Inspection·November 7, 2023

F 0760 Level of Harm - Minimal harm or potential for actual harm the button as far as it will go and see if a drop of insulin appears at the needle tip. If not, repeat the procedure until insulin appears. This deficiency represents non-compliance investigated under Complaint Number OH00147679. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 2 of 6 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 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and resident interviews the facility failed to ensure residents received diet items as ordered. This affected two residents (#10 and #30) of three residents reviewed for therapeutic diets. The facility census was 63. Findings include: 1. Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and type two diabetes with neuropathy. Resident #10's diet was reduced concentrated sweets diet. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was cognitively intact and required limited assistance with personal hygiene but was independent with all other activities of daily living. Observation of Resident #10's breakfast meal tray on 11/07/23 at 8:35 A.M. revealed the tray contained the following food items: two slices of toast, mandarin oranges, yogurt, sausage gravy, and a biscuit. Review of Resident #10's meal ticket revealed the resident had ordered two slices of toast, mandarin oranges, yogurt, and sausage gravy. At the time of the observation the resident stated she did not order the biscuit, and she was not sure if she was going to eat the biscuit or not. Observation and interview with Licensed Practical Nurse (LPN) #240 on 11/07/23 at 8:39 A.M. confirmed the food items delivered to Resident #10 did not match the food items selected by Resident #10 on her meal tray ticket, and the resident received a biscuit that was not ordered. 2. Review of Resident #30's medical record revealed the resident was admitted to the facility 10/20/23 with diagnoses including fractured hip, frequent falls at home, and urinary tract infection. The resident's diet was regular diet, no straws, and small bites. Review of Resident #30's five-day MDS assessment dated [DATE] revealed the resident had cognitive impairment, no behaviors, and required partial assistance from staff with eating. Observation of Resident #30 on 11/07/23 at 8:50 A.M. revealed the resident was lying in bed with the call light in reach, her continuous positive airway pressure (CPAP) mask in place on her face, and her eyes were closed. The room lights were off, and there was no breakfast tray in the resident room. Observation of Resident #30 on 11/07/23 at 9:00 A.M. revealed the resident was lying in her bed with the call light in reach, her CPAP mask in place on her face, and her eyes were closed, the room lights were off, and there was no breakfast tray in the resident room. Observation Resident #30's hallway revealed staff were picking up used meal trays. Interview with LPN #300 on 11/07/23 at 9:03 A.M. revealed Resident #30 used to eat in dining room, but family wanted her to sleep later and wear the CPAP longer. LPN #300 stated Resident #30 started (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 3 of 6 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 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sleeping until 8:30 A.M. or 9:00 A.M. last week. LPN #300 said the family stated the resident does not eat breakfast at home. It was explained to LPN #300 that no breakfast tray had been visualized in the resident room. LPN #300 went to find State Tested Nursing Assistant (STNA) #260 who was caring for Resident #30. The surveyor remained with LPN #300 while she went to talk to STNA #260. STNA #260 stated that breakfast trays were just picked up and returned to the kitchen. It was asked if Resident #30 should have had a breakfast tray, and STNA #260 replied she should have. The surveyor informed the staff observations were made of Resident #30, and no tray was observed in her room. LPN #300 instructed STNA #260 to go to the kitchen and get the resident a breakfast tray. Observation of the kitchen on 11/07/23 at 9:14 A.M. STNA # 260 was observed coming out of the kitchen servery and into the kitchen with a meal ticket in her hand and provide to [NAME] # 310. STNA #260 was heard telling the cook that she needed a tray for Resident #30. Interview with [NAME] #310 on 11/07/23 at 9:15 A.M. confirmed the kitchen had not provided Resident #30 a breakfast meal tray. The cook stated there was a mix up by the hospitality aide, and the tray was not served but would be served now. Observation and interview of Resident #30 with STNA #260 present in the room on 11/07/23 at 9:24 A.M. revealed the STNA removed the CPAP mask and was placing it on the bedside table. Resident #30 was sitting up in the bed with the meal tray on the over bed table with the cover still in place. Resident #30 stated she had slept well and stated she was a little hungry. The meal ticket was observed and revealed the resident was to not have a straw and was to have small bites. The food items selected on the meal ticket for the meal were French toast, sausage, scrambled eggs, mandarin oranges, syrup, and butter. The meal tray was observed, and there was no straw on the meal tray and the sausage was cut into bite size pieces. The meal tray contained all the food items requested except there were no mandarin oranges on the tray. STNA #260 verified there were no mandarin oranges on the tray. Interview with Clinical Consultant #230 on 11/07/23 at 2:40 P.M. revealed the facility had no policy regarding meal tray service and ensuring the ticket items were correct for the resident's diet and items selected by the resident stating, that seemed self-explanatory. This deficiency represents non-compliance investigated under Complaint Number OH00147679. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 4 of 6 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 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 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, staff interviews, resident interviews, review of SANI-CLOTH instructions, and policy review the facility failed to ensure the glucometer used to complete finger stick blood sugar (FSBS) testing was cleansed properly. This had the potential to affect three residents (#70, #90, and #100) who utilized the same glucometer. In addition, the facility failed to ensure ice used for ice pass was free of contamination. This had the potential to affect all 63 residing in the facility. Residents Affected - Many Findings Include: 1. Observation of Licensed Practical Nurse (LPN) # 240 on 11/07/23 at 7:38 A.M. performing a FSBS test on Resident #90, revealed the LPN took the glucometer, test strip container, lancet and alcohol prep pad into the resident's room and laid the items directly on the blanket on top of the resident's bed. The nurse completed hand hygiene and donned gloves. The nurse told the resident she was going to check his sugar and preceded to get a test strip out of the test strip container, pick up the glucometer from the bed, place the test strip in the glucometer, cleanse the resident's finger with a alcohol prep pad, stick the residents finger with the lancet, obtained a drop of blood from the resident's finger and placed the resident's finger at the end of the test strip so the drop of blood could transfer to the test strip. LPN #40 informed the resident of the FSBS reading, removed and discarded the test strip from the glucometer, removed her gloves and exited the room with the glucometer, test strip container, and lancet. The lancet was placed in the Sharp's container, and the glucometer and test strip container were placed on top of the medication cart. The LPN performed hand hygiene, opened the medication cart, and placed the glucometer and the test strip container back in the medication cart on top of the alcohol prep pads. LPN #240 stated she had one more FSBS test to complete on Resident #70, but she needed to pass six other resident's medications first. The LPN confirmed there were only three residents (#70, #90, and #100) who used the glucometer from this medication cart. The LPN was informed that the surveyor wanted to observe the next FSBS monitoring, and the LPN verbalized understanding. Observation of LPN # 240 on 11/07/23 at 8:19 A.M performing a FSBS test on Resident #70 revealed the LPN took the glucometer out the medication cart, obtained a SANI-CLOTH wipe and wiped the glucometer once with the wipe and discarded the wipe in the trash. The LPN then took the glucometer, test strip container, lancet and alcohol prep pad into the resident's room and laid them on the residents over bed table. The nurse completed hand hygiene and donned gloves. The nurse told the resident she was going to check her sugar and preceded to get a test strip out of the test strip container, pick up the glucometer from the over the bed table, place the test strip in the glucometer, cleanse the resident's finger with a alcohol prep pad, stick the residents finger with the lancet, obtained a drop of blood from the resident's finger and placed the resident's finger at the end of the test strip so the drop of blood could transfer to the test strip. LPN #240 informed the resident of the FSBS reading, removed and discarded the test strip from the glucometer, removed her gloves and exited the room with the glucometer, test strip container, and the lancet. The lancet was placed in the Sharp's container, and the glucometer and test strip container were placed on top of the medication cart. The LPN performed hand hygiene, opened the medication cart, and placed the glucometer and the test strip container back in the medication cart on top of the alcohol prep pads. Observation of the SANI-CLOTH tub with LPN #240 on 11/07/23 at 8:25 A.M. revealed the tub read SANI-CLOTH Bleach Germicidal Disposable Wipe, bactericidal, fungicidal, tuberculocidal, and virucidal in four minutes. LPN #240 confirmed after she completed the FSBS test on Resident #90 she placed the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 5 of 6 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 365815 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Club Retirement Center 1350 Yauger Road Mount Vernon, OH 43050 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many glucometer in the medication cart without cleansing the glucometer and did not remove the glucometer from the medication cart until she went to perform the FSBS on Resident #70. LPN #240 confirmed she had wiped off the glucometer with the SANI-CLOTH wipe prior to entering Resident #70's room but did not see the wipe tub stated four minutes for the disinfecting. Review of Resident #70, #90, and #100's medical records confirmed the residents required FSBS testing at the facility and the residents were free of communicable diseases. Interview with Clinical Consultant (CC) #230 on 11/07/23 at approximately 10:00 A.M. it was confirmed the glucometer should be cleansed after use and prior to storing in the medication cart. CC#230 confirmed the cleansing wipe directions should be followed which required more than wiping off the glucometer with the SANI-CLOTH wipe. CC #230 stated there should be two glucometers in the medication cart to allow the proper cleansing time of the glucometer between resident use. Review of the SANI-CLOTH instructions revealed to clean, disinfect, and deodorize using a wipe to remove heavy soil. Unfold a clean wipe and thoroughly wet surfaces. Treated surfaces must remain visibly wet for a full four minutes. Use additional wipe(s) if needed to assure continuous four minutes wet contact time. Review of the policy titled Glucometer Procedures dated 05/18/95 and last revised on 06/09/17 revealed to cleanse the glucometer after each resident use with a bleach cleaner. This includes exterior of glucometer. Allow to air dry per cleansing agent manufacturer's guidelines. 2. Observation of Resident #10 on 11/07/23 at 5:20 A.M. revealed the resident drove her power wheelchair to the red ice cooler next to the nurse's station on the back hall and opened the ice cooler. The resident was observed to get the ice scoop out of the holder and place her personal metal tumbler over the ice. The resident was observed to drop the tumbler into the ice, was overheard saying, oops and observed picking up the tumbler out of the ice with her hand, scoop ice into her tumbler using the ice scoop, and return the ice scoop to the holder, and shut the ice cooler. Interview with Resident #10 on 11/07/23 at 5:21 A.M. confirmed she obtained her own ice from the cooler. The resident was asked if she dropped her tumbler into the ice and she stated, yea, I did but it was not in there for longer than a New York minute. The resident was observed driving her power chair down the hallway back to her room. No staff were in the hallway at the time of the observation or interview. Interview with State Tested Nursing Assistant (STNA) #210 on 11/07/23 at 5:22 A.M. verified independent residents will come to the ice coolers and obtain their own ice as they desire. STNA #210 was informed of incident where Resident #10 dropped her tumbler into the ice. The STNA stated, the ice cannot be used now and removed the cooler from the hallway. This deficiency is an incidental finding discovered during the complaint investigation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 6 of 6