Inspection·March 12, 2025

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident didn't have diabetes. The type of incontinence section and three day tracker section were left blank. There was an additional typed comment that indicated the resident was continent of bowel and bladder with occasional urine dribbling. Resident doesn't meet criteria at this time for toileting program. b. Review of Resident #45's discharge MDS dated [DATE] revealed the resident's BIMS was not completed. The resident was frequently incontinent of urine. c. Review of Resident #45's quarterly MDS dated [DATE] revealed the resident's BIMS score was 14 (cognition intact). The resident was frequently incontinent of urine and was not on a toileting program. Review of Resident #45's bladder assessment dated [DATE] revealed the resident doesn't always void appropriately and was continent of urine at least daily. The resident required one assist with toileting, was confused, and needed prompting. The resident was sometimes aware of the need to toilet. The type of incontinence section and three-day tracker section were left blank. Review of Resident #45's bladder assessment dated [DATE] revealed the resident never void appropriately. The resident required one assist with toileting. The resident was confused and needed prompting. The resident was sometimes aware of need to toilet. The type of incontinence section and three-day tracker section were left blank. There was an additional typed comment that indicated the resident was incontinent of bladder and doesn't meet criteria at this time for toileting program. Review of Resident #45's bladder tracking dated 02/11/25 to 03/12/25 revealed the resident had 40 episodes of incontinence and 46 episodes of incontinence. Interview on 03/12/25 at 3:00 P.M., with the Director of Nursing (DON) confirmed Resident #45 was not on a toileting program and had a decline in urinary function and would have benefited from a toileting program. The DON confirmed the bladder assessments didn't identify the type of incontinence the resident was experiencing or a treatment plan to prevent decline or improve the resident's bladder function. The DON confirmed the facility doesn't have a procedure or system in place to determine if the resident met criteria for a program and it was the judgement of the nurse who completed the bladder assessments. 2. Closed medical record review revealed Resident #57 was admitted to the facility on [DATE] and again on 02/21/25 with diagnoses including dementia, metabolic encephalopathy, chronic kidney disease, muscle weakness, and need for assistance with personal care. a. Review of Resident #57's admission MDS dated [DATE] revealed Resident #57 had severe cognition impairment. The resident was frequently incontinent of urine and was not on a toileting program. Review of Resident #57's discharge MDS dated [DATE] revealed Resident #57 was frequently incontinent of urine and was not on a toileting program. Review of Resident #57's three-day bladder voiding diary dated 01/10/25, 01/11/25, and 01/12/25 revealed the resident had not urinated for three days. Review of Resident #57's bladder assessment dated [DATE] revealed Resident #57 doesn't always void appropriately and was continent of urine at least daily. The resident required one person assist (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 2 of 5 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 03/12/2025 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 with toileting, was forgetful but follows commands, and was always aware of need to toilet. The three-day tracker section identified no pattern determined. The type of incontinence was left blank. Review of Resident #57's bladder assessment dated [DATE] and 01/20/25 revealed Resident #57 doesn't always void appropriately and was continent of urine at least daily. The resident required one person assist with toileting, was forgetful but follows commands, and was always aware of need to toilet. The three-day tracker section identified no pattern determined. The type of incontinence was left blank. There was a comment that indicated the resident was continent of bowel and bladder, occasional urine dripping if waits too long. b. Review of Resident #57's significant change MDS dated [DATE] revealed Resident #57 had severe cognition impairment and was frequently incontinent of urine and was not on a toileting program. Review of Resident #57's bladder assessment dated [DATE] revealed the resident was never continent of urine. The resident required one assist with toileting. The resident was forgetful but followed commands and sometimes was aware of toilet needs. The type of incontinence section was blank. The comment indicated the resident was incontinent of bowel and bladder and did not feel the urge to void. The resident did not meet criteria for a toileting program. Interview on 03/12/25 at 3:00 P.M., with the DON confirmed Resident #57 was not on a toileting program. The DON confirmed the bladder assessment including the three-day bladder tracker was inaccurate due to the tracker indicated the resident did not urinate for three days. The DON confirmed the assessments didn't identify the type of incontinence the resident was experiencing or a treatment plan to prevent decline or improve the resident bladder function. The DON confirmed the facility doesn't have a policy that determines if the resident met criteria for a program and it was the judgement of the nurse who completes the bladder assessment. Review of the facility's policy titled Bowel and Bladder Assessment and Incontinence (dated 02/2019) revealed it was the facility's policy to assure that any resident who was incontinent of bladder receives the appropriate treatment and services to restore as much normal bladder function as possible and to assist the resident in attaining or maintaining his/her highest practicable physical, emotional, and social function. The facility would identify any resident with continence management problems, perform adequate incontinence assessment, and provide appropriate treatment and services congruent with the resident history of incontinence, personal goals, mental status, physical capabilities, and cognitive function. Residents identified with incontinence would be assessed by licensed nurse to attempt to identify the type of urinary incontinence, potential and or actual cause of incontinence, and reversible and irreversible causes of incontinence. A licensed nurse would develop and/or revise the resident's plan of care as determined by the assessment data and periodic evaluation of the resident response to incontinent management interventions. Review of the facility's policy titled Incontinence Policy (dated 11/2017) revealed residents that are incontinent of bladder would receive appropriate treatment to prevent infections and to restore continence to the extent possible. This deficiency represents non-compliance investigated under Master Complaint Number OH00162880 and Complaint Number OH00162831. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 3 of 5 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 03/12/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interviews, the facility failed to ensure a resident's oxygen concentrator alarm was addressed timely. This affected one resident (#45) of three residents observed with oxygen concentrators. Residents Affected - Few Findings included: Record review revealed Resident #45 was admitted to the facility on [DATE] with diagnoses including dependence on supplement oxygen, pneumonia, chronic respiratory failure with hypoxia, hypertension, heart disease, chronic obstructive pulmonary disease (COPD), hyperlipidemia, and tobacco use. Review of Resident #45's current orders dated 03/2025 revealed to check oxygen saturation twice daily and continuous oxygen at three liters via nasal cannula. Review of Resident #45's cardiac impairment related to hypertension, coronary heart disease (CAD), and hyperlipidemia and potential for alteration in respiratory function related to COPD plan of care dated 11/19/24 revealed to administer oxygen as ordered. Observation on 03/10/25 at 10:04 A.M., revealed Resident #45's oxygen concentrator was alarming as the surveyor walked by the room. The concentrator reading indicated flowrate was low. The flow rate was set on zero. Staff were observed passing by the room in the hallway, but no one stopped to address the alarm sounding. The surveyor activated the resident's call light at 10:05 A.M., due to no one had responded to the oxygen concentrator alarm. At 10:10 A.M., no one had responded to the call light and the resident had voiced concerns she was having trouble breathing and she had opened the window to help her breathe. The surveyor walked to the door and two certified nurse's aides (CNA's) were observed standing in the doorway of a room across the hall from the resident's room. CNA #166 reported she was the CNA for Resident #45; however, she did not hear the call light activation at 10:05 A.M., go over her pager. The CNA reported the computer at the nurse's station would confirm if Resident #45's call light was activated. CNA #166 went to dispose of a bag of trash and the surveyor went to the nurse's station of find a nurse. The computer confirmed Resident #45's call light was activated 10:05 A.M. The surveyor alerted Registered Nurse (RN) #112 that Resident #45's oxygen concentrator was alarming and the resident voiced concerns of difficulty with breathing. Resident #45 reported the oxygen concentrator had been beeping for sometime. RN #112 assessed the concentrator and reported the resident needed a new concentrator and she left the room to get a new concentrator and alerted the staff walking by to find the nurse. The surveyor asked the unidentified staff member to ask the nurse to bring a pulse ox. CNA #166 assisted the resident to the bathroom while the RN went to get a new concentrator. RN #112 returned with a new concentrator and the resident finished using the bathroom and sat on her respiratory walker while the nurse hooked up the new concentrator. The new concentrator was not working as well. The surveyor observed the resident's oxygen tubing and noted the tubing was kinked completely off around the resident's neck. RN #112 removed the nasal cannula off the resident and straightened out the tubing and re-applied. RN#159 arrived and placed a pulse ox on the resident's finger. The pulse ox originally would not register. RN #159 asked the resident to take deep slow breaths. The pulse ox then registered at 81 percent. The oxygen concentrator was set on three liters. The resident's pulse ox was 90 percent when the surveyor left the room, however the nurses were still present and instructing the resident to take slow deep breaths. These findings were confirmed with RN#112 and RN #159 during observation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 4 of 5 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 03/12/2025 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 0695 This deficiency represents an incidental finding of non-compliance investigated under Master Complaint Number OH00162880. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365699 If continuation sheet Page 5 of 5