Health inspection·December 10, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on review of facility in-service records, review of the resident concerns/grievances log, review of the resident council minutes, interviews with residents and staff, and review of facility policy, the facility failed to ensure resident grievances were resolved in an appropriate manner and time frame regarding the answering of call llights. This affected nine residents (#30, #33, #34, #35, #39, #41, #44, #47, and #53) of nine residents reviewed for resident rights. The facility census was 54.Findings included: Review of a facility in-service record dated 09/23/25 revealed staff were in-serviced on answering call lights in a timely manner and it was everyone's responsibility to ensure call lights were answered.Review of the resident concerns/grievances log dated September 2025 to November 2025 revealed on 10/15/25 Resident #33 indicated a concern about call lights not being answered timely.Review of the concern form dated 10/15/25 revealed that Resident #33 had her call light on for over an hour before it was answered. The resolution was education.Review of the resident council minutes dated 10/30/25 revealed that new business was that call lights were not being answered timely.Review of call light logs for November 2025 revealed the following call light response times: On 11/07/25 the call light for Resident #35 was activated for 29 minutes 34 seconds. On 11/11/25 the call light for Resident #53 was activated for 27 minutes 14 seconds. On 11/13/25 the call light for Resident #39 was activated for 29 minutes 21 seconds. On 11/16/25 the call light for Resident #47 was activated for 122 minutes 44 seconds. On 11/16/25 the call light for Resident #41 was activated for 47 minutes 46 seconds. On 11/17/25 the call light for Resident #53 was activated for 59 minutes 35 seconds. On 11/18/25 the call light for Resident #34 was activated for 26 minutes 27 seconds. On 11/23/25 the call light for Resident #44 was activated for 50 minutes 52 seconds. On 11/24/25 the call light for Resident #44 was activated for 48 minutes 48 seconds.Interview on 12/09/25 at 2:20 P.M. with Resident #30 revealed that he usually waited half an hour before the call light was answered.Interview on 12/10/25 at 2:00 P.M. with Resident #34 revealed that it depended on the day and time when staff would answer the call lights and stated it is getting slightly better. Interview on 12/10/25 at 2:10 P.M. with Resident #47 revealed that she waits a long time for her call light to be answered. Interview on 12/10/25 at 9:45 A.M. with Regional Corporate Nurse (RCN) #302 revealed that she found the in-service completed on 09/23/25 but there were no audits or any follow-up on call lights.Review of the undated facility policy titled, Grievance Policy, revealed that the grievance official will take immediate action to prevent further potential violations of any resident right. This deficiency represents noncompliance investigated under Complaint Number 2626390, 2604068, and 2603368. 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 12/10/2025 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)