Health inspection·August 8, 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, resident and staff interview, and facility policy review, the facility failed to conduct quarterly care plan conferences are required. This affected three (#12, #24, and #32) of three residents reviewed for care planning conferences. The facility census was 60. Findings include: 1. Review of the medical record revealed Resident #12 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, hemiplegia and hemiparesis following cerebral infarction, alcoholic cirrhosis of the liver without ascites, generalized idiopathic epilepsy and epileptic syndromes, muscle weakness, bipolar disorder, hyperlipidemia, and major depressive disorder mild. Review of the Minimum Data Set (MDS) assessment, dated 07/04/24, revealed the resident was moderately cognitively impaired. Review of care conference documentation revealed no care conferences were completed. 2. Review of the medical record revealed Resident #24 was admitted on [DATE]. Diagnoses included acute and chronic respiratory failure with hypoxia, paralysis of vocal cords and larynx, chronic obstructive pulmonary disease, essential (primary) hypertension, anxiety disorder, heart failure, anemia, and unspecified atrial fibrillation. Review of the MDS assessment, dated 07/24/24, revealed the resident was moderately cognitively impaired. Review of the care plan conference summaries, dated since admission, revealed Resident #24 had one care conference completed on 03/29/24. Interview on 08/07/24 at 8:55 A.M. with Social Services #398 verified Resident #12 had no care conferences and Resident #24 did not have a quarterly care plan conferences. 3. Review of the medical record revealed Resident #32 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, dyspnea, benign prostatic hyperplasia with lower urinary tract symptoms, anxiety disorder, depression, carpal tunnel syndrome, essential hypertension, hyperlipidemia, and paroxysmal atrial fibrillation. Review of the MDS assessment, dated 06/29/24, revealed the resident was cognitively intact. (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: 366073 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 366073 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Embassy of Swanton 214 S Munson Rd Swanton, OH 43558 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)