Inspection·June 27, 2024

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 interview, and review of facility policy, the facility failed to ensure care conferences were completed as required. This affected two (#15 and #48) of three residents reviewed for care conferences. The facility census was 42. Findings include: 1. Review of the medical record revealed Resident #15 was initially admitted on [DATE], discharged on 01/26/24, and was readmitted on [DATE]. Diagnoses included metabolic encephalopathy, type two diabetes mellitus, colostomy status, gastrostomy status, pressure ulcer of sacral region (stage 3), anxiety disorder, and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Review of care conference progress notes revealed Resident #15 care conference were completed on 02/15/24, 02/16/24, 04/10/24, and 06/27/24. There was no care conference completed in January when the resident admitted . 2. Review of the medical record review revealed Resident #48 was admitted on [DATE]. Diagnoses included unspecified sequelae of cerebral infarction, type two diabetes mellitus without complications, respiratory failure, atherosclerotic heart disease of native coronary artery, hyperlipidemia, essential primary hypertension, cognitive communication deficit, chronic kidney disease stage three. Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact. Review of care conference progress notes revealed Resident #48 care conferences were completed on 08/09/23, 02/07/24, and 06/10/24. There was no care conference completed in May 2023 when the resident admitted and care conferences were not completed quarterly. Interview on 06/27/24 at 12:02 P.M. with Social Services #200 verified Resident #15 and Resident #48's care conferences were not completed timely. Review of the policy Baseline Care Plan/48 Hour Care Plan, no date, verified the baseline care plan must be completed within 48 hours of admission including weekends and holidays and will be printed and shared with the resident and/or resident representative. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365809 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 06/27/2024 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)