Cycle 1
Health 2024-09-30 · Fire 2024-09-30
22 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Bellaire, OH
Country Club Retirement Ctr Iv
3-star overall rating with 2-star inspections with 22 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
55801 Conno-Mara Drive, Bellaire, OH
(740) 676-2300
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Country Club Rehabilitation Campus
Operator or chain grouping
Approved since
1987-06-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing
LPN hours / resident day
0.98
Licensed practical nurse staffing
Aide hours / resident day
2.31
Nurse aide staffing
Weekend hours
3.41
Weekend nurse staffing
RN turnover
29%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.7% |
94.5%
3.2 pts better
|
95.5%
2.2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.8% |
3.3%
4.5 pts worse
|
3.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
26.1%
19 pts better
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 9.9% |
6.2%
3.7 pts worse
|
5.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.1% |
25.4%
3.7 pts worse
|
19.6%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 2.5% |
11.5%
9 pts better
|
16.7%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 2.3% |
7.7%
5.4 pts better
|
16.3%
14 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
6.2%
2.2 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.5%
0.2 pts worse
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.7% |
21.7%
7 pts worse
|
19.8%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
3.7%
0.4 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.8% |
78.1%
10.7 pts better
|
81.7%
7.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
12.5%
5 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
75.6%
18.7 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.8% |
25.1%
1.3 pts better
|
23.9%
0.1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-09 · Fire 2022-11-09
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-12-18 · Fire 2019-12-18
9 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2026-01-29
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2026-02-11
F · Potential for more than minimal harm
2024-09-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-09-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-09
F · Potential for more than minimal harm
2022-11-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-29
F · Potential for more than minimal harm
2022-11-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-03-30
F · Potential for more than minimal harm
2022-11-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-11-29
E · Potential for more than minimal harm
2022-11-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-29
E · Potential for more than minimal harm
2022-11-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-11-29
F · Potential for more than minimal harm
2019-12-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-02-18
F · Potential for more than minimal harm
2019-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-01
F · Potential for more than minimal harm
2019-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-02-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-26
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-17
F · Potential for more than minimal harm
2025-11-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-11-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-11-25
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-12-18
E · Potential for more than minimal harm
2025-11-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-18
D · Potential for more than minimal harm
2025-11-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-18
G · Actual harm
2025-08-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-12
D · Potential for more than minimal harm
2025-03-12
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-03-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-21
D · Potential for more than minimal harm
2024-09-30
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-10-09
D · Potential for more than minimal harm
2024-09-30
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-10-09
D · Potential for more than minimal harm
2023-03-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-22
F · Potential for more than minimal harm
2022-11-09
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-11-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-11-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-11-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-11-09
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-11-29
J · Immediate jeopardy
2019-12-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-02-01
F · Potential for more than minimal harm
2019-12-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2020-02-01
D · Potential for more than minimal harm
2019-12-18
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-02-01
D · Potential for more than minimal harm
2019-12-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2020-02-01
D · Potential for more than minimal harm
2019-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-01
D · Potential for more than minimal harm
2019-12-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-02-01
D · Potential for more than minimal harm
2019-12-18
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2020-02-01
D · Potential for more than minimal harm
2019-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-01
Penalties and ownership
What sits behind the stars
Ownership
Gresock, Joshua
5% Or Greater Indirect Ownership Interest · Individual
Holland, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Holland, Nicholas
5% Or Greater Indirect Ownership Interest · Individual
Holland, Noah
5% Or Greater Indirect Ownership Interest · Individual
Holland-Gresock, Adam
5% Or Greater Indirect Ownership Interest · Individual
Holland-Gresock, Patricia
5% Or Greater Indirect Ownership Interest · Individual
Muirden-Holland, John
5% Or Greater Indirect Ownership Interest · Individual
Harris, Janet
Operational/Managerial Control · Individual
Harris, Janet
Corporate Officer · Individual
Holland Group Ii, Ltd
5% Or Greater Direct Ownership Interest · Organization
Holland, John
5% Or Greater Direct Ownership Interest · Individual
Holland-Grescock, Teresa
5% Or Greater Direct Ownership Interest · Individual
Kureishy, Zaveen
Operational/Managerial Control · Individual
Maroni, Anthony
Operational/Managerial Control · Individual
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#3
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