Country Club Retirement Ctr Iv

F 0609 Level of Harm - Minimal harm or potential for actual harm

or designee will notify ODH of all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property and injuries of unknown source as soon as possible, but in no event later than 24 hours from the time the incident/allegation was made known to the staff member. This deficiency represents an incidental finding of non-compliance investigated under Complaint Number

1. 2649219. Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

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 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

On 11/25/25 at 10:00 A.M., an interview with Director of Nursing revealed skin assessments were completed on residents during showers. She confirmed shower sheets for Resident #37 and also confirmed only 11/09/25 and 11/12/25 revealed any information regarding skin assessments. The other shower forms did not address the skin assessment area.

1. 5. Review of the medical record for Resident #30 revealed an admission date of 10/09/25. Diagnoses

included periprosthetic fracture around internal prosthetic right knee joint; diverticulitis of intestine; muscle weakness, fall on same level from slipping; unspecified asthma; hyperlipidemia; morbid obesity, depression, gastro-esophageal reflux; hyperparathyroidism; essential hypertension; obstructive sleep apnea; sciatica; generalized anxiety disorder; chronic pain syndrome, and low back pain.

Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE REDACTED] revealed a Brief

Interview for Mental Status (BIMS) of 15 on a 0-15 scale. A score of 15 would indicate the resident was cognitively intact.

The MDS further revealed the resident had been assessed to need scheduled and as needed pain medications. The resident was assessed to have lower extremity impairment on one side, required a wheelchair, and substantial or maximal assistance for toileting, showering or bathing, putting on footwear, and for bed mobility, which included transferring from bed to chair. She was dependent with lower body dressing.

Review of a care plan for Resident #30, dated 10/14/25, revealed a focus of care for risk of skin breakdown related to decreased mobility and incontinence. Interventions for this focus included assisting resident with incontinence care using soap and water, and assisting the resident with toileting as needed.

On 11/24/25 at 3:32 P.M., an interview with Resident #30 revealed concerns regarding staff responding to call lights. She indicated on 10/18/25 at 9:20 A.M., she rang her call light for staff assistance when she had to have a bowel movement. The staff did not respond until some time after 9:45 A.M. By the time the staff arrived, the resident had been incontinent of bowel. She reported this incident left her humiliated. She stated, It is bad enough to have to need help, but to be in that situation was horrible.

This deficiency represents non-compliance investigated under Complaint Number 2649219

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

only 11/09/25 and 11/12/25 revealed any information regarding skin assessments. The other shower forms were blank.

Review of a facility provided document titled shower schedule revealed shower schedules for both nursing shifts, 6:00 A.M. to 6:00 P.M (day shift), and 6:00 P.M. to 6:00 A.M.(evening shift). Resident #37 was scheduled for a shower every day, alternating between evening and day shift. Resident #30 was scheduled for shower on Sunday, Monday, Wednesday, and Friday on day shift, and Saturday on evening shift.

Resident #37 was scheduled Sunday and Thursday day shift. This was confirmed by Director of Nursing on 11/25/25 at 10:25 A.M.

This deficiency represents non-compliance investigated under Complaint Number 2649219.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

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 0755

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

During interview on 11/25/25 at 9:07 A.M, the Director of Nursing (DON) confirmed there was a discrepancy between the Controlled Drug Receipt and the MAR for Residents #9, #19, #23, #4, #13, and #44. The DON further confirmed all medications administered should be correctly documented in the medical records at the time of administration.

Review of the facility's policy titled, Specific Medication Administration Procedures, dated 07/01/21, revealed after administration, document administration in MAR and Treatment Administration Record (TAR), and controlled substance sign out record, if indicated.

This deficiency represents non-compliance investigated under Complaint Number 2649219

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

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 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 follow proper hand hygiene and management of soiled linens during incontinence care. The affected one (#5) of one resident reviewed for incontinence care. The facility census was 46. Findings include:Review of the medical record for Resident #5 revealed an admission date of 10/21/25. Diagnoses included chest pain, unspecified; atherosclerotic heart disease; essential hypertension; cerebrovascular disease; old myocardial infarction; paranoid schizophrenia; and displaced intertrochanteric fracture of unspecified femur.Review of a care plan for Resident #5 , dated 10/21/25, revealed the resident needed assistance from staff to meet activities of daily living (ADL) needs due to decreased mobility. Staff was to assist resident with incontinent care, toileting, bed mobility, dressing, and laundry.On 11/24/25 at 10:10 A.M., an observation of incontinence care for Resident #5 revealed the Certified Nurse Aide (CNA) #115 failed to maintain infection control while performing incontinence care. After cleansing the resident's perineal area following a bowel movement, CNA #115 did not wash her hands or change her gloves before she applied barrier cream and applied a new incontinence brief. Further, when changing linens, CNA #115 placed the soiled linens on the floor of Resident #5's room and did not place the linens in a bag or a soiled linen container. Following care, CNA #115 confirmed she did not wash hands, change gloves, or use a linen bag for soiled linens during the care process.On 11/24/25 at 10:43 A.M., an interview with Director of Nursing confirmed hands should be washed between performing peritoneal care and putting on new gloves. She also confirmed the soiled linens should be placed into a bag or linen barrel immediately and not placed on the floor.Review of a facility policy titled Perineal Care, dated 06/04/21, revealed the purpose of the of the procedure was to prevent infection and odors and promote comfort. The policy further indicated the staff was to wear gloves

during perineal care. During the cleansing process the staff was to place soiled washcloths, towels and linens on an impermeable barrier. The policy further indicated following care, the staff was to remove gloves and wash hands. There was no guidance of hand hygiene or glove changing when applying incontinent brief or barrier cream following perineal care. This deficiency represents non-compliance investigated under Complaint Number 2649219.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet