Health inspection·March 15, 2024

F 0568 Level of Harm - Minimal harm or potential for actual harm $389.00 missing from the envelope. The Administrator and herself were the only ones that had codes for the safe. The BOM denied misappropriating the funds. The Corporate BOM #300 confirmed the facility did not follow accounting principles and should have placed the remaining $2,153.51 back into the resident funds account. The BOM confirmed there was no documented evidence the cash was reconciled while in the safe. Residents Affected - Few Review of the facility policy titled Resident Trust dated 02/01/20 revealed it was the facility policy to maintain accurate, organized records for all resident funds activity. All records were to be maintained according to the facility's State regulations. The person that disburses the funds cannot be the same person posting the funds and reconciling. The Administrator BOM, or designee is responsible to account for all funds during reconciliation on a daily basis. The daily count sheet must be completed and signed daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 2 of 8 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 03/15/2024 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 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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, review of the self-reported incident (SRI), review of the police report, policy review, and interview the facility failed to ensure resident's money was not misappropriated. This affected one (Resident #68) of one review for misappropriation. Residents Affected - Few Findings included: Closed record review revealed Resident #68 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including anxiety, bipolar, and cerebral infarction. The resident's primary insurance was Medicaid and secondary was Medicare part B. Review of Resident #68's resident fund statement dated 07/01/23 to 09/29/23 revealed on 08/15/23 $2500.00 was debited for spend down. Review of Resident #68's withdrawal transaction report dated 11/22/23 revealed $2,500.00 was withdrawn from Resident #68's account. Review of check #002225 dated 11/22/23 revealed a check was made out to the Administrator for $2,500.00. The memo indicated cash for resident spend down. Review of a Walmart receipt dated 11/27/23 revealed $346.49 was spent at Walmart. Review of Resident #68 account statement dated 09/01/23 to 02/26/24 revealed no documented evidence that the remaining $2,153.51 was deposited back into the resident's account or reconciled. Review of the facility SRI #244603 dated 02/26/24 revealed an investigation was initiated due to inventory being taken from the safe. Interview of staff revealed no knowledge of missing funds for Resident #68. Law enforcement was notified, and the report was not yet completed. The son was notified, and funds were replaced. The disposition was unsubstantiated due to the evidence being inconclusive and misappropriation was not suspected. Further review of the SRI and investigation revealed there was a statement from the Administrator and Business Office Manager (BOM) #117, petty cash reconciliation sheets dated 02/07/24 and 02/26/24, safe audit completed 02/26/24, four staff statements, a letter from the Corporate BOM dated 03/01/24, and the policy on resident funds. There was no documented evidence of the police report, resident interviews, review of the security camera, no evidence the staff (Administrator and BOM #117) were suspended who had access to the safe, and no evidence staff were educated on the abuse/misappropriation policy. Review of BOM #117's typed statement dated 02/26/24 revealed in November (2023) she had processed a spend down check for Resident #68 due to her account growing and being above Medicaid requirement. She had spoken to Resident #68's son, and he did not have the time to spend down and thought it would be helpful if she could buy some new clothes for Resident #68. The Administrator took the check to the bank and cashed it, then when she brought the money back to the office it was immediately locked up in the safe until she could go to the store. She had taken the envelope with her to Walmart on 11/27/23 and she had spent $346.49 on clothes. She returned to the facility with the items purchased and took the time and the envelope with the remaining funds back to her office where it was locked (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 3 of 8 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 03/15/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few back up into the safe. Staff took the clothes back to the resident room for her to try on. The remaining money remained in the safe until 02/26/24 when the son requested copies of the receipts from the spend down. When she got into the safe to retrieve the leftover fund and receipts, she found that the envelope was $389.00 short. She informed the Administrator of the shortage to which they checked the safe for any loose funds or receipts. She also balanced the other two cash boxes in the safe to ensure there were no extra funds in them. Upon looking for the money we remembered the safe had been left unlocked on at least one occasion but herself or the Administrator could not remember what day that had been. She could only remember she had been either off the previous day of the incident or had been out of the building. When she returned, she noticed the safe was open and had asked the Administrator if she had been in the safe, to which she stated she must have forgotten to close it back up. The Administrator was unsure of how long the safe had been left open. At that time, she had checked the safe to make sure all credit cards were accounted for and balanced the cash in the resident fund box and petty cash box. At the time of the incident, it had appeared nothing was missing but neither of them remembered there was spend down money in the safe and it was not accounted for at that time. Review of the Administrator's typed statement dated 02/26/24 revealed the BOM had informed her on 02/26/24 around 2:00 P.M., that she was closing a Resident funds account and she remembered she had cash in the safe for that resident. Upon counting the envelope, the envelope was short $389.00. Inventory of safe was done at that time, both money boxes were reconciled and all funds in the two money boxes were accounted for. The facility credit cards receipts were gone through to see if we had charged something for the resident and took the cash and forgot to leave a receipt, but nothing was found. The son, police, and ombudsman were notified. Missing funds were replaced by the facility and mailed to the son. Verified limited access of safe to just the BOM and Administrator. Interviewed other staff regarding the knowledge of missing funds and had no knowledge identified. The cash boxes were reconciled by VP of operations on 02/07/24 and no issues found. On 03/01/24 the Corporate Director was in the facility and did an audit and found no issues with any resident accounts from 12/2022 to current. She also educated the Administrator and BOM on policy for handling cash. Review of the resident funds petty cash audit dated 02/26/24 revealed the petty cash was audited by the BOM and Administrator (the only staff members who had the pin number to the safe). Review of the safe audit dated 02/26/24 revealed the audit was completed by the Administrator. Review of the four typed statements dated 02/27/24 revealed the Assistant Director of Nursing #164, the admission Coordinator #176, the Activities Director #173, and the Maintenance Director #184 signed a statement that they had no knowledge of any resident fund missing. Review of signed letter by Corporate BOM #300 dated 03/10/24 revealed she had audited all cash/checks received from 12/2022 to current. Her finding showed that all deposits/withdrawals from resident accounts were accurate and according to the receipts present. Training was provided to BOM #117. Weekly reconciliation must be completed and signed off on by the BOM and Administrator. The corporate team will continue to count cash and reconciliation when visiting the facility until further notice. Review of the police report printed on 03/15/24 revealed on 02/27/24 at 2:39 P.M., the Administrator reported $380.00 was missing from Resident #68. The caller thinks they just lost a receipt from using her money but can't prove it, so they needed to report it per the facility policy. On scene the Manager reported $389 was missing from a former resident's account. The manager believes they misplaced a receipt when the resident was living there. $2,100 was left in the same safe that the $389 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 4 of 8 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 03/15/2024 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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few missing. The manager denied a formal report and reported she just wanted to note. There was no evidence the facility followed up with the police after they determined the money had been misappropriated. Review of the facility policy titled Resident Trust dated 02/01/20 revealed it was the facility policy to maintain accurate, organized records for all resident funds activity. All records were to be maintained according to the facility's State regulations. The person that disburses the funds cannot be the same person posting the funds and reconciling. The Administrator BOM, or designee is responsible for accounting for all funds during reconciliation daily. The daily count sheet must be completed and signed daily. Review of the facility policy and procedure titled Abuse dated 11/01/16 and revised 01/31/20 revealed residents had the right to be free from misappropriation of resident property. It was the facility policy to investigate all alleged violations. If a staff member was accused or suspected of misappropriation of resident property, the facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. The investigation protocol should generally take the following action: interview the resident, the accused or witness. If there was no direct witness, then the interviews may be expanded to employees and residents. If the accused was an employee, then review the employment records. After the investigation has been completed, we will determine if modification to policies is needed and complete staff training. Interview on 03/15/24 at 2:18 P.M. with the Business Office Manager (BOM) #117 and Corporate BOM #300 revealed the son was notified that his mom had too much in her resident funds account and the money needed spent down. The son was not able to spend the money and asked the facility to spend the money down. The facility wrote a check out to the Administrator in November of 2023 for $2,500.00 and staff went to Walmart and bought $346.49 worth of items for the resident. The remaining $2,153.51 was placed in an envelope in the safe and had been forgotten about until the son inquired about her account and requested receipts on 02/23/24. The BOM reported she did not reconcile the cash or place it back into the resident fund account. There was no account for the money. On 02/26/24 when she was gathering information for the son, she had realized there was $389.00 missing from the envelope. The Administrator and herself were the only ones that had codes to the safe. The BOM denied misappropriating the funds. The Corporate BOM #300 confirmed the facility did not follow accounting principles and should have placed the remaining $2,153.51 back into the resident funds account. The BOM reported sometime this year but,could not provide which month, the safe was left open by the Administrator. She reconciled the two lock boxes, however never reconciled Resident #68's money envelope to ensure all the money was accounted for. The facility has cameras in the hallways; however, they were not utilized as part of the investigation. There were only four staff that were interviewed that may have had access to the BOM office. The staff confirmed residents were not interviewed to ensure money was not misappropriated from their rooms as part of the investigation, or was the Administrator or BOM suspended during the investigation (they were the only two with codes to the safe). The BOM and Administrator were also the ones that did the initial audits after it was identified money was missing out of the safe. The Corporate BOM did not conduct her audit until 03/01/24 (three days after the findings). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 5 of 8 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 03/15/2024 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. 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, review of the self-reported incident (SRI), review of the police report, policy review, and interview the facility failed to thoroughly investigate misappropriated funds. This affected one (Resident #68) of one review for misappropriation. Residents Affected - Few Findings included: Closed record review revealed Resident #68 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including anxiety, bipolar, and cerebral infarction. The resident primary insurance was Medicaid and secondary was Medicare part B. Review of Resident #68's resident fund statement dated 07/01/23 to 09/29/23 revealed on 08/15/23 $2500.00 was debited for spend down. Review of Resident #68's withdrawal transaction report dated 11/22/23 revealed $2,500.00 was withdrawal from Resident #68's account. Review of check #002225 dated 11/22/23 revealed a check was made out to the Administrator for $2,500.00. The memo indicated cash for resident spend down. Review of a Walmart receipt dated 11/27/23 revealed $346.49 was spent at Walmart. Review of Resident #68 account statement dated 09/01/23 to 02/26/24 revealed no documented evidence that the remaining $2,153.51 was deposited back into the resident's account or reconciled. Review of the facility SRI #244603 dated 02/26/24 revealed an investigation was initiated due to inventory being taken from the safe. Interview of staff revealed no knowledge of missing funds for Resident #68. Law enforcement was notified, and the report was not yet completed. The son was notified, and funds were replaced. The disposition was unsubstantiated due to the evidence being inconclusive and misappropriation was not suspected. Further review of the SRI and investigation revealed there was a statement from the Administrator and Business office Manager (BOM) #117, petty cash reconciliation sheets dated 02/07/24 and 02/26/24, safe audit completed 02/26/24, four staff statements, a letter from the Corporate BOM dated 03/01/24, and the policy on resident funds. There was no documented evidence of the police report, resident interviews, review of the security camera, no evidence the staff (Administrator and BOM #117) were suspended who had access to the safe, and no evidence staff were educated on the abuse/misappropriation policy. Review of BOM #117 typed statement dated 02/26/24 revealed in November (2023) she had processed a spend down check for Resident #68 due to her account growing and being above Medicaid requirement. She had spoken to Resident #68 son, and he did not have the time to spend down and thought it would be helpful if she could buy some new clothes for Resident #68. The Administrator took the check to the bank and cashed it, then when she brought the money back to the office it was immediately locked up in the safe until she could go to the store. She had taken the envelope with her to Walmart on 11/27/23 and she had spent $346.49 on clothes. She returned to the facility with the items purchased and took the time and the envelope with the remaining funds back to her office where it locked back up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 6 of 8 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 03/15/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few into the safe. Staff took the clothes back to the resident room for her to try on. The remaining money remained in the safe until 02/26/24 when the son requested copies of the receipts form the spend down. When she got into the safe to retrieve the leftover fund and receipts, she found that the envelope was $389.00 short. She informed the Administrator of the shortage to which they checked the safe for any loose funds or receipts. She also balanced the other two cash boxes in the safe to ensure there were no extra funds in them. Upon looking for the money we remembered the safe had been left unlocked on at least one occasion but herself or the Administrator could remember what day that had been. She could only remember she had been either off the previous day of the incident or had been out of the building. When she returned, she noticed the safe was open and had asked the Administrator if she had been in the safe, to which she stated she must have forgotten to close it back up. The Administrator was unsure of how long the safe had been left open. At that time, she had checked the safe to make sure all credit cards were accounted for and balanced the cash in the resident fund box and petty cash box. At the time of the incident, it had appeared nothing was missing but neither of them remembered there was spend down money in the safe and it was not accounted for at that time. Review of the Administrator typed statement dated 02/26/24 revealed the BOM had informed her on 02/26/24 around 2:00 P.M., that she was closing a Resident funds account and she remembered she had cash in the safe for that resident. Upon counting the envelope, the envelope was short $389.00. Inventory of safe was done at that time, both money boxes were reconciled and all funds in the two money boxes were accounted for. The facility credit cards receipts were gone through to see if we had charged something for the resident and took the cash and forgot to leave a receipt, but nothing was found. The son, police, and ombudsman were notified. Missing funds were replaced by the facility and mailed to the son. Verified limited access of safe to just the BOM and Administrator. Interviewed other staff regarding the knowledge of missing funds and had no knowledge identified. The cash boxes were reconciled by VP of operations on 02/07/24 and no issues found. On 03/01/24 the Corporate Director was in the facility and did an audit and found no issues with any resident accounts from 12/2022 to current. She also educated the Administrator and BOM on policy for handling cash. Review of the resident funds petty cash audit dated 02/26/24 revealed the petty cash was audited by the BOM and Administrator (the only staff members who had the pin number to the safe) Review of the safe audit dated 02/26/24 revealed the audit was completed by the Administrator. Review of the four typed statements dated 02/27/24 revealed the Assistant Director of Nursing #164, the admission Coordinator #176, the Activities Director #173, and the Maintenance Director #184 signed a statement that they had no knowledge of any resident fund missing. Review of signed letter by Corporate BOM #300 dated 03/10/24 revealed she had audited all cash/checks received from 12/2022 to current. Her finding showed that all deposits/withdrawals from resident accounts were accurate and according to the receipts present. Training was provided to BOM #117. Weekly reconciliation must be completed and signed off on by the BOM and Administrator. The corporate team will continue to count cash and reconciliation when visiting the facility until further notice. Review of the police report printed on 03/15/24 revealed on 02/27/24 at 2:39 P.M., the Administrator reported $380.00 was missing from Resident #68. The caller thinks they just lost a receipt from using her money but can't prove it, so they needed to report it per the facilities policy. On scene the Manager reported #389 was missing from a former resident's account. The manager believes they misplaced a receipt when the resident was living there. $2,100 was left in the same safe that the $389 was missing. The manager denied a formal report and reported she just wanted to note. There was no (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 7 of 8 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 03/15/2024 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 0607 evidence the facility followed up with the police after they determined the money had been misappropriated. Level of Harm - Minimal harm or potential for actual harm Review of the facility policy titled Resident Trust dated 02/01/20 revealed it was the facility policy to maintain accurate, organized records for all resident funds activity. All records were to be maintained according to the facility's State regulations. The person that disburses the funds cannot be the same person posting the funds and reconciling. The Administrator BOM, or designee is responsible for accounting for all funds during reconciliation daily. The daily count sheet must be completed and signed daily. Residents Affected - Few Review of the facility policy and procedure titled Abuse dated 11/01/16 and revised 01/31/20 revealed residents had the right to be free from misappropriation of resident property. It was the facility policy to investigate all alleged violations. If a staff member was accused or suspected of misappropriation of resident property, the facility should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. The investigation protocol should generally take the following action: interview the resident, the accused or witness. If there was no direct witness, then the interviews may be expanded to employees and residents. If the accused was an employee, then review the employment records. After the investigation has been completed, we will determine if modification to policies is needed and complete staff training. Interview on 03/15/24 at 2:18 P.M. with the Business Office Manager (BOM) #117 and Corporate BOM #300 revealed the son was notified that his mom had too much in her resident funds account and the money needed spent down. The son was not able to spend the money and asked the facility to spend the money down. The facility wrote a check out to the Administrator in November of 2023 for $2,500.00 and staff went to Walmart and bought $346.49 worth of items for the resident. The remaining $2,153.51 was placed in an envelope in the safe and had been forgotten about until the son inquired about her account and requested receipts on 02/23/24. The BOM reported she did not reconcile the cash or place it back into the resident fund account. There was no account for the money. On 02/26/24 when she was gathering information for the son, she had realized there was $389.00 missing from the envelope. The Administrator and herself were the only ones that had codes to the safe. The BOM denied misappropriating the funds. The Corporate BOM #300 confirmed the facility did not follow accounting principles and should have placed the remaining $2,153.51 back into the resident funds account. The BOM reported sometime this year but,could not provide which month, the safe was left open by the Administrator. She reconciled the two lock boxes, however never reconciled Resident #68 money envelope to ensure all the money was accounted for. The facility has cameras in the hallways; however, they were not utilized as part of the investigation. There were only four staff that were interviewed that may have had access to the BOM office. The staff confirmed residents were not interviewed to ensure money was not misappropriated from their rooms as part of the investigation, or was the Administrator or BOM suspended during the investigation (they were the only two with codes to the safe). The BOM and Administrator were also the ones that did the initial audits after it was identified money was missing out of the safe. The Corporate BOM did not conduct her audit until 03/01/24 (three days after the findings). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365815 If continuation sheet Page 8 of 8