Inspection·July 11, 2019

F 0580 Level of Harm - Minimal harm or potential for actual harm for Resident #8 revealed a final status report on 08/01/18. The U/A C&S result revealed greater than 100,000 Escherichia Coli (E. Coli). Record review of nursing progress notes dated on 08/01/18 revealed a call was placed to MD #310 office in regards to the UA results and indicated his nurse stated MD #310 would address the results that day. Residents Affected - Few Record review of a nursing progress note dated 08/02/19 revealed a follow-up call was made to MD #310 indicating again the facility nursing staff was seeking a response on the UA results. MD #310's nurse indicated the doctor would address the results after he finished with his patients he was seeing in the office. Record review of MD #300 progress note dated 08/06/18 revealed Resident #8 had been seen for a monthly visit. MD #300 documented that MD #310, nephrologist, had ordered a UA on 07/30/18. MD #300 documented the U/A was greater than 100,000 E. Coli and sensitive to Cipro antibiotic. MD #300 documented Resident #8 was symptomatic with belly pain, low grade fever, and nausea. The assessment and plan revealed MD #300 was prescribing Cipro 500 milligrams (mg) two times a day for seven days to treat the UTI. Review of physician order revealed MD #300 ordered Cipro 500 mg two times a day for seven days to treat the UTI. Review of Emergency Ebox use form verified Cipro 250 mg, quantity two was taken out of inventory on 08/07/19 at 4:15 P.M.; nurses signature was not legible. Record review of Medication Administration Record, (MAR) revealed the Cipro 500 mg two times per day prescribed by MD #300 on 08/06/18 was not administered until the evening of 08/07/19. Record review of consultation dated 08/08/18 for Resident #8 with MD #310 revealed he was evaluating and treating for decreased renal function. MD #310 documented Resident # 8 had decreased renal function, a distended abdomen, nausea and a Foley catheter in place for one week. There was no documentation of the Resident # 8 being treated by MD # 300 for UTI or that he had been notified that week of the U/A C&S results. Interview on 07/09/19 at 02:33 P.M. with the Director of Nursing, (DON) verified that when C/S results are returned with more than 100,000 organisms of E-Coli what are the expectations of your nursing staff. The DON revealed the expectation is to notify the in-house physician or specialist. When the DON had been given the scenario of the specialist not returning the notification for several days. The DON revealed there is an in-house physician group at the facility three days a week and the nurse could put the results in front of them and see if the in house group would order and antibiotic. Interview via telephone on 07/09/19 at 3:54 P.M. with MD #300 and the Medical Director of the facility. MD # 300 verified it would be his expectation for the nursing staff to contact him if they could not get a response for an order from a specialist. When given the scenario of what had taken place 07/27/18 through 08/09/18 by the, MD #300 revealed it was a problem the nursing staff did not contact him sooner. MD #300 further revealed as a medical director his primary problem is the nursing staff doesn't always notify him when needed. MD #300 verified he would have treated the Resident #8 sooner if he would have been notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 2 of 8 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 365254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Center 10357 Van Wert Decatur Road Van Wert, OH 45891 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 0580 Level of Harm - Minimal harm or potential for actual harm Interview on 07/09/19 at 6:20 P.M. with the DON was not able to explain a reason as to why the nurse waited until the evening of 08/07/18 to administer the antibiotic ordered on 08/06/18 for Resident #8 . The DON then verified this resulted in the Resident # 8 not receiving treatment for seven days for a UTI. The DON revealed she could not get in touch with the nurse who should have administered the antibiotic sooner. Residents Affected - Few Policy review of the facilities undated, Change in Condition Policy, revealed the facility was to notify the attending physician or physicians on call within 24 hours for a non-emergency significant change in condition. In addition the facility is to continue to monitor and document the status of the resident. Policy review of the facilities Urinary Tract Infections/Bacteruria-Clinical Protocol, revealed the facility refers to the current guidelines of McGeer's for criteria that define a UTI. Review of information from McGreer Criteria for Long-Term Care Surveillance Definitions for infections updated 2012, revealed criteria of a diagnosis of a UTI with a catheter documents a resident must have signs and symptoms for a UTI and have a culture specimen greater than 100,000 of units of any organism. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 3 of 8 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 365254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Center 10357 Van Wert Decatur Road Van Wert, OH 45891 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure Resident #32, who required staff assistance with activities of daily living, received adequate and timely care to maintain good personal hygiene including facial shaving. This affected one (#32) out of three residents reviewed for assistance with personal hygiene. The facility census was 79. Residents Affected - Few Finding include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses including Alzheimer's disease, abnormal weight loss, restlessness and agitation, dementia with behavioral disturbance, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, heart failure, delusional disorders, chronic ischemic heart disease, anxiety disorder, hyperlipidemia, diabetes mellitus type two, iron deficiency anemia, hypertension, depressive disorder, unspecified psychosis, atherosclerotic heart disease, coronary artery disease without angina, cardiac pacemaker. Record review of Minimal Data Sheet, (MDS), Quarterly assessment dated [DATE], Brief Interview of Mental Status, (BIMS) score of two indicating severe cognitive impairment. Further review of the MDS revealed the residents required extensive assistance with activities daily living (ADL). Record review of comprehensive care plan for Resident # 32 revealed an ADL Self Care Performance Deficit related to impaired cognition, impaired range of motion, (ROM), Limited Mobility, short of breathe, (SOB) with exertion, becomes agitated and combative with staff assist at times. Record review of progress notes revealed no documentation for Resident # 32 regarding being shaved with ADL's. Record review of Resident #32 for showers and personal hygiene look back report from 06/26/19 through 7/09/19 reveled no documentation for shaving. Observation on 07/09/19 at 11:22 A.M. of Resident #32 revealed she had chin hairs. At the time of the observation State Tested Nursing Assistant (STNA) #150 verified she did not attempt to shave Resident #32 when she saw her/provided care today. She further verified Resident #32 needs shaved and she will attempt it today. STNA #150 revealed she didn't know the last time Resident #32 was shaved. STNA #150 also verified the STNA's and/or facility doesn't document when residents are shaved so there no way to know when she was shaved last. Interview on 07/09/19 at 11:38 AM with the Director of Nursing (DON) verified she would expect a STNA to shave any resident who needs shaved. The DON revealed the expectation for STNA's is to attempt more than once to shave a combative resident and to get assistance with staff. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 4 of 8 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 365254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Center 10357 Van Wert Decatur Road Van Wert, OH 45891 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, policy review and review of information from on infection from McGreer's, the facility failed to ensure treatment was provided to a resident timely for the treatment of a urinary tract infection (UTI). This affected one (#8) out of four residents reviewed for hospitalization. The facility census was 79. Findings included: Review of Resident #8's medical record revealed resident was admitted to facility on 04/03/2018. Diagnosis include atherosclerotic heart disease, coronary artery disease with angina, muscle weakness, type two diabetes mellitus with diabetic neuropathy, essential hypertension, hyperlipidemia, chronic obstructive pulmonary disease, diabetic chronic kidney disease, gastro esophageal reflux disease with out esophagitis, major depressive disorder, sleep apnea, retention of urine, hypothyroidism, anemia, old myocardial infraction, chronic kidney disease. Review of the Quarterly Minimum Data Sheet, (MDS) dated [DATE] revealed Resident #8 was assessed as cognitively intact with no deficits. Resident #8 was also assessed as requiring extensive assist plus two for toileting. She was also assessed as occasionally incontinent and did not have an urinary catheter during the assessment period. Review of Resident #8 comprehensive care plan documented she had recurrent UTI's with interventions including nursing staff to monitor, document, and report all signs and symptoms of UTIs to the medical doctor as needed. Record review of nursing progress notes dated on 07/27/18 revealed Resident #8 was seen by Medical Doctor, (MD) #320 on 07/27/18 and returned with Foley Catheter in place and appointment card only. The nursing progress notes indicated the facility called MD #320 office for progress notes and documentation of the appointment. Record review of nursing progress notes dated on 07/28/18 revealed facility received a call from Hospital #1 indicating MD #320 had ordered a CT of abdomen and pelvis without contrast to be completed there on 08/06/19. Record review of nursing progress notes dated on 07/30/2018 revealed a urine specimen had been ordered Microalbumin was added to the order. Record review from a urinary analysis with culture and sensitivity (U/A, C&S), laboratory result for Resident #8 revealed a final status report on 08/01/18. The U/A C&S result revealed greater than 100,000 Escherichia Coli (E. Coli). Record review of nursing progress notes dated on 08/01/18 revealed a call was placed to MD #310 office in regards to the UA results and indicated his nurse stated MD #310 would address the results that day. Record review of a nursing progress note dated 08/02/19 revealed a follow-up call was made to MD #310 indicating again the facility nursing staff was seeking a response on the UA results. MD #310's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 5 of 8 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 365254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Center 10357 Van Wert Decatur Road Van Wert, OH 45891 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurse indicated the doctor would address the results after he finished with his patients he was seeing in the office. Record review of MD #300 progress note dated 08/06/18 revealed Resident #8 had been seen for a monthly visit. MD #300 documented that MD #310, nephrologist, had ordered a UA on 07/30/18. MD #300 documented the U/A was greater than 100,000 E. Coli and sensitive to Cipro antibiotic. MD #300 documented Resident #8 was symptomatic with belly pain, low grade fever, and nausea. The assessment and plan revealed MD #300 was prescribing Cipro 500 milligrams (mg) two times a day for seven days to treat the UTI. Review of physician order revealed MD #300 ordered Cipro 500 mg two times a day for seven days to treat the UTI. Review of Emergency Ebox use form verified Cipro 250 mg, quantity two was taken out of inventory on 08/07/19 at 4:15 P.M.; nurses signature was not legible. Record review of Medication Administration Record, (MAR) revealed the Cipro 500 mg two times per day prescribed by MD #300 on 08/06/18 was not administered until the evening of 08/07/19. Record review of consultation dated 08/08/18 for Resident #8 with MD #310 revealed he was evaluating and treating for decreased renal function. MD #310 documented Resident # 8 had decreased renal function, a distended abdomen, nausea and a Foley catheter in place for one week. There was no documentation of the Resident # 8 being treated by MD # 300 for UTI or that he had been notified that week of the U/A C&S results. Interview on 07/09/19 at 02:33 P.M. with the Director of Nursing, (DON) verified that when C/S results are returned with more than 100,000 organisms of E-Coli what are the expectations of your nursing staff. The DON revealed the expectation is to notify the in-house physician or specialist. When the DON had been given the scenario of the specialist not returning the notification for several days. The DON revealed there is an in-house physician group at the facility three days a week and the nurse could put the results in front of them and see if the in house group would order and antibiotic. Interview via telephone on 07/09/19 at 3:54 P.M. with MD #300 and the Medical Director of the facility. MD # 300 verified it would be his expectation for the nursing staff to contact him if they could not get a response for an order from a specialist. When given the scenario of what had taken place 07/27/18 through 08/09/18 by the, MD #300 revealed it was a problem the nursing staff did not contact him sooner. MD #300 further revealed as a medical director his primary problem is the nursing staff doesn't always notify him when needed. MD #300 verified he would have treated the Resident #8 sooner if he would have been notified. Interview on 07/09/19 at 6:20 P.M. with the DON was not able to explain a reason as to why the nurse waited until the evening of 08/07/18 to administer the antibiotic ordered on 08/06/18 for Resident #8 . The DON then verified this resulted in the Resident # 8 not receiving treatment for seven days for a UTI. The DON revealed she could not get in touch with the nurse who should have administered the antibiotic sooner. Policy review of the facilities undated, Change in Condition Policy, revealed the facility was to notify the attending physician or physicians on call within 24 hours for a non-emergency significant change in condition. In addition the facility is to continue to monitor and document the status of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 6 of 8 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 365254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Center 10357 Van Wert Decatur Road Van Wert, OH 45891 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 0690 the resident. Level of Harm - Minimal harm or potential for actual harm Policy review of the facilities Urinary Tract Infections/Bacteruria-Clinical Protocol, revealed the facility refers to the current guidelines of McGeer's for criteria that define a UTI. Residents Affected - Few Review of information from McGreer Criteria for Long-Term Care Surveillance Definitions for infections updated 2012, revealed criteria of a diagnosis of a UTI with a catheter documents a resident must have signs and symptoms for a UTI and have a culture specimen greater than 100,000 of units of any organism. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 7 of 8 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 365254 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/11/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Center 10357 Van Wert Decatur Road Van Wert, OH 45891 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 observation and staff interview, the facility failed to ensure personal items including attends, wash basins and bed pans were appropriately stored to prevent cross contamination. This affected five (#8, #20, #32, #33, and #63) out of 24 residents observed during the initial pool sample. The facility census was 79. Residents Affected - Some Findings include: On 07/08/19 11:25 A.M. an observation was made of Residents (#8, #33 and #32) shared bathroom. During the observation two packs of attends, a bed pan and a wash basin were observed laying inside the bed pan. All the items were observed lying on the floor of the bathroom without any bags or barriers over the personal items to ensure proper infection control was maintained. On 07/08/19 at 11:29 A.M. an observation was made of Resident #20 and Resident #63 shared bathroom. During the observation a bed pan and a wash basin was observed laying inside of the bed pan. All the items were observed lying on the floor of the bathroom without any bags or barriers over the personal items to ensure proper infection control was maintained. On 07/09/19 11:23 A.M. interview with State Tested Nurse Aide (STNA) #150 verified items including the attends, bad pans, and wash basin were being to be stored on the floor of the bathrooms. She further verified the attends should be stored in the closets on the self and the bed pan and wash basins should be stored in a bag and placed in the residents nigh stand. She then verified she will be throwing all the observed personal items away. She also verified Resident (#8, #33 and #32) shared a bathroom and Resident #20 and Resident #36 shared a bathroom. On 07/09/19 11:30 A.M. interview with the Director of Nursing (DON) verified all personal items including attends wash basins and bed should not be stored on the floor or not bagged. She verified attends should be stored in a closet on the shelf and wash basins and bed pans should be placed in a bag stored on a self or in a drawer of the residents night stand. She verified the facility has no policy for storing all personal items in a sanitary manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 8 of 8