F 0584
Level of Harm - Minimal harm
or potential for actual harm
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
Based on observation and interview, the facility failed to maintain a resident room in a clean, organized,
and sanitary manner. This affected one resident (#15). The facility census was 62.
Residents Affected - Few
Findings include:
During the tour of the facility on 04/29/25 beginning at 4:30 P.M. with Regional Maintenance Director #100 it
was noted Resident #15 had an empty medication cup on the floor, a basin on the sofa with what appeared
to be a dried dark brownish red substance on the bottom of the basin, clothes lying on the floor, brown
discoloration in the toilet with what appeared to be a splattered spot of stool on the toilet tank, and dried
yellow substance in the bottom of the container of the suction machine sitting on the stand at his bedside.
On 04/29/25 during the tour, Regional Maintenance Director #100 verified Resident #15's room was not
clean, organized and sanitary.
This deficiency represents non-compliance investigated under Complaint Number OH00163989.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
365417
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
365417
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/01/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Country Club Center I
860 Iron Avenue
Dover, OH 44622
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 medical record review, observation, and interview, the facility failed to ensure appropriate
personal protective equipment (PPE) was utilized during a dressing change. This affected one resident
(#15) of one resident observed for a dressing change. The facility census was 62.
Residents Affected - Few
Findings include:
Review of Resident #15's medical record revealed diagnoses including malignant neoplasm of the
esophagus, dysphagia (difficulty swallowing), tracheostomy status, and encounter for attention to a
gastrostomy. An order dated 04/26/25 revealed the area around the J-tube (jejunostomy feeding tube) was
to be cleaned with normal saline and a clean drain sponge applied three times a day. A nursing note dated
04/29/25 at 5:30 P.M. indicated Resident #15's trach was removed at the doctor's office. The trach bandage
was to changed every day until healed.
During the tour on 04/29/25, Resident #15 was noted to have an enhanced barrier precaution (EBP) sign
posted on his doorway.
On 04/30/25 at 10:57 A.M., Registered Nurse (RN) #110 was observed changing the dressing to Resident
#15's J-tube site. The dressing and the top of Resident #15's pants had green drainage on them. RN #110
donned gloves when changing the dressing but did not wear a gown.
On 04/30/25 at 10:08 A.M., RN #110 verified he had not worn a gown while changing Resident #15's
dressing but should have.
Review of the facility's Enhanced Barrier Precautions policy (undated) revealed EBP precautions involved
gown and glove use during high-contact resident care activities for residents at risk of multi drug-resistant
organisms (MDRO) acquisition. High-contact resident activities included device care and wound care.
Chronic wounds included unhealed surgical wounds and indwelling medical devices included feeding tubes.
The policy explained devices and wounds were risk factors that placed residents at a higher risk for
carrying or acquiring a MDRO.
This deficiency represents non-compliance investigated under Complaint Number OH00164497.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365417
If continuation sheet
Page 2 of 2
