Health inspection·February 13, 2023

F 0641 Level of Harm - Minimal harm or potential for actual harm Review of the quarterly MDS assessment dated [DATE] revealed Resident #28 had intact cognition. Further review revealed he received an anticoagulant daily during the previous seven days. Review of the active orders in November 2022 revealed Resident #28 was on Plavix (an anti-platelet drug), Pletal (an anti-platelet drug), and a low-dose aspirin. Residents Affected - Some Interview on 02/08/23 at 2:39 P.M., with the Regional Mobile MDS Nurse #533 confirmed the BIMS assessments for Resident #1 and Resident #17 were completed inaccurately, and should have been completed by asking the residents the final three questions rather than indicating the residents were not assessed. Further interview at that time with the Regional Mobile MDS Nurse #533 revealed the anticoagulant assessments for Resident #26 and Resident #28 were coded inaccurately based on the active orders at the time of the review. Review of the undated policy titled MDS Responsibilities revealed the assessment must be completed accurately. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 2 of 17 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 02/13/2023 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 resident representative interviews, and policy review; the facility failed to conducted care conferences. This affected two (#18 and #26) of two resident reviewed for care planning. The census was 36. Findings include: 1. Review of the medical record for Resident #18 revealed an initial admission date of 10/27/21, with re-entry admission on [DATE]. Diagnosis for Resident #18 included: altered mental status, muscle weakness, acute kidney failure, Parkinson's disease, dysphagia oropharyngeal phase, type two diabetes mellitus without complications, hypercalcemia, and major depressive disorder recurrent severe with psychotic symptoms. Review of the Minimum Data Set (MDS) Assessment, dated 12/15/22, revealed the resident was severely cognitively impaired. Review of the medical record, dated since 06/08/22 to date of survey, revealed no evidence of a care conferences being held. Interview on 02/06/23 at 2:39 P.M., with Resident #18's Representative verified they were not aware of care plan conferences being held. Interview on 02/08/23 at 5:00 P.M., with Activities Director/Social Services Designee #529 verified there were no care conferences held for Resident #26 since re-admission. 2. Review of the medical record revealed Resident #26 was admitted on [DATE]. Diagnosis included end stage renal disease, dependence on renal dialysis, heart failure, type two diabetes mellitus with other diabetic kidney complication, major depressive disorder recurrent, essential (primary) hypertension, acute respiratory failure with hypoxia, and acute respiratory failure with hypercapnia. Review of the Minimum Data Set (MDS) assessment, dated 11/23/22 revealed the resident was cognitively intact. Interview on 02/06/23 at 11:40 A.M., with Resident #26 revealed she was not familiar with care plan conferences and had never been invited nor participated in one. Review of social services progress note, dated 11/10/22, revealed she spoke with resident's sister about her upcoming care conference and the sister would like to reschedule until after they get back from vacation and will call upon return to schedule. Interview on 02/08/23 at 5:00 P.M., with Activities Director/Social Services Designee #529 revealed she had talked to the sister in the hallway after she had returned from vacation and did not reschedule the care conference. Activities Director/Social Services Designee #529 verified there were no care conferences held for Resident #26 since admission. Review of the undated policy titled Plan of Care Overview, revealed resident/representatives will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 3 of 17 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 02/13/2023 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 be offered opportunities to voice their view in the development and implementation of his/her own plan of care. This will include holding meetings at a time when resident is functioning at his/her best, schedule meetings to accommodate a resident representative that may include conference calls, video calls or live sessions, and plan adequate meeting times. The care plan team shall include an interdisciplinary team. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 4 of 17 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 02/13/2023 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, review of the activity calendar, review of activity documentation, resident council meeting minutes, and review of policy, the facility failed to provide sufficient and quality activities to meet the needs of residents. This affected seven (#5, #15, #18, #22, #23, #29, and #30) of seven residents reviewed for activities with the potential to affect all residents the facility. The facility census was 36. Residents Affected - Many Findings include: 1. Review of medical record for Resident #5 revealed admission of 07/10/19 with diagnoses including chronic obstructive pulmonary disease, post-traumatic stress disorder, depression, hypertension, and dementia. Review of Minimum Data Set (MDS) assessment, dated 01/15/23, revealed Brief Interview of Mental Status (BIMS) score of six which indicated severe cognitive impairment. Resident required extensive assist of one for transfers. Resident independent for activities of daily living. Review of activity preferences interview, dated 08/01/22, for Resident #5 revealed resident was Baptist and was a member of a church prior to admission to facility, current interests included playing cards, reading magazines and newspaper, drawing, going for walks, watching football, being outside when weather is good going for sitting and relaxing, and talking and visiting family and friends. Resident prefers to participate in scheduled activities in the morning and afternoon. Review of care plan dated 01/10/23 for Resident #5 revealed resident attends activities of choice/interest and engages in self-initiated leisure activities. Interventions included encourage to attend activities, interview, and determine resident activity preferences, introduce to other residents with similar interests, provide a schedule of activities available, provide activity materials of interest such as magazines, library books, word puzzles. Residents preferred activities are listening to music in corridor and visiting with other residents. Interview on 02/07/23 at 2:05 P.M. with Resident #5 stated he would like to have more activities and is tired of sitting in his room all the time. He would like to have more residents involved in activities. Interview on 02/08/23 1:35 P.M. with Resident #5 states he attends some activities. Resident stated he would like different activities and more activities to sharpen his mind. Resident stated he was Catholic. Resident was indifferent regarding church services not being offered. Resident stated activities offered him include word search books and snacks. 2. Review of medical record for Resident #15 revealed admission [DATE] with diagnoses including iron deficiency anemia, anxiety, depression, other genetic related intellectual disability, and amnesia. Review of MDS assessment, dated 01/12/23, for Resident #15 revealed BIMS score of 15 which indicated cognitively intact. Resident #15 independent for activities of daily living. Review of activities preferences interview dated 07/29/22 for Resident #15 revealed resident was a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 5 of 17 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 02/13/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many member of Catholic church. Resident #15 current interests included cards, bingo, games, books, exercise, walking, jogging, sports, horror movies, keeping up with news, religious activity, bible study, spending time outdoors, talking, conversing, helping others, parties, social events, groups, and organizations. Resident #15 prefers to participate in scheduled activities in the afternoon and evening. Interview on 02/08/22 at 3:09 P.M. with Resident #15 revealed he would like to have more activities offered at the facility and have more to do. 3. Review of the medical record revealed Resident #18 was initially admitted to the facility on [DATE] with re-entry on 06/08/22. Diagnoses for Resident #18 included: fracture of base of skull left side subsequent encounter for fracture with routine healing, traumatic subarachnoid hemorrhage without loss of consciousness subsequent encounter, altered mental status, muscle weakness, acute kidney failure, Parkinson's disease, dysphagia oropharyngeal phase, type two diabetes mellitus without complications, hypercalcemia, and major depressive disorder recurrent severe with psychotic symptoms. Review of the MDS Assessment, dated 12/15/22, revealed the resident was severely cognitively impaired. Resident #18 is extensive one person assistance for bed mobility, transfers, walking in room, and locomotion on and off unit. Review of Resident #18's care plan, updated 12/21/22, revealed the resident participates in activities at times and prefers to participate in independent activities in her room. Goals include to one to one visits, participating in activities of choice, and show engagement of activities of interest through the review date. Interventions included to assist with transport to activities as needed, ensure activities are compatible with residents capabilities, encourage resident to attend, interview and determine activity preferences, provide one to one room visits if unable to attend out of room events, and other appropriate interventions. Review of activities preference interview, dated 12/14/22, revealed Resident #18 needs assistance getting to and from activities and is most active in the afternoon. Resident #18 religious preference is the Methodist Church, likes bingo games, crafts, bowling, watching programs, enjoying music, and likes to talk but is slow to respond. Resident #18 did not indicate any activities she would like the activities department to provide. Review of activity documentation, dated 01/01/23 to 02/07/23, revealed Resident #18 had a checkmark for a one on one visit three times. Observation on 02/06/23 and 02/07/23 of Resident #18 intermittently throughout the day revealed the resident laying in bed awake looking at the ceiling or out the door. The resident's side of the room was absent of a television or music. Resident #18 was only observed outside of the room for meals. Interview on 02/07/23 at 2:10 P.M., with Resident #18 indicated she would like to get out of her room sometimes and more than just for meals. Resident #18 does not want music or a television in her room. Resident #18 would like to have her nails painted or to have staff come and talk to her. Interview on 02/07/23 at 3:08 P.M., with Activities Director/Social Services Designee #529 verified Resident #18 does not have any documented participation of recent activities. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 6 of 17 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 02/13/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 4. Review of medical record for Resident #22 revealed admission [DATE], with diagnoses including atherosclerotic heart disease, hypertension, glaucoma, polyosteoarthritis, gastro-esophageal reflux disease, and type two diabetes. Review of MDS assessment, dated 12/05/22, revealed BIMS score of 15 which indicated cognitively intact. Resident independent for activities of daily living. Review of activity preferences interview dated 08/01/22 for Resident #22 revealed resident was a member of Methodist church. Resident #23 current interest included solitaire, reading books, listening to the television, keeping up with news, helping others, and talking. Resident #23 prefers to participate in scheduled activities in the morning, afternoon, and evening. Review of care plan dated 12/13/22 for Resident #22 revealed resident prefers activities in her room such as reading and watching television. Resident will participate in activities of choice through review date. Resident will accept/participate in one-on-one visits. Interventions included assist with transport to activities as needed, encourage resident's representative to bring in personal items from home, encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities, introduce to other residents with similar interests, invite to scheduled activities, provide one on one room visits if unable to attend out of room events, provide a schedule of activities available, and provide activity materials of interest. Interview on 02/08/23 at 2:59 P.M., with Resident #22 stated she would like more activities including more bingo. Resident #22 stated the facility did not provide church services on Sundays. Resident #22 would like church services on Sunday. 5. Review of medical record for Resident #23 revealed admission [DATE], with diagnoses including Alzheimer's with late onset, dementia with agitation, bipolar disorder, hypertension, type two diabetes, depression, post-traumatic stress disorder, anxiety, osteoarthritis, and benign prostatic hyperplasia. Review of MDS assessment, dated 01/02/23, revealed BIMS score of 11 which indicated moderately impaired cognition. Resident independent for activities of daily living. Review of activity preferences interview dated 12/20/22 for Resident #23 revealed resident was Methodist and went to weekly services on Sunday. Resident #23 current interests included reading murder mystery books, walking when back and legs are not bothering him, mystery movies, watching news daily, talking to others telling stories and jokes, and member of masonic lodge. Resident #23 prefers to participate in activities in the morning, afternoon, and evening and do independently on his own time. Review of care plan dated 12/08/22 for Resident #23 revealed person centered care. Staff to provide person centered care through the next review. Interventions included resident enjoys being up, and about at times walking, snack time, reading murder mysteries, watching murder mystery movies, and news, talking to others, and telling jokes. Resident naps at times. Interview on 02/08/23 at 2:54 P.M., with Resident #23 stated he only plays bingo at the facility. Resident stated the facility did not have church on Sundays. Resident stated he would like to attend church on Sunday. Resident stated he watches church currently on the television. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 7 of 17 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 02/13/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 6. Review of medical record for Resident #29 revealed admission [DATE] with diagnoses including chronic obstructive pulmonary disease, overactive bladder, dementia, hypertension, atrial fibrillation, osteoarthritis, and history of falling. Review of MDS dated [DATE] for Resident #29 revealed BIMS score of seven which indicated severe cognitive impairment. Resident required extensive assist for activities of daily living. Review of activity preferences interview dated 11/18/22 for Resident #29 revealed resident current interests included bingo, playing cards, reading the newspaper, country music, watch television all day, and watch the news at 6:30 P.M. Resident prefers to participate in activities in the afternoon and evenings. Review of care plan dated 01/09/23 for Resident #29 revealed resident participates with activities of choice. Interventions included assist with transport to activities as needed, assure that the activities are compatible with resident's physical and cognitive capabilities, encourage attendance to entertainment programs, large and small group activities, volunteer demonstrations, and religious activities, interview and determine resident activity preferences, introduce to other residents with similar interests, invite resident to scheduled activities, provide one on one in room visits if unable to attend out of room events, provide a schedule of activities available, and provide activity materials of interest. Interview on 02/08/23 at 1:38 P.M. with Resident #29 stated she had played bingo once. Resident stated the facility did not have church on Sunday's. Resident #29 stated she would like to have church service at the facility on Sunday's. 7. Review of medical record for Resident #30 revealed admission [DATE], with diagnoses including hypo-osmolality and hyponatremia, volume depletion, headache, hypothyroidism, depression, and gastro-esophageal reflux disease. Review of MDS assessment, dated 12/08/22, for Resident #30 revealed BIMS score of 15 which indicated cognitively intact. Activity preference revealed the following were very important books, magazines, newspapers to read, going outside, participate in religious services or practices. The following are somewhat important doing favorite activities, doing things with groups of people, and listening to music. Resident #30 was independent for activities of daily living. Review of activity preferences interview, dated 12/06/22, for Resident #30 revealed resident is Catholic. Residents' current interests included bingo, bridge, crazy eights, documentaries, fiction, nonfiction, arts and crafts, walking, golfing, fishing, classical and country music, watching soap operas, baking, news, shopping and community outings, worship services, bible study, spending time outdoors, and talking. Resident prefers to participate in scheduled activities in the afternoon. Interview on 02/08/23 at 2:59 P.M., with Resident #30 stated she could use more activities and more bingo. Resident #30 stated the facility did not have church on Sundays and she would like to have church services. Observations on 02/06/23 to 02/09/23 over various times throughout the survey, revealed only one group activity was scheduled and offered at 1:30 P.M. No other group activities were observed being offered to meet the needs and desires of the residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 8 of 17 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 02/13/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Review of the activity calendars, dated September 2022 through February 2023, revealed one activity is scheduled once per day at 1:30 P.M. The offered activity examples included resident council, games (bingo, uno, music trivia, dominoes), food (cream puff day, peppermint stick ice cream, popcorn day, muffin day, make your own pizza, pancakes, donut day), birthday party, spa day, and crafts . Every other weekend Saturday was scheduled for music and games and Sunday was scheduled for movie and games. Review of special notes on calendar revealed for resident's to participate in activities they must come to the dining room and there will be no more room to room activities. Review of large activity calendar posted in the resident hall for February 2023 revealed an activity offered every day at 1:30 P.M. only. Review of special notes on calendar revealed for resident's to participate in activities they must come to the dining room and there will be no more room to room activities. Review of the resident council meeting minutes, dated November 2022, revealed residents requested more activities. The facility response was to provide additional books, games, and movies to the cabinet in the common area available for residents to access. Interview on 02/07/23 at 3:08 P.M., with Activities Director/Social Services Designee #529 revealed there is a part-time activities assistant that comes in four day a week to offer the 1:30 P.M. resident activity. On the week days the activity aide is not here then she will complete the 1:30 P.M. activity and on every other weekend the aides fill in. Activities Director/Social Services Designee #529 verified one activity is offered per day, occasionally two. It was also verified at the November 2022 resident council resident's asked for more activities and the facility response was to provide additional books, games, and movies to the cabinet in the common area available for residents to access. Interview on 02/08/23 at 1:06 P.M., with Activities Aide #506 verified working three days a week and every other weekend. Activities Aide #506 reported she works from 11:30 A.M. to 3:00 P.M. and has time to complete the 1:30 P.M., group activity and provide one on one visits. Activities Aide #506 described the activities offered. For example, on popcorn day she will make popcorn for the residents who come to participate but she always makes extra and will deliver the extra to residents who stayed in their room if their diet allows. Activities Aide #506 verified there are no religious activities. Activities Aide #506 verified the facility has not reached out to any churches but needs to and nothing has been set up with a church prior to COVID-19. Activities Aide #506 reports she needs to reach out to an individual who provided a prayer service; another who played the piano and sang to see if they will come back. She stated her physician had offered to say the rosary with those who would want that and needs to follow up. Interview on 02/09/23 at 1:10 P.M., with the Administrator verified on the weekend when Activity Aide #506 is not working the aides will follow the activity schedule show a movie in the dining room for the activity for the day. The manager on the weekend may also assist or do a little extra. Review of the undated policy titled, Activities Program, revealed the activity program is designed to encourage restoration to self-care and maintenance of normal activity that is geared to the individual resident needs. The activity program is scheduled daily and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the program. Activities of individual, small, and large are designed to meet the needs of residents including social activities, indoor and outdoor, religious programs, creative, intellectual and educational, exercise, individualized, in-room, and community. Activities shall reflect the cultural and religious (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 9 of 17 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 02/13/2023 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 0679 interests of the residents. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 10 of 17 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 02/13/2023 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 0680 Ensure the activities program is directed by a qualified professional. Level of Harm - Minimal harm or potential for actual harm Based on observations, review of activity calendars, review of resident council minutes, review of personnel file and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional. This had the potential to affect 36 of 36 residents in the facility. Residents Affected - Many Findings include: Observations on 02/06/23 to 02/09/23 over various times throughout the group survey, revealed only one activity was scheduled and offered at 1:30 P.M. No other group activities were observed being offered to meet the needs and desires of the residents. Review of the activity calendars, dated September 2022 through February 2023, revealed one activity is scheduled once per day at 1:30 P.M. The offered activity examples included resident council, games (bingo, uno, music trivia, dominoes), food (cream puff day, peppermint stick ice cream, popcorn day, muffin day, make your own pizza, pancakes, donut day), birthday party, spa day, and crafts . Every other weekend Saturday was scheduled for music and games and Sunday was scheduled for movie and games. Review of special notes on calendar revealed for resident's to participate in activities they must come to the dining room and there will be no more room to room activities. Review of large activity calendar posted in the resident hall for February 2023 revealed an activity offered every day at 1:30 P.M. only. Review of special notes on calendar revealed for resident's to participate in activities they must come to the dining room and there will be no more room to room activities. Review of the resident council meeting minutes, dated November 2022, revealed residents requested more activities. The facility response was to provide additional books, games, and movies to the cabinet in the common area available for residents to access. Review of the personnel record for Activities Director/Social Services Designee (AD/SSD) #529 revealed a hire date of 02/28/22. AD/SSD #529 personnel record had job descriptions signed for Social Services Director and Charge Nurse. The personnel record was silent for a job description for Activities Director. Review of the job employment application submitted 02/07/22 revealed the employee had formally worked as a State Tested Nursing Assistant (STNA) and Licensed Practical Nurse (LPN). Interview on 02/07/23 at 3:08 P.M., with AD/SSD #529 verified she has been in the role as the Activity Director and Social Services since March 2022 and is also a LPN. AD/SSD #529 stated when they hired her they needed a nurse more then they needed activities. AD/SSD #529 verified she does not meet criteria of an Activity Director but plans to get her certificate in the future. Interview on 02/07/23 at approximately 3:45 P.M., with the Administrator verified AD/SSD #529 does not meet the criteria of an Activities Director. The Administrator stated corporate preferred the position to be held by a LPN and due to the facility being small the position is split between social services and activities. Interview on 02/08/23 at 3:00 P.M., with the Administrator verified AD/SSD #529 did not have a signed Activities Director job description in the personnel file. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 11 of 17 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 02/13/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident and staff interviews, and policy review, the facility failed to ensure a resident received the care and services for daily use of alcohol. This affected one (#17) of one resident reviewed for alcohol. The facility census was 36. Residents Affected - Few Findings include: Review of medical record for Resident #17 revealed admission of 01/25/20, with diagnoses including unspecified convulsions, anxiety, insomnia, depression, migraine, atrial fibrillation, cerebral infarction with right sided hemiparesis/hemiplegia, and expressive language disorder. Review of Minimum Data Set (MDS) assessment dated [DATE], for Resident #17 revealed the mental status was unable to be assessed. Staff interviews revealed the resident independent for daily decision making. Resident #17 was assessed as independent for activities of daily living. Observation on 02/06/23 at 11:30 A.M., revealed two [NAME] Lite cans on over the bed table. One can noted to be open. Interview on 02/06/23 at 12:53 P.M., with Resident #17 stated she gets two beers a day. Resident #17 stated she gets both at the same time. Two empty beer cans noted in the trash can. Review of physician orders for January 2023 and February 2023 revealed no orders for beer consumption. There was no care plan in place to address the use of alcohol. Interview on 02/06/23 at 1:48 P.M., with Licensed Practical Nurse (LPN) #632 stated Resident #17 is allowed two beers per day. LPN #632 verified the resident received two beers today. LPN #632 verified no orders were in point click care for beer. Review of the undated policy titled Alcoholic Beverage Dispensing revealed a physician's order must be obtained to dispense alcohol to a resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 12 of 17 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 02/13/2023 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 observation, staff interview, record review, and review of the policy, the facility failed to ensure fall interventions were in place for a resident at risk for falls. This affected one (#20) of three residents reviewed for falls. The facility census was 36. Findings include: Review of the medical record for Resident #20 revealed an admission date of 12/19/22, with medical diagnoses of unspecified dementia, acute on chronic respiratory failure with hypoxia, morbid obesity, weakness, pain in lower extremities, and cerebral infarction. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 had impaired cognition and required extensive assistance of two people for bed mobility, transfers, dressing, toileting, and hygiene, and required supervision with one person assist for eating. Further review revealed Resident #20 fell two or more times without injury since the previous assessment. Review of a physician order dated 01/16/23 revealed Resident #20 needed a low bed with mats on the floor bilaterally for safety. Review of the current care plan revealed Resident #20 was at risk for falls. Interventions included having his bed in the lowest position with bilateral floor mats. Observation on 02/06/23 at 1:38 P.M., revealed Resident #20 in bed sleeping. Further observation revealed a floor mat on the right side of his bed only and the bed was not in the low position. Interview and concurrent observation with State Tested Nurse Aide (STNA) #531 on 02/06/23 at 1:46 P.M., confirmed Resident #20's bed was not in the low position and floor mats were not on both sides of the bed. STNA #531 lowered the bed to the lowest position and placed a floor mat on the left side of the bed at that time. Observation on 02/08/23 at 10:06 A.M., revealed Resident #20 lying in bed asleep. Two floor mats were folded and leaning against the wall. No mats were on the floor. The bed did not appear to be in the lowest position. Interview and observation on 02/08/23 at approximately 10:01 A.M., with Licensed Practical Nurse (LPN) #530 confirmed Resident #20 should have floor mats placed on both sides of his bed and further confirmed his bed was not in the lowest position. LPN #530 placed floor mats on both sides of Resident #20's bed and lowered the bed at that time. Interview on 02/09/23 at 3:32 P.M., with the Administrator confirmed staff were expected to implement fall interventions indicated in each resident's care plan. Review of the undated facility policy titled Fall Prevention and Management revealed the resident's care plan should include fall interventions specific to the needs of each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 13 of 17 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 02/13/2023 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to follow physician orders regarding tube feed administration. This affected one (#138) of one resident reviewed for tube feed. The facility census was 36. Findings include: Review of medical record for Resident #138 revealed admission of 02/01/23, with diagnoses of fusion of spine cervical region, spinal stenosis, unspecified cord compression, cerebral palsy, dysphagia, conversion disorder with seizures or convulsions, hypothyroidism, aphasia, pneumonitis due to inhalation of food and vomit, and anxiety. Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #138 revealed resident is rarely/never understood. Staff interview revealed resident is independent for daily decision making skills. Review of physician order dated 02/08/23 for Resident #138 revealed nepro at 45 milliliters (ml) per hour for 20 hours a day, off at 8:00 A.M. and on at 12:00 P.M. Observation on 02/08/23 at 3:04 P.M. of Resident #138 tube feed revealed tube feed not hooked up or on for resident. Interview on 02/08/23 at 3:05 P.M. with Licensed Practical Nurse (LPN #635) stated Resident #138 tube feed was to be held for four hours. Stated it was to be unhooked today from 9:15 A.M. to 1:15 P.M. LPN #138 verified tube feed had not been restarted and was unhooked. Review of policy titled Enteral Nutrition with Continuous Pump dated 01/05/22, revealed the nurse will monitor the flow rate during the shift to ensure proper functioning. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 14 of 17 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 02/13/2023 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 provide rationale for gradual dose reduction (GDR) not indicated. This affected one (#21) of five residents reviewed for GDR's. The facility census was 36. Findings include: Review of medical record for Resident #21 admitted on [DATE], with diagnoses including Alzheimer's with early onset, dementia, hypertension, adult failure to thrive, depression, and schizoaffective disorder. Review of Minimum Data Set (MDS) assessment dated [DATE], for Resident #21 revealed a Brief Interview for Mental Status (BIMS) score of five which indicated severe cognitive impairment. Resident #21 was independent for activities of daily living. Review of the form titled: CommuniCare: Psychotropic Medication Evaluation (Pharmacy and Therapeutics Committee), dated 02/09/22, for Resident #21 revealed GDR not indicated at this time, due since (pick one, note rational below). No rationale listed on GDR form. Review of the form titled: CommuniCare: Psychotropic Medication Evaluation (Pharmacy and Therapeutics Committee), dated 05/17/22, for Resident #21 revealed GDR is indicated at this time. No recommended dosage reduction was listed. Interview on 02/08/23 at 10:16 A.M., with Director of Nursing (DON) verified on 05/17/22, GDR was marked for dose reduction is indicated at this time with no recommendation for gradual dose. DON stated it was supposed to be marked as GDR not indicated at this time. No rationale provided. DON verified on 02/09/22, no rationale was provided for gradual dose reduction not indicated. Review of the undated policy titled: Antipsychotic Second Clinical Review, revealed documentation to support the use of antipsychotics in this setting includes prescriber is required to document use, goals, and ongoing assessments. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 15 of 17 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 02/13/2023 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to administer medications per physician order. This affected one (#25) of three residents reviewed for medication administration. The facility census was 36. Residents Affected - Few Findings include: Review of medical record for Resident #25 revealed admission date 09/22/21, with diagnoses including wernicke's encephalopathy, unspecified mood disorder, anxiety, bipolar disorder, and cognitive communication disorder. Review of Minimum Data Set (MDS) assessment dated [DATE] for Resident #25 revealed a brief interview of mental status (BIMS) score of 14 which indicated cognitively intact. Observation on 02/07/23 at 7:34 A.M., during medication pass with Licensed Practical Nurse (LPN) #632 revealed the nurse administered Seroquel 50 milligrams (mg) and Seroquel 25 mg to Resident #25. Review of physician order dated 02/02/23 for Resident #25 revealed discontinue previous Seroquel order. Start Seroquel 25 mg by mouth twice daily for five days then discontinue on 02/07/22. Start Seroquel 25 mg by mouth at bedtime on 02/07/23 for five days then discontinue on 02/13/23. Gradual dose reduction attempt, notify physician if resident does not tolerate. Review of physician orders for February 2023 for Resident #25 revealed Seroquel 25 mg twice daily was started on 02/03/23 and discontinued on 02/08/23. Seroquel 25 mg at bedtime was started on 02/08/23 to be discontinued on 02/14/23. Interview on 02/07/23 at 9:44 A.M., with LPN #632 verified Resident #25 was given Seroquel 25 mg tablet and Seroquel 50 mg tablet for a total of 75 mg. LPN #632 verified Seroquel 25 mg was to be given per the physician orders. Review of the policy titled Medication Administration reviewed on 01/05/2022 revealed facility to administer medication only as prescribed by the provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 16 of 17 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 02/13/2023 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 0791 Provide or obtain dental services for each resident. 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, resident and staff interview, and policy review, the facility failed to ensure a resident was seen by a dentist timely. This affected one (Resident #23) of one resident reviewed for dental concerns. The facility census was 36. Residents Affected - Few Findings include: Review of the medical record revealed Resident #23 was admitted to the facility on [DATE]. Diagnoses included Alzheimer's disease with late onset, dementia in other diseases classified elsewhere severe with agitation, essential (primary) hypertension, hyperlipidemia, type two diabetes mellitus with diabetic neuropathy, acute kidney failure, acute kidney failure. Review of the Minimum Data Set (MDS) assessment, dated 12/09/22, revealed the resident was moderately cognitively impaired. Review of the care plan, dated 12/08/22, revealed the care plan was silent for dental needs. Review of the nurse's progress note, dated 09/17/22, revealed Resident #23 reported that while he was eating an apple four to five of his top teeth fell out. Resident's Representative reported he will call the dentist on Monday. The gum line was observed and no broken teeth were observed. Interview on 02/06/23 at 10:36 A.M., with Resident #23 revealed he bit into an apple more then 10 weeks ago and lost six teeth stating that the facility has not done anything about it. Interview on 02/27/23 at 3:08 P.M., with Activities Director/Social Services Designee #529 confirmed she was aware Resident #23 had broke or lost teeth after biting on apple in September 2022. Activities Director/Social Services Designee #529 reports it depends on the day if it is causing him problems or if he complains about it. She reports his son was trying to find in a dentist because he will take him to outside appointments and the facility was having issues finding a dentist to take Medicaid. The facility dentist came when the resident was out at the hospital in December 2022. Activities Director/Social Services Designee #529 confirmed not attempting to contact any outside dentist for services. Interview on 02/08/23 at 2:56 P.M., with Activities Director/Social Services Designee #529 revealed there is no scheduled date for the dentist to come. She did email them this morning to schedule. Activities Director/Social Services Designee #529 was able to confirm the dentist was scheduled on 12/02/22 but had a staffing issue and scheduled for 12/14/22 when the resident was out at the hospital. Review of the undated policy titled: Dental Services, stated the facility will assist the resident in obtaining routine dental services, providing emergency dental services, obtaining services to the resident to meet the needs of each resident, making appointments, and arrange for transportation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365809 If continuation sheet Page 17 of 17