Inspection·January 4, 2020

F 0558 4.7 cm in width and 0.5 cm in depth. Level of Harm - Minimal harm or potential for actual harm Review of the Skin/Wound assessment, dated 01/02/20 documented the area to the top of right foot now measured 6 cm in length by 3.5 cm in width with 0.02 cm depth. There was a slight amount of yellow green drainage with no odor. In addition the resident was noted to have a scabbed area to right foot second digit measuring 1 cm by 0.5 cm. A new treatment of betadine was started. Residents Affected - Few Interview with Resident #11 on 01/02/20 at 4:30 P.M. stated he had an appointment with the wound clinic on 01/03/20 for an open area on the top of his right foot. He stated the area started with a blood blister caused by hitting his foot on the bed when he was in the hospital. It was observed there was an extra wide wheelchair in his room at the time of the interview. He stated he just got his wheelchair back in his room a couple of days ago. He stated he would have to go by stretcher to the wound clinic as he had not been up in his wheelchair for months. He expressed concerns about being transported to the wound clinic appointment in a wheelchair because he had not been up in an extremely long time. Interview with Resident #11 on 01/03/20 at 10:20 A.M. stated his appointment with the wound clinic was canceled because the facility did not arrange for transportation. Interview with Director of Nursing (DON) on 01/03/20 at 11:30 A.M. stated the facility was going to transport Resident #11 in a wheelchair with the facility's van to the wound clinic. She stated the resident had refused to go to the appointment. Interview with Registered Nurse (RN) #105 on 01/03/20 at 1:30 P.M. stated she had made the appointment with the wound clinic last Friday on 12/27/19 for the following Friday, 01/03/20. She stated she put the appointment on the 2019 calendar instead of the 2020 calendar. She verified she became busy and forgot to arrange for transportation. She verified the resident was unable to be transported by a wheelchair because he has not been up in a chair for more than 20 minutes in months. She verified he had to be transferred by stretcher. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 2 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) included the explanation of estimated cost. This affected two (#19 and #31) out of three residents review for beneficiary protection notification. The facility census was 31. Residents Affected - Few Findings include: 1. Review of medical record for Resident #19 revealed an admission date of 10/21/19 with diagnosis including acute kidney failure, tachycardia, iron deficiency, chronic kidney disease, hypertension, hypothyroidism and muscle weakness. Review of physician order dated 11/18/19 Resident #19 documented physical therapy recertification complete for five time a week for one week to address therapy active training, gait training and patient caregiver education. Review of SNFABN documented Physical Therapy services were to end on 11/23/19. Resident #19 refused to sign the notice on 11/20/19. Resident #19 wasn't informed of the estimated cost as part of the SNFABN notification requirements. 2. Review of medical record for Resident #31 revealed and admission date of 12/04/19 with diagnosis including Rheumatoid Arthritis, venous inefficiency, contracture, hypoglycemia, muscle weakness, and symbolic dysfunction. Review of physician order dated 12/05/19 documented Resident #31 to continue physical therapy to address activity training, neurological training, gait training, group functional training and patient and caregiver training. Review of SNFABN documented therapy services were to end 12/26/19. Resident #19 signed 12/24/19 documented the notice was given for discontinuation of therapy service. Resident #31 wasn't informed of the estimated cost as part of the SNFABN notification requirements. On 01/02/20 at 1:15 P.M. interview with Registered Nurse (RN) #360 verified the estimated cost was not included in the SNFABN for Resident #19 and #31. RN #360 confirmed the estimated cost should have been part of the notice as required. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 3 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interview and policy review, the facility failed to ensure residents were free from involuntary seclusion when the facility used a coded secure entrance/exit door at the main entrance of the facility without providing the code to resident's who were cognitively intact, alert, oriented and independently mobile. This affected four (#4, #2, #10, #3) of four residents reviewed for involuntary seclusion. The facility identified 12 (#28, #9, #31, #15, #12, #25, #24, #27, #18, #26, #30 and #29) additional residents who were cognitively intact, alert, oriented and independently mobile who could potentially be affected by the secured entrance/exit door. The facility census was 31. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #4 revealed the resident was admitted to the facility on [DATE]. Diagnoses include coronary artery disease, depression, anxiety, mild cognitive impairment, obesity, urinary incontinence, symbolic dysfunction, weakness, muscle weakness and chronic obstructive pulmonary disease. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficits. It further revealed the resident had no abnormal behaviors or episodes of wandering. Further review of the medical record revealed no orders, consent or assessment for the resident to be on a secured unit. Additionally, there was no evidence in the medical record the resident had been provided a code to entrance/exit door. Interview with the Administrator on 01/04/20 at 1:00 P.M. verified the entrance/exit to the facility was secured with a coded entry system and residents were unable to enter or exit without staff assistance. The Administrator stated it was company policy not to provide the code to anyone except stiff members. She further stated if residents wanted to go in or out, they would have to wait for staff assistance, even if the resident was alert and independently mobile. Interview with Resident #4 on 01/04/20 at 2:00 P.M. revealed he would like to go outside on the porch when he wanted without having to wait on someone to let him out. He stated he had never been given the code to the entry system or asked if he wanted to go outside on his own. Observation of the front main door entrance and exit from the facility between 01/02/20 and 01/04/20 at 1:00 P.M. revealed facility staff was required for visitors or alert and independently mobile residents to go outside or to re-enter the facility. A coded entry system was observed to the side of the door with the light on red. 2. Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses include non displaced trimalleolar fracture of left lower leg, morbid obesity, right heart failure, depression, diabetes mellitus type II, diabetic neuropathy, chronic obstructive pulmonary disease, persistent mood disorder, ischemic heart disease, urine retention, neurogenic dysfunction of bladder, bipolar, hyperlipidemia, hypertension and anxiety. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 4 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0603 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had no cognitive deficits, episodes of wandering or abnormal behaviors. The resident required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene, with supervisions for locomotion and eating. Further review of the medical record revealed no orders, consent or assessment for the resident to be on a secured unit. Additionally, there was no evidence in the medical record the resident had been provided a code to entrance/exit door. 3. Review of the medical record for Resident #10 revealed the resident was admitted on [DATE]. Diagnoses include hemiplegia, hemiparesis, aphasia, anxiety, depression, muscle spasm, hyperlipidemia, lack of coordination, muscle weakness, unsteadiness, symbolic dysfunctions and expressive language disorder. Review of a 60-day Minimum Data Set (MDS) 3.0 assessment revealed the resident had no issues with short or long term memory. The resident required only supervision with locomotion. There were no abnormal behaviors or wandering episodes. Further review of the medical record revealed no orders, consent or assessment for the resident to be on a secured unit. Additionally, there was no evidence in the medical record the resident had been provided a code to entrance/exit door. 4. Review of the medical record for Resident #3 revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia with Lewy bodies, dysphagia, hypoxemia, abnormal gait, muscle weakness, depression, symbolic dysfunction, syncope and Parkinson's disease. Review of a Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed the resident had no cognitive deficits. Only set-up assistance and a walker of wheelchair were required for supervision. Further review of the medical record revealed no orders, consent or assessment for the resident to be on a secured unit. Additionally, there was no evidence in the medical record the resident had been provided a code to entrance/exit door. Further interview with the Administrator on 01/04/20 at 2:10 P.M. revealed there was no facility policy regarding the use of the secured entry system at the main door. The Administrator confirmed Resident #4, #2, #10 and #3 were cognitively intact, alerted, oriented and were not provided with the code to exit door. The facility identified 12 (#28, #9, #31, #15, #12, #25, #24, #27, #18, #26, #30 and #29) additional residents who are cognitively intact, alert, oriented and independently mobile who could potentially be affected by the secured entrance/exit door Review of facility policy Ohio Abuse, Neglect and Misappropriation dated 04/01/19 included involuntary seclusion as a sample of abuse. It defined involuntary seclusion as the separation from other residents or confinement to their room against their will. The policy did not address a resident being in a secured unit. Review of facility policy Physical Restraint and Management dated 05/3/19 revealed a physical restraint was any manual method, physical or mechanical device, equipment or material that was attached or adjacent to a resident's body, could not be removed easily and restricted their freedom of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 5 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0603 movement. A resident was to be assessed for the need of the restraint, care planned for the restraint and have a consent form and a physician order. A secured unit was not included in the examples of a restraint. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 6 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure residents were provided written notification of transfer upon transfer from the facility. This affected one (#11) of five residents reviewed for hospitalizations. The facility census was 31. Findings include: Review of Resident #11's medical record revealed the resident was admitted to he facility on 10/07/19. Diagnoses included chronic obstructive pulmonary disease, diabetes type II, hypertension, gastro esophageal reflux disease, hypothyroidism, atrial fibrillation, major depression, urine retention and morbid obesity. Further review of Resident #11's medical record revealed the resident was transferred to the hospital and hospitalized on [DATE] and returned to the facility on [DATE]. Resident #11 was admitted to the hospital again on 12/08/19 and readmitted [DATE]. Review of the medical record revealed no reason for the transfers to the hospital on [DATE] and 12/08/19 given to resident and representative in writing. On 01/03/19 at 3:40 P.M. the Administrator verified Resident #11 and the representative were not given the reason for transfer and discharge for the hospitalizations on 10/28/19 and 12/08/19. Review of facility policy Admission, Discharge and Transfer dated 05/30/19, revealed the resident and the resident's representative were to be notified before the facility transferred or discharged a resident, in writing and in a language and manner they understood. The notice was to include why the resident was being transferred as well as a statement of the resident's appeal rights, including the name of the entity which received appeal requests along with their contact information as well as the Ombudsman's. The notice was to be given before the transfer or as soon as practical if the safety or health of the individuals in the facility would be endangered or if a resident's urgent medical needs required an immediate transfer. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 7 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review and staff interview, the facility failed to ensure a Discharge-return not anticipated Minimum Data Set (MDS) assessment was completed and submitted within 14 days to Center for Medicare & Medicare Services (CMS) database. This affected one (#1) out of one resident reviewed for resident assessments based on information submitted to CMS. The facility census was 31. Residents Affected - Few Findings include: Review of closed medical record documented Resident #1 was admitted to the facility on [DATE] with diagnosis including hypothyroidism, hypertension, history of falls, hyperlipidemia, constipation, atrial fibrillation and muscle weakness. Review of census record documented Resident #1 was discharge from the facility on 09/29/19 and moved to the assisted living in the same building. Review of discharge-return not anticipated MDS for Resident #1 dated 09/29/19 was not completed until 01/02/19 and was not submitted to the CMS database until 01/03/19. On 01/03/20 at 10:15 A.M. an interview with MDS Nurse #360 verified Resident #1's discharge assessment was not completed and transmitted to the CMS database with in 14 days after discharge from the facility. She verified it was completed on 01/02/19 and submitted to the CMS database on 01/03/19. She also verified resident was discharged fro the skilled side and moved to the assisted living side located in the same building. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 8 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff, resident and family interview and policy review, the facility failed to ensure residents and responsible parties were provided personalized care planning conferences on admission and on a quarterly basis. This affected two (#2 and #21) of two residents reviewed for care planning. Facility census was 31. Findings include: 1. Review of the medical record for Resident #2 revealed the resident was admitted to the facility on [DATE]. Diagnoses include non displaced trimalleolar fracture ( fracture of the ankle including the ankle bone and the lower part of the tibial bone) of left lower leg, morbid obesity, right heart failure, depression, diabetes mellitus type II, diabetic neuropathy, chronic obstructive pulmonary disease, persistent mood disorder, ischemic heart disease, urine retention, neurogenic dysfunction of bladder, bipolar, hyperlipidemia, hypertension and anxiety. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had no cognitive deficits or abnormal behaviors. The resident required extensive assistance for bed mobility, transfers, dressing, toileting and personal hygiene, with supervisions for locomotion and eating. Review of a plan of care for Resident #2 revealed a comprehensive plan of care had ben developed and updated on 11/23/19. Review of an Interdisciplinary Team (IDT) note dated 01/03/20 at 6:20 P.M. revealed a care conference was held for Resident #2 in the resident's room. Interview with Resident #2 on 01/02/20 at 1:32 P.M. revealed she had not been invited to a care conference meeting and would like to go. Resident #2 further stated she had never been given a copy of her plan of care. Interview with the Administrator on 01/03/20 at 9:30 A.M. revealed care conference invitations were to be sent out a month in advance. The Administrator further stated the invitation was to be sent to the resident if they were their own responsible party, otherwise it was to be sent to the resident's responsible party. The IDT was to document on the form if the resident or family attended the conference. Further interview with the Administrator on 01/04/20 at 11:45 A.M. verified there had been no care conference held for Resident #2 since the resident's admission to the facility until 01/03/20. The Administrator further verified the interdisciplinary team did have an impromptu meeting with Resident #2 on 01/03/20 after the IDT had been informed by the surveyor there had been no care conferences for the resident since admission. Interview with MDS nurse #360 on 01/04/20 at 1:00 P.M. verified the facility had not provided Resident #2 with a care conference on admission or at her quarterly update. She stated there was a care conference with the resident last night. She further verified there had been no care conferences on any resident since she started in 11/2019 and was not aware of who was supposed to be notifying (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 9 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0657 Level of Harm - Minimal harm or potential for actual harm residents and/or families if there was a care conference. She further verified the resident was not provided a copy of the plan of care from admission or after the first care conference last month. Review of a blank undated form revealed the facility did have a form to invite residents and family to a care conference but had not been used. Residents Affected - Few 2. Review of the medical record for Resident #21 revealed the resident was admitted to the facility on [DATE]. Diagnoses include Alzheimer's disease, hypertension, psychosis, hypothyroidism, coronary artery disease, vitamin B12 deficiency, muscle weakness, symbolic dysfunction shortness of breath and chronic obstructive pulmonary disease. Review of a quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had short and long term memory issues and modified independence with cognitive skills for daily decision making. The MDS assessment revealed the resident had other behavioral symptoms not directed towards others on one to three days and no rejection of care. Extensive assistance was required for bed mobility, transfers, locomotion, dressing, eating, toileting and personal hygiene. The resident was always incontinent of urine and frequently incontinent of bowel. The resident had non-verbal signs of pain three to four days a week. The resident received a mechanically altered diet and had no weight issues or pressure ulcers. Review of a plan of care dated 11/13/19 revealed a comprehensive plan of care had been developed for Resident #21 upon admission to the facility. Review of the care conference note held on 01/03/20 at 7:52 P.M. revealed the family member did have concerns and requests which were discussed at the meeting including use of napkins at meal times, pain, use of smaller drinking glasses and missing dentures. It revealed the resident chose not to attend. It revealed the family member was notified of the care conference on 01/02/20 at 6:55 P.M. Interview with the family member for Resident #32 on 01/02/20 at 2:46 P.M. revealed she did not remember being invited to or attending a care conference meeting. She further revealed she did not receive a copy of the care plan the facility had come up with nor was she aware of what goals had been set for her, but would like to have a meeting. Interview with the Administrator on 01/03/20 at 9:30 A.M. revealed care conference invitations were to be sent out a month in advance. The Administrator further stated the invitation was to be sent to the resident if they were their own responsible party, otherwise it was to be sent to the resident's responsible party. The IDT was to document on the form if the resident or family attended the conference. Further interview with the Administrator on 01/04/20 at 11:45 A.M. verified there had been no care conference held for Resident #21 since the resident's admission to the facility. The Administrator further verified the interdisciplinary team did have an impromptu meeting with Resident #2 on 01/03/20 after the IDT had been informed by the surveyor there had been no care conferences for the resident since admission. The Administrator further verified the facility did not timely notify the resident or family of the care conference and it had only been determined to meet that day. Interview with MDS nurse #360 on 01/04/20 at 1:00 P.M. verified the facility had not provided Resident #21 with a care conference on admission or at her quarterly update. She further verified there had been no care conferences on any resident since she started in 11/2019 and was not aware of who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 10 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was supposed to be notifying residents and/or families if there was a care conference. She further verified the resident and or family was not provided a copy of the plan of care from admission or after the first care conference last night. Review of a blank undated form revealed the facility did have a form to invite residents and family to a care conference. Review of facility policy Care Planning Meeting dated 02/04/19 revealed a care plan meeting was to be held to discuss the care plan and discharge planning. Conferences were to be held at least quarterly and invitations were to be extended to the resident and/or resident representative to attend the care conference. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 11 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, observation, and staff interview the facility failed to assess and implement interventions for a resident who was exhibiting exit seeking behaviors. Additionally, the facility failed to implement physician orders fall interventions for a resident at risk for falling. This affected two (#33 and #7) out of three residents reviewed for accidents and hazards. The facility census was 31. Findings include: 1. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, congestive heart failure, major depressive disorder, schizophrenia and asthma. Review of the nursing admission Assessment, dated 12/09/19 revealed there was on documentation indicating if the resident was at risk elopement risk. Review of the admission minimum data set (MDS) assessment, dated 12/12/19, revealed the resident scored a four out of 15 on the Brief Interview for Mental Status (BIMS) indicating the resident has severe cognitive impairment. During the assessment look back period the resident did not display behaviors, rejection of care, or wandering. Review of the plan of care, dated 12/12/19 documented Resident #33 has been feeling down due to being back in a nursing home and having acute health conditions. The interventions include social service will continue to provide, services, monitor for changes, and report changes to the physician. Review of the nursing progress notes, dated 01/02/20 at 11:36 A.M. documented Resident #33 came out of her room with all of her belongings packed. She went to the back door and tried to get out. She stated she was waiting on her family member to come and take her to the trailer park. The resident was redirected and taken back to her room. Observation on 01/03/20 at 10:30 A.M. revealed the resident was sitting on the side of her bed in he room. She did not have a room mate. Observation of the location of the resident's room revealed she was the last room on the hallway next to the emergency exit door. Observation of the resident's room revealed her personal belongings were in bags and a small open tote on a chair across form her bed. Observation of the resident on 01/04/20 at 9:30 A.M. revealed the Resident # 33 was walking back and forth in the hallway outside of her room carrying her purse. Interview with the Director of Nursing on 01/04/20 at 4:15 P.M. verified Resident #33 was confused. She verified on 01/02/20 she exited the facility via the back door with her belongings. She verified the Resident #33 was at risk for elopement based on confusion, her attempt to leave the facility unattended, and the proximity of the back door to her room. She verified Resident 33 had not been assessed for elopement risk on admission or following 01/02/20 when she attempted to leave the facility unattended. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 12 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 01/04/19 at 4:40 P.M. the Administrator stated the facility did not have a policy for assessing or implementing a plan for residents who were at risk for elopement. 2. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses including heart failure, chronic obstructive pulmonary disease, diabetes, atrial fibrillation, poly arthritis and anxiety disorder. Review of the quarterly minimum data set (MDS) assessment, dated 10/09/19, revealed the resident scored an eight on the BIMS indicating severe cognitive impairment. The assessment stated the resident had experienced two falls without injuries since the last MDS assessment. Review of the plan of care, dated 10/25/19, documented the resident was at risk for falls. The intervention included placing the right side of her bed against the wall. Review of the January 2020 monthly physician orders revealed an order initiated on 12/21/19 documented a floor mat was to be placed at the resident's bedside for fall prevention/injury every day and and through out the night. Observation on 01/04/20 at 11:15 AM revealed Resident #7 was in low bed lying on the very edge of the left side of the bed. The right side of the bed was against the wall. The floor mat was folded up against the wall at the foot of the bed. On 01/04/20 at 11:20 A.M. Registered Nurse (RN) #710 verified the resident was lying on the very edge of the bed and there was no floor mat by the bed. RN #710 verified there was a physician order for a floor mat to be placed by her bed because she sleeps so close to the edge and has fallen in the past. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 13 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure physician ordered pre and post dialysis evaluations were completed. This affected one (#16) out of one resident reviewed for dialysis. The facility identified two resident currently receiving dialysis treatment. Residents Affected - Few Findings include: Review of medical record for Resident #16 revealed an admission date of 11/14/19 with diagnosis including diabetes type two, obesity, and stage renal disease, anemia, fluid volume overload, atrial fibrillation, dependency on renal dialysis, non compliance with renal dialysis, liver disease, hypertension and congestive heart failure. Review of physician order dated 11/14/19 documented Resident #16 is to receive dialysis treatment on Mondays, Wednesdays and Fridays. Review of admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident #16 was cognitively intact and currently received dialysis treatment. Review of comprehensive care plan for dialysis documented an intervention to follow obtain vital signs and weight as ordered per protocol. Review of physician order dated 11/29/19 documented Resident #16 was to have a pre-dialysis evaluation completed and sent to dialysis every day shift on Mondays, Wednesdays and Fridays . Further review documented a post dialysis evaluation needs to be completed upon return from dialysis on every night shift on Mondays, Wednesdays and Fridays. Review of nursing notes from 12/01/19 through 12/31/19 lacked any documented pre or post dialysis assessments completed on dialysis treatments. Review of dialysis treatment record for Resident #16 on Wednesday received dialysis treatment on 12/04/19. There lacked any documented pre or post dialysis treatment evaluations were completed. Review of dialysis treatment record for Resident #16 on Monday received dialysis treatment on 12/09/19. There lacked any documented pre or post dialysis treatment evaluation were completed. Review of dialysis treatment record for Resident #16 on Friday received dialysis treatment on 12/13/19. There lacked any documented pre or post dialysis treatment evaluation were completed. Review of dialysis treatment record for Resident #16 on Wednesday received dialysis treatment on 12/18/19. There lacked any documented pre or post dialysis treatment evaluation were completed. Review of dialysis treatment record for Resident #16 on Monday received dialysis treatment on 12/23/19. There lacked any documented pre or post dialysis treatment evaluation were completed. On 01/03/20 at 2:17 P.M. an interview with Director of Nursing (DON) verified the pre and post dialysis treatment evaluation were not completed as ordered for Resident #16. She also verified its part of the dialysis policy to complete a pre and post dialysis evaluation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 14 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0698 Level of Harm - Minimal harm or potential for actual harm Review of hemodialysis care and monitoring policy and procedure revised 03/23/18 documented pre and post dialysis evaluations are to be completed for dialysis treatments which include complete assessments including vital signs and weights. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 15 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record, and staff interview, the facility failed to administer Coumadin (anticoagulant) as ordered by the physician. This affected one (#7) out of five residents reviewed for unnecessary medication. The facility census was 31. Findings include: Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include heart failure, chronic obstructive pulmonary disease, diabetes, atrial fibrillation, poly arthritis and anxiety disorder. Review of the quarterly minimum data set (MDS) assessment, dated 10/09/19, revealed the resident scored an eight out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The resident received, insulin, antianxiety, diuretic and anticoagulant medication all seven days of the assessment. Review of the plan of care, dated 10/25/19 documented the resident was at risk for abnormal bleeding or hemorrhage due to anticoagulant use related to atrial fibrillation. The goal stated the resident will be free from signs and symptoms of abnormal bleeding through next review date. The interventions included administering anticoagulant medications as currently prescribed by the physician, and obtain labs per physician order to monitor coagulation factors. Review of the December 2019 and January 2020 monthly physician orders included an order for Coumadin four milligrams (mg) once a day due to atrial fibrillation. Review of the international normalized ratio (INR) results, dated 12/30/19, revealed an INR of 4.2 (normal range between two to three for residents receiving anticoagulants). The physician wrote an order on the laboratory INR results sheets instructing staff to hold Coumadin for three days (12/31/19, 01/01/20 , and 01/02/20) and repeat the INR. Review of the medical record revealed there was no INR results dated 01/03/20. Review of the December 2019 medication administration record (MAR) revealed Coumadin four mg was not given on 12/31/19. Review of the January 2020 MAR revealed Coumadin four mg was not given on 01/01/20, 01/02/20, and 01/03/20. On 01/04/20 at 12:06 PM. Registered Nurse (RN) #710 found an INR lab result that had been faxed to the facility on [DATE]. The INR result was 2.73. She verified the physician had not been aware of the the INR results until 01/04/19 when the surveyor asked for the laboratory results. She stated she spoke to the physician on the phone and informed him of the INR results and he gave her a verbal order to resume the Coumadin four mg daily. She verified the resident did not receive Coumadin four mg on 01/03/20. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 16 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure monthly medication reviews were completed for Resident #7 and failed to ensure pharmacy recommendations were followed up on for Resident #3. This affected two (#7 and #3) out of five residents reviewed for unnecessary medications. The facility census was 31. Findings include: 1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, chronic obstructive pulmonary disease, diabetes, atrial fibrillation, poly arthritis and anxiety disorder. Review of the quarterly minimum data set (MDS) assessment, dated 10/09/19, revealed the resident scored an eight out of 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The assessment stated the resident received, insulin, antianxiety, diuretic and anticoagulant medication all seven days of the assessment. Review for the monthly pharmacy visits revealed there was no record that the pharmacy reviewed the resident's medication regimen on 04/19, 06/19, 07/19, 11/19 and 12/19. On 01/04/19 at 11:58 AM the Director of Nursing (DON) verified there is no record of the pharmacy reviewing the resident's medication regimen for 04/19, 06/19, 07/19,11/19 and 12/19. 2. Review of Resident #3's medical record review revealed and admission date of 01/06/17. Diagnoses include dementia with Lewy bodies, dysphagia, hyperlipidemia, major depression, mental disorder, weakness and hypertension. Review of pharmacy recommendation dated 07/02/19 documented a recommendation to consider separating the administration of Carbidopa/Levodopa and Calcium/Vitamin D with iron by at least two hours. Further review documented the physician did not review the the recommendations until 11/19/19. Review of pharmacy recommendation dated 08/15/19 documented a recommendation to consider a gradual dose reduction for Seroquel (antipsychotic), Depakote Sodium (mood stabilizer) and Lexapro (antidepressant). The physician did not decline the recommendation until 12/09/19. Review of the quarterly minimum data set (MDS) assessment, dated 10/02/19, revealed the resident scored an 14 on out of 15 on the BIMS indicating no cognitive impairment. The assessment stated the resident received, antipsychotic, antidepressant, diuretic medication all seven days of the assessment. On 01/04/19 at 1:00 P.M. an interview with DON verified the physician is not following up on pharmacy recommendations timely for Resident #3's pharmacy recommendations dated 07/02/19 and 08/15/19. Review of medication regimen review policy and procedure revised 09/23/19 documented the Pharmacist shall conduct a monthly medication review and these reports will be acted upon in a timely manner by the attending physician, medical director or DON. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 17 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the physician of the results of a urine culture and sensitivity resulting in the use antibiotic which the organism was not sensitive to. This affected one (#6) of five residents laboratory results reviewed during review of unnecessary medications. The facility census was 31. Findings include: Resident #6 was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney failure, congestive heart failure, hypertension, anemia and Stage IV pressure ulcer to the sacrum. Review of the quarterly minimum data set (MDS) assessment, dated 10/09/19, revealed the resident's Brief Interview for Mental Status (BIMS) score was an eight out 15 indicating severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility and transfers. He is no ambulatory and no longer propels his wheelchair on or off the unit. He has a suprapubic catheter in place He is always incontinent of bowel. He has unhealed Stage IV pressure ulcer. Review of the plan of care, updated 10/19/19 documented the resident has a suprapubic catheter in place due to a non healing Stage IV pressure ulcer. The plan of care stated he is at risk for urinary tract infections due to long term catheter placement. The interventions include monitor the resident for signs and symptoms of urinary tract infection and report the findings to the physician. Review of nursing progress note dated,12/26/19 at 7:03 PM, documented the urinalysis results was received and the physician was called with the results. A new order was received for Cipro (antibiotic) 500 milligrams (mg) twice a day for ten days for a urinary tract infection. Review of the urinalysis results that were faxed to the facility on [DATE] showed small amount of blood, positive nitrate, and large amount of leukocytes in the urine. The urinalysis results were signed by the physician. Review of the urine culture and sensitivity that were faxed to the facility on [DATE] revealed a colony count of greater than 100,000 CFU (colony forming units) per milliliter (ml) of proteus mirabilis (organism). The sensitivity documented Cipro has an intermediate susceptibility to Cipro at a dose of 750 mg twice a day. There was no physician signature on the urine culture and sensitivity report. Further review of the progress notes dated 12/29/19 through 01/03/20 made not mention the physician had been notified of the urine culture and sensitivity results. On 01/03/20 at 3:34 P.M. Director of Nursing (DON) verified she had spoken to the physician today and he was unaware of the urine culture and sensitivity results on 12/29/19. She stated on 01/03/20 the physician, after reviewing the urine culture and sensitivity, discontinued the Cipro and started the resident on Rocephin (antibiotic) which was listed as being sensitive to the organism identified on the urine culture and sensitivity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 18 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Based on review of a snack sign out sheet, observations, staff and resident interview and policy review, the facility failed to ensure residents received substantial bedtime snacks due to the time span of greater than 14 hours between the dinner meal and breakfast. The facility identified all 31 residents residing in the facility who received food from the kitchen. Facility census was 31. Findings include: Review of bedtime snack sign out sheets dated 10/1/19 through 1/03/20 revealed bed time snacks were documented as not passed on 11/01/19, 11/03/19, 11/04/19, 11/07/19, 11/10/19, 11/17/19, 11/20/19, 11/23/19, 11/24/19, 11/25/19 and 12/01/19. 12/10/19, 12/12/19, 12/14/19, 12/23/19, 12/25/19 and 12/26/19. Review of morning meeting notes dated 12/06/19, 12/15/19, 12/31/19 and 01/02/20 revealed Dietary Manager #420 had informed management during the morning meeting of bedtime snacks not being provided to residents. Interview with four residents (#3, #4, #24 and #27) during the resident council meeting on 01/03/20 at 10:04 A.M. revealed they did not receive bedtime snacks on a routine basis. They further stated they did get hungry at night at times. Interview with Dietary Manager #420 on 01/03/10 at 10:30 A.M. verified there was a time span of greater than 14 hours between the supper meal and breakfast. She stated all residents were to be offered a substantial snack. She stated this could include peanut butter and jelly sandwiches, cold cut meat sandwiches, peanut butter crackers, cookies or ice cream. She stated some residents had informed her of their preferred snack and she would have it delivered with their name on it. She further stated the kitchen staff had delivered the snack cart to the nursing unit and on several occasions it had been returned to her with sometimes minimal items removed from the cart. She stated the dietary staff utilized a snack cart sheet to verify the bedtime snacks had been delivered to the nursing unit and a nurse was to sign that it had been received. Dietary Manager #420 further stated she had started marking the days she had received the snack cart back and the snacks had not been passed. She stated she had discussed this at the daily morning management meetings. She further stated she was approached today by a resident who voiced concerns to her that she was not getting snacks at night, and stated she had informed the Director of Nursing (DON). Interview with [NAME] #450 on 01/03/20 at 1:30 P.M. revealed she worked the evening shift in the kitchen and made the bedtime snack cart each night. She stated she delivered them to the nursing unit and the nurse signed the sheet to acknowledge receipt of the snacks. She stated there were plenty of snacks on the cart for every resident to have whatever they wanted. She stated she normally had the cart to the nursing staff around 6:00 P.M. Further interview with Dietary Manger #420 on 01/03/20 at 6:15 P.M. verified the bedtime snack cart had already been taken to the nursing unit. She stated there were 20 peanut butter and jelly sandwiches and 20 cold cut sandwiches. Observation of the snack cart with the Dietary Manager #420 revealed 20 sandwiches. Dietary Manager #420 stated the other 20 sandwiches had already been passed. The 20 remaining sandwiches were observed to be in a small hard plastic bin with ice in it, with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 19 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0809 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many sandwiches on top of the ice. A separate container was observed to have four frozen nutritional supplements, a vanilla health shake and one container of ice cream on top of ice. The container of ice cream was mushy and partially melted. Dietary Manager #420 verified the ice cream was no longer frozen and the ice in the containers may not keep the food items at the appropriate temperature. Additional items on the snack cart included bananas, water, peanut butter crackers and graham crackers. The facility confirmed all resident receive meals and snacks from the kitchen. Interviews with State Tested Nursing Assistant (STNA) #456 and #458 on 01/03/20 at 6:20 P.M. revealed all bedtime snacks had been passed at that time. They verified there were still residents eating supper at that time and supper was still in progress and snacks were to be passed by 7:00 P.M. Observation on 01/02/20 and 01/03/20 revealed residents's breakfast trays were getting to the residents at 8:00 A.M. Lunch trays were delivered at 12:15 P.M. and supper trays were delivered at 5:30 P.M. Further observation on 01/03/20 at 5:55 P.M. revealed bedtime snacks were delivered to the nurses station. Continued observation of the snack cart on 01/03/20 until 6:30 P.M. revealed three residents came to the nurses' station requesting a snack. Snacks labeled with resident names for specific snacks had been passed. A room to room observation was made by two surveyors between 6:30 P.M. and 6:40 P.M. Four residents were observed with a snack in their room. No snacks were observed left in the resident rooms for later resident use. Most of the snacks not labeled with resident names remained on the snack cart after staff stated the snacks had been passed. Observation of a posted note by the dietary and dining room entrance revealed meal times in the dining room were 8:00 A.M., 12:00 P.M. and 5:30 P.M. Resident meal trays delivered to their rooms were to go out at 7:45 A.M., 11:45 A.M. and 5:15 P.M. Review of facility policy Frequency of Meals dated 09/2017 revealed at least three meals were to be provided, at regular times comparable to normal mealtimes in the community. The time between a substantial evening meal and breakfast the following day was not exceed 14 hours, except when a nourishing snack is provided. It revealed suitable nourishing alternative meals and snacks were to be provided to a resident who wanted to eat at non traditional times outside of scheduled meals and consistent with the resident plan of care. A nourishing snack was defined as an item from the basic food groups, either singly or in combination with each other. A nourishing evening snack was to be provided if the time span between dinner one night and breakfast the next morning exceeded 14 hours. Review of facility policy Snacks dated 09/20/17 revealed bedtime snacks were to be provided to all residents. The policy further revealed the Dining Services department would assemble and deliver the snacks to the nursing units to be offered and Nursing Services were responsible to delivering the individual snacks to all residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 20 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 documentation/record review, staff interview and review of policy and procedures, the facility failed to establish and implement specific testing protocols for their water management program through the Legionella policy and procedure. This had the potential to affect all 31 residents residing in the facility. Facility census was 31. Residents Affected - Many Findings include: Review facility Centers for Disease Control and Prevention (CDC) toolkit risk assessment for Legionella undated documented the facility was at increased risk for Legionella growth and spread. Further review documented the facility needed a water management program for the buildings hot and cold water distribution system. Review of CDC toolkit assessment for Legionella last revised 06/05/17 documented control measures should be applied where there are hazardous conditions for Legionella to possibly grow. Review of the facility Legionella policy and procedure revised 11/18/19 documented Water Management Plan documented the Center for Medicare and Medicaid (CMS) only requires the facility to consider the CDC toolkit and the facility doesn't follow it explicitly. Further review documented since water heater, storage tanks and boilers are kept greater to or equal to 108 degree Fahrenheit (F), they are not at any risk for Legionella growth or spread and are not addressed as control points. The policy defined control measures as elements within a building water system to limit the growth and spread of Legionella, such as heating, adding disinfectant, or cleaning. Additionally, the policy documented CMS Memorandum S&C 17-30-Hospitals/CAHs/NHs Revised 07/06/18 Requires that Nursing Homes Operators develop a plan that 'considers' the American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE) industry standard 188 and the CDC Toolkit on 'Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings'. The policy and procedure did not address specific testing protocols. Review of QSO-17-30 titled Hospitals/CAHs/NHs revealed facilities must have water management plans and documentation that, at a minimum, ensure each facility: 1. Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system; 2. Develops and implements a water management program that considers the ASHRAE industry standard and the CDC toolkit; and 3. Specifies testing protocols and acceptable ranges for control measures, and document the results of testing and corrective actions taken when control limits are not maintained. Testing protocols are at the discretion of the provider. Review of a reference from www.ashrae.org revealed water in direct hot and cold water pipes can pose multiple hazardous conditions. First, the process of heating the water can reduce disinfectant levels. Second, if hot water is allowed to sit in the pipes (stagnation), it might reach a temperature where Legionella can grow and could encourage sediment to accumulate or biofilm to form. With recirculating hot water pipes, the greatest risk is that returning water with reduced or no disinfectant cools to a temperature where Legionella can grow. If this happens, Legionella in the return line can travel to central distribution points and contaminate the entire plumbing system of the building. Additionally, control measures and limits should be established for each control point. You will need to monitor to ensure your control measures are performing as designed. Control limits, in which a chemical or physical parameter must be maintained, should include a minimum and maximum value. Water (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 21 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many quality should be measured throughout the system to ensure that changes that may lead to Legionella growth (such as a drop in chlorine level) are not occurring and water heaters should be maintained at appropriate temperatures. Review of an untitled form from the City of St. Mary's documented the Environmental Protection Agency (EPA) requires regular sampling to ensure drinking water safety. The City of St. Mary's conducted sampling for (bacteria; inorganic; radiological; synthetic organic; volatile organic) during 2016. For years, samples have been collected for over 150 different contaminants most of which were not detected in the City of St. Mary's water supply. The Ohio EPA requires us to monitor for some contaminants less than once per year because the concentration of these contaminants do not change frequently. Some of our date, though accurate, are more than one year old. A complete listing of all the contaminants we monitor is available upon request. Further review of the form revealed total chlorine in 2017 (specific date not provided) was 2.0 parts per millions (ppm). This form did not specify where the samples were obtained in the City of St. Mary's and there were no evidence of samples collected at the facility. On 01/02/20 at 2:30 P.M. interview with Maintenance Director #390 verified the facility did not apply control measure to reduce the risk of Legionella growth because the facility's water storage tanks and heater are set at 140 degrees F. Maintenance Director #390 verified the water is then mixed at a mixing valve point near the hot water heaters then distributed at lower temperatures of approximately 110 degrees F throughout the facility. Maintenance Director #390 verified the facility does not have any control measures or testing protocols for the water distribution system which would include super heating, flushing the lines at at the water tank, monitoring water temperatures or chlorination past the the hot water tanks storage mixing valve being distributed throughout the facility. Maintenance Director #390 confirmed the City of St. Mary's instills chlorine into the city's water supply; however, there were no evidence of samples obtained at the facility and whether the levels are maintained high enough to prevent the growth of Legionella. The facility confirmed this had the potential to affect all 31 residents residing in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 22 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and policy review the facility failed to implement antibiotic stewardship policy to ensure a resident received optimal antibiotic therapy. This affected one (#6) out of five resident reviewed for unnecessary medications. The facility census as 31. Residents Affected - Few Findings include: Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney failure, congestive heart failure, hypertension, anemia and Stage IV pressure ulcer to the sacrum. Review of the quarterly minimum data set (MDS) assessment, dated 10/09/19, revealed the resident's Brief Interview for Mental Status (BIMS) score was an eight out of 15 indicating severe cognitive impairment. The resident required extensive assistance of two staff for bed mobility and transfers. He is no ambulatory and no longer propels his wheelchair on or off the unit. He has a suprapubic catheter in place He is always incontinent of bowel. He has unhealed Stage IV pressure ulcer. Review of the plan of care, updated 10/19/19 documented the resident has a suprapubic catheter in place due to a non healing Stage IV pressure ulcer. The plan of care documented the resident is at risk for urinary tract infections due to long term catheter placement. The interventions include monitor the resident for signs and symptoms of urinary tract infection and report the findings to the physician. Review of nursing progress note dated,12/26/19 at 7:03 PM, documented the urinalysis results were received and the physician was called with the results. A new order was received for Cipro (antibiotic) 500 milligrams (mg) twice a day for ten days for a urinary tract infection. Review of the urinalysis results that were faxed to the facility on [DATE] showed small amount of blood, positive nitrate, and large amount of leukocytes in the urine. The urinalysis results were signed by the physician. Review of the urine culture and sensitivity that were faxed to the facility on [DATE] revealed a colony count of greater than 100,000 CFU (colony forming units) per milliliter (ml) of proteus mirabilis (organism). The sensitivity documented Cipro has an intermediate susceptibility to Cipro at a dose of 750 mg twice a day. There was no physician signature on the urine culture and sensitivity report. Further review of the progress notes dated 12/29/19 through 01/03/20 made not mention the physician had been notified of the urine culture and sensitivity results. On 01/03/20 at 3:34 P.M. the Director of Nursing (DON) verified she had spoken to the physician today and he was unaware of the urine culture and sensitivity results on 12/29/19. She stated on 01/03/20 the physician, after reviewing the urine culture and sensitivity, discontinued the Cipro and started the resident on Rocephin (antibiotic) which was listed as being sensitive to the organism identified on the urine culture and sensitivity. On 01/04/19 at 2:17 P.M. Registered Nurse (RN) #105 verified the protocol for antibiotic use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 23 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0881 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete included identification of the organism and treating the organism with the antibiotics that were reported sensitive to the organism on the culture and sensitivity report. She verified Resident #6 antibiotic use did not follow the protocol. Review of the Antibiotic Stewardship Overview policy dated 08/30/18, documented the purpose of the policy is to optimize the treatment of infections while reducing adverse events associated with antibiotics. Section E titled Accountability indicated the DON will set the practice standards for assessing, monitoring and communicating changes in the residents condition by the front -line nursing staff. Event ID: Facility ID: 365809 If continuation sheet Page 24 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to ensure resident's were offer and administer the influenza and pneumococcal vaccine. This affected five (#6, #11, #84, #7 and #33) out f five residents reviewed for immunizations in the infection control task. The facility census was 31. Residents Affected - Some Findings include: 1. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include chronic obstructive pulmonary disease, atrial fibrillation, chronic kidney failure, congestive heart failure, hypertension, anemia and Stage IV pressure ulcer to the sacrum. Review of the resident's immunization record revealed no evidence the resident had been offered or received the pneumonia vaccine. 2. Review of Resident #11's medical record revealed the resident was admitted to he facility on 10/07/19 and readmitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease (COPD), diabetes type II, hypertension, gastro esophageal reflux disease (GERD), hypothyroidism, atrial fibrillation, major depression, urine retention and morbid obesity. Review of the resident's immunization record revealed no evidence the resident had been offered or received the pneumonia vaccine. 3. Review of Resident #84's medical record revealed the resident was admitted to the facility 12/27/19. Diagnoses include congestive heat failure (CHF), morbid obesity, COPD, diabetes, anemia, hypertension, peripheral vascular disease (PVD), GERD, and major depressive disorder. Review of the resident's immunization record revealed no evidence the resident had been offered or received the influenza or pneumonia vaccine. 4. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include heart failure, COPD, diabetes, atrial fibrillation,poly arthritis, anxiety disorder and GERD. Review of the resident's immunization record revealed no evidence the resident had been offered or received the influenza or pneumonia vaccine. 5. Review of Resident #33's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include COPD, CHF, major depressive disorder, schizophrenia, asthma and GERD. Review of the resident's immunization record revealed no evidence the resident had been offered or received the pneumonia vaccine. On 01/04/19 at 11:00 A.M. the Director of Nursing verified there was no additional records or information to show Residents #6, #11, #84, #7, and #33 were offered or received the immunizations not found in the electronic immunization record. Review of the Infection Control Prevention Program policy, updated 08/23/18, documented on page (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 25 of 26 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 365809 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/04/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Grande Lake Healthcare Center 1209 Indiana Avenue St Marys, OH 45885 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 0883 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some four under the subheading, Immunization Screening, indicated immunizations are offered as appropriate to residents to decrease the incidence of preventable infectious diseases including but not limited to an annual influenza vaccine and appropriate pneumonia vaccines. Review of the Pneumonic Vaccine Administration policy, updated 11/11/18 documented the nurse will assist in the collection data for the resident's vaccination history, and other factors to provide the information to the physician who will determine which pneumonia vaccine schedule the resident should receive. Review of the Resident Influenza Vaccine policy updated 10/31/18, documented residents residing in the facility prior to the onset of the influenza season will be offered the influenza vaccine, unless medically contraindicated or the resident has already been immunized for this season. All new admissions will be offered the influenza vaccine upon admission in the event the the admission occurs during the influenza season , October 1 through March 31. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 26 of 26