Health inspection·August 22, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Administrator stated there was hot water available on the 400 and 500 halls, including the 500-hall shower room. The Administrator stated several companies had been out to look at the hot water issue, but it had not been fixed yet. Interview on 08/18/25 at 1:30 P.M. with MD #255 revealed that around 08/01/25, he was told by a CNA that there was no hot water in the 200-hall shower room. MD #255 stated he went down to the shower room and confirmed the water was cold. Interview on 08/19/25 at 8:53 A.M. with Resident #22 revealed the hot water in her bathroom sink had been out for three weeks or more. Resident #22 stated she was not able to take bed baths or wash up if she wanted to. Resident #22 stated the shower room was busy, and she needed assistance to take showers. Observation of water temperatures on 08/19/25, beginning at 11:40 A.M. with the Administrator, revealed Resident #22's bathroom sink hot water temperature was 73.5 degrees F, Resident #23's bathroom sink hot water temperature was 66.0 degrees F, the 200-hall shower room hot water temperature was 72.5 degrees F, Resident #31's bathroom sink hot water temperature was 69.8 degrees F, Resident #9's bathroom sink hot water temperature was 68.0 degrees F, and Resident #2's bathroom sink hot water temperature was 65.0 degrees F. The Administrator verified the water temperatures. Review of an estimate for the replacement of the hot water heater revealed it was dated 07/23/25. Further review revealed no evidence the facility took action related to the acceptance of the estimate to make needed repairs. This deficiency represents noncompliance investigated under Master Complaint Number 2589044 and Complaint Number 2566950. Event ID: Facility ID: 365364 If continuation sheet Page 2 of 4 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 365364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Court Nursing and Rehabilitation Center 4911 Covenant House Drive Dayton, OH 45426 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of food delivery invoices and review of facility policy, the facility failed to ensure foods were properly stored and further failed to ensure dishes were clean and sanitized in a manner to prevent foodborne illness. This had the potential to affect all 42 residents residing in the facility. The facility census was 42. Finding include:1. Interview on 08/18/25 at 10:13 A.M. with the Administrator revealed the facility's freezer did not work. The Administrator stated an air compressor was received to repair the freezer, but the repair did not fix it. The Administrator stated the facility did not use frozen food at this time. Observation on 08/18/25 at 10:18 A.M. of the freezer revealed that it was empty and contained no food items. Further observation of refrigerator number two revealed foods that should have been stored in the freezer, including eight 32-ounce bags of carrots, one 40 count box of sausage patties, one 12-pound box of sliced beef, 12 pounds of turkey meat, a 10-pound box of fish patties, and three 40-ounce bags of corn.Interview on 08/18/25 at 10:19 A.M. with [NAME] #245 confirmed the fish patties, corn, carrots, sausage patties, turkey and beef were stored in the refrigerator and should have been stored in the freezer until they were pulled for use. [NAME] #245 stated all of those foods were delivered to the facility on [DATE] and had been in the refrigerator since delivery because the freezer did not work.Interview on 08/18/25 at 11:25 A.M. with Public Health Department (PHD) #303 revealed they inspected the facility last week and found that both of the facility's refrigerators exceeded the recommended maximum temperature of 41 degrees F. PHD #303 stated that dietary staff were making homemade pizzas that included eggs, cheese and sausage and the refrigerator that the pizzas were being held in prior to baking had a temperature of 50 degrees F. Observation on 08/18/25 at 12:32 P.M. of refrigerator number one revealed an internal temperature of 47 degrees F. The refrigerator contained a large box of ground beef and a large box of French toast. Further observation of refrigerator number two revealed an internal temperature of 43 degrees F. The refrigerator contained eggs, milk, fresh fruit, bread, fresh vegetables and the frozen food items identified above. Concurrent interview with [NAME] #245 verified the temperatures of refrigerator number one and two. Additionally, [NAME] #245 confirmed the boxes of ground beef and French toast should have been stored in a freezer.Review of the food vendor invoice, dated 08/14/25, confirmed the facility had sausage patties, sliced beef, and breaded fish delivered on that date. Review of the facility policy titled, Date Marking for Food Safety, undated, revealed that refrigerated, ready-to-eat, time/temperature control for food safety (for example, perishable food) foods should be held at a temperature of 41 degrees F or less. Review of the facility policy titled, Food Safety Requirements, undated, revealed the facility policy was to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food would be stored in accordance with professional standards for food service safety. Foods that required refrigeration should be refrigerated immediately upon receipt or placed in the freezer, whichever was applicable. 2. Interview on 08/18/25 at 11:49 A.M. with the Administrator revealed the hot water in the kitchen had been turned off due to the ventilation. The Administrator verified there was no hot water available in the kitchen, but there was hot water on the 400 and 500 halls of the facility. The Administrator stated dietary staff boiled water to sterilize the pots and pans. Observation on 08/19/25 at 8:57 A.M. of the water temperatures in the kitchen with the Administrator revealed the sink near the coffee machine was 74.4 degrees Fahrenheit (F), the sink across from the stove was 74.9 degrees F, the three compartment sink had two faucets, with the one closest to the refrigerator being 74.9 degrees F and the second faucet water temperature being 70.4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365364 If continuation sheet Page 3 of 4 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 365364 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Garden Court Nursing and Rehabilitation Center 4911 Covenant House Drive Dayton, OH 45426 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete degrees F. The Administrator verified the water temperatures. Observation on 08/18/25 from 12:31 P.M. through 12:50 P.M. revealed [NAME] #220 prepared the three-compartment sink to wash dishes. The first sink held water poured from a 33 gallon pan that had boiling water from the stove. [NAME] #220 poured pot and pan detergent directly from a one-gallon jug into the water in the first sink, without measuring the amount. The second sink contained plain hot water for rinsing. The third sink had cold water. [NAME] #220 proceeded to pour just under one-half of a full gallon sized jug of sanitizer into the water in the third sink. Further observation revealed [NAME] #220 tested the sanitation level in the third sink and the test strip read 400 parts per million (ppm), which was a dark blue color on the test strip. [NAME] #220 verified there was too much sanitizer in the water, noting the color on the test strip should be more of a green color, and stated he had no measuring devices to ensure appropriate chemicals were used to ensure safe sanitation of the dishes. Interview on 08/22/25 at 3:50 P.M. with Dietary Manager (DM) #944 revealed the hot water in the kitchen went out approximately one month ago. DM #944 stated the device to measure the chemical solutions for the three-compartment sink had been broken for a long time and staff did not have a way to measure cleaning or sanitation solutions to ensure safe and effective cleaning of the dishes. DM #944 confirmed dietary staff washed dishes in the three-compartment sink since the kitchen had no hot water to use the dishwasher. This deficiency represents noncompliance investigated under Master Complaint Number 2589044. Event ID: Facility ID: 365364 If continuation sheet Page 4 of 4