Health inspection·June 30, 2025

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, resident interview, staff interview, review of the test tray, review of facility policy, and review of United States Department of Agriculture (USDA) guidelines, the facility failed to maintain palatable and appetizing food temperatures. This had the potential to affect all residents in the facility. The census was 56. Residents Affected - Many Findings included: Review of the resident council minutes dated 05/22/25 revealed an unidentified resident complained of cold biscuits and gravy. On 06/25/25 at 7:40 A.M. an interview with Resident #25 revealed the food was sometimes cold. On 06/25/25 at 9:13 A.M. an interview with Resident #42 revealed the food was sometimes cold, but he understood it due to how far it had to come from the kitchen. On 06/25/25 at 9:17 A.M. an interview with Resident #39 revealed the food was always cold. Observation of the meal service on 06/25/25 from 10:50 A.M. to 12:50 P.M., revealed the dietary staff prepared the lunch meal that consisted of barbeque (BBQ) chicken, mashed potatoes, a broccoli, cauliflower and carrot blend, and apple crisp. Cooking temperatures obtained at this time by Assistant Dietary Manager #201, using a facility thermometer, revealed the BBQ chicken was 205 degrees Fahrenheit (F), the broccoli, cauliflower and carrot blend was 163 degrees F and the mashed potatoes were 180 degrees F. Food and beverage items prepared for this meal were confirmed to be consistent with the printed menu. Observation of food supplies confirmed the facility had sufficient amounts of various nutritious food and beverage selections. Further observation continued as dietary staff plated the lunch meal from a steam table in the kitchen. As the tray line neared an end, the surveyor requested a test tray be prepared and placed on the D hall food cart. Observation was made as the test tray was prepared and placed under the heat lamp at 12:40 P.M. until a Certified Nursing Assistant (CNA) came to pick up the meal cart. Then all of the meal trays were loaded onto the meal cart, transported down the hallway and passed out by the staff. The test tray remained on the cart in view of the surveyor until all other trays were distributed to residents. The test tray was removed from the cart at 12:50 P.M. by Dietary Manager #111 who used a facility thermometer that confirmed the temperatures were 122 degrees F for the BBQ chicken, 107.5 degrees F for the broccoli, cauliflower and carrots blend and 112 degrees F for the mashed potatoes and gravy. He verified the food dropped in temperature and should not have dropped that much. Immediately following confirmation of the test tray temperatures, the surveyor taste-tested the food, which was cold in temperature. Review of the facility policy titled, Food Preparation, dated 06/20/17 revealed the purpose was to ensure food was prepared in accordance with the USDA food code guidelines. Dietary staff would ensure all foods are held at an appropriate temperature of 135 degrees F for holding hot foods. Review of the USDA guidelines revealed leaving food out too long at room temperature can cause bacteria to grow to dangerous levels that can cause illness and bacteria grow most rapidly in the range of temperatures between 40 degrees F and 140 degrees F, doubling in number in as little as 20 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365417 If continuation sheet Page 2 of 3 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 06/30/2025 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 0804 Level of Harm - Minimal harm or potential for actual harm minutes. It stated that temperature range was known as the Danger Zone. The guidelines further stated to keep hot food hot, at or above 140 degrees F and to place cooked food in chafing dishes, preheated steam tables, warming trays, and/or slow cookers. This deficiency represents non-compliance investigated under Complaint Number OH00166266. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365417 If continuation sheet Page 3 of 3