitor halls. b. On 11/09/22 between 8:59 A.M. and 9:05 A.M. interviews with STNA #450 and STNA #475 revealed it was difficult to respond to call lights in a timely manner around meals. STNA #450 stated there were supposed to be two nursing assistants in the dining room and two on the floor when there were four aides. If other departments did not pitch in and help pass trays one of the aides from the hall were pulled to the dining room leaving one person to respond to call lights and requests on the hall. It was difficult for one aide to respond to call lights in a timely manner. STNA #475 agreed. On 11/09/22 at 9:23 A.M. interview with the Director of Nursing (DON) revealed the restorative aide was scheduled to work the dining room. The DON indicated there had been sufficient staff to keep two aides on the units to respond to call lights on 11/07/22 and 11/08/22. The DON verified 40 minutes to one hour wait time for call light response was not acceptable. This deficiency represents non-compliance investigated under Complaint Number OH00137391. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 7 of 7