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
Chain footprint
7 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,809
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9955
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.95
Baseline 26.31% · Performance 20.32% · Measure score 5.95 · Achievement 2.39 · Improvement 5.95
Healthcare-associated infections
5.50
Baseline 11.49% · Performance 7.60% · Measure score 5.50 · Achievement 0.80 · Improvement 5.50
Total nurse turnover
3.59
Baseline 59.32% · Performance 49.02% · Measure score 3.59 · Achievement 3.59 · Improvement 2.49
Adjusted total nurse staffing
2
Baseline 2.58 hours · Performance 3.38 hours · Measure score 2 · Achievement 1.06 · Improvement 2
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.36% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 14.29% · Lower 95% interval 8.22% |
| Discharge to community | 62.45% |
50.57%
11.9 pts better
|
Better than the National Rate · Eligible stays 61 · Observed rate 60.66% · Lower 95% interval 50.7% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 86.79% |
95.27%
8.5 pts worse
|
Numerator 46 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 20 · Denominator 35 |
| Discharge mobility score | 62.86% |
50.94%
11.9 pts better
|
Numerator 22 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 53 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.6% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 4.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 70 |
| Staff flu vaccination coverage | 7.23% |
42%
34.8 pts worse
|
Numerator 6 · Denominator 83 |
| Discharge function score | 62.86% |
56.45%
6.4 pts better
|
Numerator 22 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 3.7% |
25.2%
21.5 pts worse
|
Numerator 1 · Denominator 27 |
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 · Adjusted 1.7 · Observed 1.6 · Expected 1.8 · Used in QM five-star |
| 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 · Adjusted 2.2 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 97.7% |
| 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 · Q1 2.6% · Q2 7.3% · Q3 10.3% · Q4 11.4% · 4Q avg 7.8% · Used in QM five-star |
| 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 · Q1 7.9% · Q2 5.4% · Q3 14.7% · Q4 0.0% · 4Q avg 7.1% |
| 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 · Q1 6.5% · Q2 8.0% · Q3 4.3% · Q4 22.7% · 4Q avg 9.9% |
| 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 · Q1 29.0% · Q2 24.0% · Q3 24.0% · Q4 40.9% · 4Q avg 29.1% |
| 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 · Q1 4.2% · Q2 0.0% · 4Q avg 2.5% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 2.3% · Used in QM five-star |
| 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 · Q1 3.3% · Q2 4.0% · Q3 8.3% · Q4 0.0% · 4Q avg 4.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · Used in QM five-star |
| 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 · Q1 16.9% · Q2 46.4% · Q3 22.3% · Q4 28.2% · 4Q avg 28.7% |
| 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 · Q1 5.4% · Q2 4.7% · Q3 2.7% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| 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 · Q1 96.5% · Q2 95.3% · Q3 93.7% · Q4 67.8% · 4Q avg 88.8% |
| 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 · Adjusted 7.5% · Observed 7.8% · Expected 11.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.5% · Used in QM five-star |
| 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 · 4Q avg 94.3% |
| 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 · Adjusted 23.8% · Observed 25.5% · Expected 25.5% · Used in QM five-star |
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
Nearby options
Other facilities in reach
#1
Rolling Hills Rehab And Care Ctr
Bridgeport, OH
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $139,320 in total fines with 32 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Continuing Healthcare Of Shadyside
Shadyside, OH
2-star overall rating with 2-star inspections with $20,885 in total fines with 9 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Continuous Care Center Wheeling Hospital
Wheeling, WV
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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