Inspection·October 13, 2022

F 0641 Ensure each resident receives an accurate assessment. 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 and staff interview, the facility failed to ensure accuracy of the minimum data assessment. This affected two residents (#16 and #259) out 16 residents reviewed. The facility census was 57. Residents Affected - Few Findings include: 1. Review of the medical record of Resident #16 revealed an admission date of 07/11/22. Diagnoses included orthopedic aftercare, fracture of unspecified part of neck of left femur (07/06/22), cognitive communication deficit, difficulty in walking, type II diabetes mellitus without complications, major depressive disorder, anemia and sleep apnea. Review of the admission Minimum data set (MDS) assessment dated [DATE] revealed Resident #16 had moderate impaired cognition. The resident required extensive assistance of two staff for bed mobility, and extensive assistance of one staff for transfers, walking in the room, for locomotion on unit, dressing, toilet use and for personal hygiene. Resident #16 required limited assistance of one staff for locomotion in the corridor. The assessment indicated the resident had fallen in the month prior to admission but indicated no fracture in the six months prior to admission. Interview on 10/06/22 at 1:30 P.M. with Licensed Practical Nurse #159 provided verification of the inaccuracy of the MDS assessment with no fracture identified upon admission. 2. Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. There was no further documentation of skin conditions. Review of the progress notes of the admission skin assessment for Resident #259 revealed her buttocks was red and non-blanchable, the left great toe wound measured 3.5 centimeters (cm) by 4.5 cm by unable to determine the depth due to black eschar tissue, a second left toe measurement of 2.5 cm by 2.0 cm by unable to determine the depth due to black eschar tissue, the third left toe measurement of 1.0 cm by 1.3 cm by unable to determine the depth due to black eschar tissue, the right great toe measurement of 2.0 cm by 1.5 cm scarring, the second right toe amputation with black tissue scarring, three scabs noted to the third right toe, the fifth right toe amputation noted, and bilateral heels were soft and mushy. It was also documented Resident #259 was followed by the physician for bilateral feet due to the peripheral vascular disease and the next visit was scheduled 09/29/22. Interview on 10/11/22 at 1:51 P.M., with the Licensed Practical Nurse (LPN) #252 verified the only documentation of the skin concerns on Resident #259's admission MDS were of three stage one pressure ulcers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 2 of 21 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 10/13/2022 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the baseline care plan was accurately completed. This affected one resident (#259) out of 24 resident reviewed. The facility census was 57. Finding include: Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. There was no further documentation of skin conditions. Review of the progress notes of the admission skin assessment for Resident #259 revealed her buttocks was red and non-blanchable, the left great toe wound measured 3.5 centimeters (cm) by 4.5 cm by unable to determine the depth due to black eschar tissue, a second left toe measurement of 2.5 cm by 2.0 cm by unable to determine the depth due to black eschar tissue, the third left toe measurement of 1.0 cm by 1.3 cm by unable to determine the depth due to black eschar tissue, the right great toe measurement of 2.0 cm by 1.5 cm scarring, the second right toe amputation with black tissue scarring, three scabs noted to the third right toe, the fifth right toe amputation noted, and bilateral heels were soft and mushy. It was also documented Resident #259 was followed by the physician for bilateral feet due to the peripheral vascular disease and the next visit was scheduled 09/29/22. Review of the baseline care plan for Resident #259 revealed only a potential for alteration in skin integrity related to debility and decreased self-mobility. Interventions included to encourage food and fluid, keep the skin dry and clean and turn and reposition frequently. Interview on 10/11/22 at 1:51 P.M., with the Licensed Practical Nurse (LPN) #252 verified there was no care plan for Resident #259's actual wounds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 3 of 21 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 10/13/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff and resident interview, the facility failed to ensure the care plan was accurately developed and implemented. This affected two residents (#259 and #07) out of 24 residents reviewed. The facility census was 57. 1. Review of the medical record for Resident #07 revealed an admission date of 06/10/19. Diagnoses included congested heart failure (CHF), hypertension (HTN), and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #07 had intact cognition and required extensive one person assistance for bed mobility, transfers, and toilet use. Review of the care plan for potential for impairment of skin integrity listed betadine to the right ear for proactive skin health and scabs to bilateral feet. Interventions included assess areas over bony prominences, encourage to remove shoes when resting in the chair and betadine as per order and monitor for effectiveness (03/30/22). Review of subsequent care plans dated 05/07/22 and 07/14/22 revealed no change regarding the intervention for the right ear to apply betadine and monitor for its effectiveness. Observation on 10/04/22 at 2:31 P.M. of Resident #07's right ear revealed an approximate one inch grey colored dry scabbing area to the superior helix (the top of the ear). Interview at the time of the observation revealed Resident #07 said the scab had been on her ear for some time. Review of the weekly skin assessment dated [DATE] for Resident #07 revealed a reddened area to the right ear. Further skin assessment revealed no new areas however no further assessments of the area were noted aside from on 07/27/22 which documented scab continued, no signs or symptoms of infection and resident denied pain; on 08/02/22 two small scabs noted no signs or symptoms of infection, the resident denied pain and the area showed signs of healing. Observation and interview on 10/06/22 at 2:20 P.M. with the Director of Nursing (DON) of Resident #07's ear revealed she believed the scab may be larger than she remembered. Interview on 10/11/22 at 1:51 P.M., with the Licensed Practical Nurse (LPN) #252 regarding the care plan for Resident #07's right ear revealed she had not assessed the resident or completed the previous care plans. She verified the wound was on going from the original date of 03/30/22 with no documentation the effectiveness of the intervention had been monitored nor had it been updated. 2. Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. There was no further documentation of skin conditions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 4 of 21 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 10/13/2022 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the progress notes of the admission skin assessment for Resident #259 revealed her buttocks was red and non-blanchable, the left great toe wound measured 3.5 centimeters (cm) by 4.5 cm by unable to determine the depth due to black eschar tissue, a second left toe measurement of 2.5 cm by 2.0 cm by unable to determine the depth due to black eschar tissue, the third left toe measurement of 1.0 cm by 1.3 cm by unable to determine the depth due to black eschar tissue, the right great toe measurement of 2.0 cm by 1.5 cm scarring, the second right toe amputation with black tissue scarring, three scabs noted to the third right toe, the fifth right toe amputation noted, and bilateral heels were soft and mushy. It was also documented Resident #259 was followed by the physician for bilateral feet due to the peripheral vascular disease and the next visit was scheduled 09/29/22. Review of the baseline care plan for Resident #259 revealed only a potential for alteration in skin integrity related to debility and decreased self-mobility. Interventions included to encourage food and fluid, keep the skin dry and clean and turn and reposition frequently. Review of the comprehensive care plan for Resident #259 revealed an added focus for pressure ulcer or potential for pressure ulcer related to decreased mobility and extensive assistance with bed mobility with interventions which included but were not limited to, bilateral heel boots on at all times while in bed, skin prep to bilateral heels and buttocks and administer treatments as ordered and monitor for effectiveness. No additional focus was made for the actual non pressure wounds present on admission. Interview on 10/11/22 at 1:51 P.M., with the LPN #252 verified there was no care plan for Resident #259's actual non pressure wounds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 5 of 21 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 10/13/2022 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 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, observation and staff and resident interview, the facility failed to ensure interventions were reviewed and revised after a fall. This affected one resident (#16) out of two residents reviewed for falls. In addition, the facility failed to ensure resident skin care plans were reassessed, reviewed, and revised This affected two (#259 and #07) of three residents reviewed for skin alterations. The facility census was 57. Findings include: 1. Review of the medical record of Resident #16 revealed an admission date of 07/11/22. Diagnoses included orthopedic aftercare, fracture of unspecified part of neck of left femur, cognitive communication deficit, difficulty in walking, type II diabetes mellitus without complications, major depressive disorder, anemia, and sleep apnea. Review of the admission Minimum data set (MDS) assessment dated [DATE] revealed Resident #16 had moderate impaired cognition. The resident required extensive assistance of two staff for bed mobility, and extensive assistance of one staff for transfers, walking in the room, locomotion on the unit, dressing, toilet use and for personal hygiene. Resident #16 required limited assistance of one staff for locomotion in the corridor. The assessment indicated she had fallen in the month prior to admission but indicated no fractures in the six months prior to admission. Review of the fall risk assessment dated [DATE] revealed Resident #16 was a low risk for falls however, all sections of the assessment were not completed as the section titled Systolic Blood Pressure was unmarked. Fall risk assessments dated 08/10/22 and 09/19/22 revealed Resident #16 was a high risk for falls. Review of the initial care plan dated 07/12/22 revealed a potential for/at risk for injuries/falls related to unsteadiness with various transfers, and a fall history. No interventions were initiated until 07/22/22, and the intervention was to instruct the resident not to get up without assistance. Interventions initiated on 07/26/22 included half assist rail/transfer enabler to both sides of the bed to enhance independent bed mobility, assist in positioning for comfort as needed, anticipate needs as able, maintain uncluttered environment, monitor safety/preventative devices for application, instruct on the use of adaptive equipment as needed, observe for signs and symptoms of pain, medicate per physician orders, pharmacy medication review as needed, refer to therapy services as needed, physical and occupational therapy evaluation and treat as ordered or as needed. No new interventions were added after the fall on 08/04/22 or on 08/08/22. Interview on 10/05/22 at 2:30 P.M. with Licensed Practical Nurse (LPN) #159 provided verification of the lack of interventions for fall precautions in the initial care plan, and no new interventions following falls on 08/04/22 or 08/08/22. Review of the progress note dated 07/22/22 timed 9:34 P.M. revealed a temporary nurse (agency) was alerted at 8:40 P.M. Resident #16 was on the floor, face down. Resident stated she hit her head, a hematoma was noted on her left face. The resident complained of pain in her left wrist upon palpation and movement. She was sent to the emergency room and returned approximately three hours later with a diagnosis of a left wrist fracture. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 6 of 21 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 10/13/2022 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 0657 Review of the emergency department notes dated 07/22/22 revealed a splint was applied to the left wrist. Level of Harm - Minimal harm or potential for actual harm Review of the progress note dated 07/23/22 at 12:47 A.M. revealed Resident #16 returned to the facility with a splint to the left wrist. Residents Affected - Few Review of the progress note dated 08/04/22 at 10:55 A.M. revealed Resident #16 was found on the floor on her belly with her left arm tucked under her body and her left leg slightly under her right leg. The left side of her head was lying flat on the floor. She had non-skid socks on both feet and the call light was attached to the bed rail. Resident #16 was complaining of pain to the left side of her head and the left hip and was asked to remain still until the emergency squad arrived. No visual injuries were observed. Resident #16 returned from the emergency department as 2:15 P.M. with diagnosis of contusion to the knee and the hip. Review of the progress note dated 08/08/22 at 3:49 A.M. revealed Resident #16 was found on the floor, sitting next to her bed with her left leg crossed under her right leg. She had complaints of pain to the left leg. Resident was sent to the emergency department. A follow-up progress note dated 08/08/22 at 6:54 A.M. revealed the emergency department called to inform facility Resident #16 was being admitted with a left lower femur fracture and surgical repair would be initiated. Interview on 10/06/22 at 1:45 P.M., with Licensed Practical Nurse #159 verified the care plan had not been updated timely after a fall on 07/22/22, 08/04/22, and on 08/08/22. 2. Review of the medical record for Resident #07 revealed an admission date of 06/10/19. Diagnoses included congested heart failure (CHF), hypertension (HTN), and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #07 had intact cognition and required extensive one person assistance for bed mobility, transfers, and toilet use. Review of the care plan for potential for impairment of skin integrity listed betadine to the right ear for proactive skin health and scabs to bilateral feet. Interventions included assess areas over bony prominences, encourage to remove shoes when resting in the chair and betadine as per order and monitor for effectiveness (03/30/22). Review of subsequent care plans dated 05/07/22 and 07/14/22 revealed no change regarding the intervention for the right ear to apply betadine and monitor for its effectiveness. Observation on 10/04/22 at 2:31 P.M. of Resident #07's right ear revealed an approximate one inch grey colored dry scabbing area to the superior helix (the top of the ear). Interview at the time of the observation revealed Resident #07 said the scab had been on her ear for some time. Interview on 10/04/22 at 3:01 P.M., with the Licensed Practical Nurse (LPN) #113 revealed Resident #07's right ear wound began as a scratch and they had applied triple antibiotic ointment to it, then the physician decided it needed to dry and changed the order to betadine in May 2022. The scab then falls off and reappears, and she was unsure if a physician has looked at it. Review of the weekly skin assessment dated [DATE] for Resident #07 revealed a reddened area to the right ear. Further skin assessment revealed no new areas however no further assessments of the area were noted aside from on 07/27/22 which documented scab continued, no signs or symptoms of infection and resident denied pain; on 08/02/22 two small scabs noted no signs or symptoms of infection, the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 7 of 21 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 10/13/2022 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 0657 resident denied pain and the area showed signs of healing. Level of Harm - Minimal harm or potential for actual harm Observation and interview on 10/06/22 at 2:20 P.M. with the Director of Nursing (DON) of Resident #07's ear revealed she believed the scab may be larger than she remembered. Residents Affected - Few Interview on 10/11/22 at 1:51 P.M., with the Licensed Practical Nurse (LPN) #252 regarding the care plan for Resident #07's right ear revealed she had not assessed the resident or completed the previous care plans. She verified the wound was on going from the original date of 03/30/22 with no documentation the effectiveness of the intervention had been monitored nor had it been updated. 3. Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. There was no further documentation of skin conditions. Review of the progress notes of the admission skin assessment for Resident #259 revealed her buttocks was red and non-blanchable, the left great toe wound measured 3.5 centimeters (cm) by 4.5 cm by unable to determine the depth due to black eschar tissue, a second left toe measurement of 2.5 cm by 2.0 cm by unable to determine the depth due to black eschar tissue, the third left toe measurement of 1.0 cm by 1.3 cm by unable to determine the depth due to black eschar tissue, the right great toe measurement of 2.0 cm by 1.5 cm scarring, the second right toe amputation with black tissue scarring, three scabs noted to the third right toe, the fifth right toe amputation noted, and bilateral heels were soft and mushy. It was also documented Resident #259 was followed by the physician for bilateral feet due to the peripheral vascular disease and the next visit was scheduled 09/29/22. Review of the baseline care plan for Resident #259 revealed only a potential for alteration in skin integrity related to debility and decreased self-mobility. Interventions included to encourage food and fluid, keep the skin dry and clean and turn and reposition frequently. Review of the comprehensive care plan for Resident #259 revealed an added focus for pressure ulcer or potential for pressure ulcer related to decreased mobility and extensive assistance with bed mobility with interventions which included but were not limited to, bilateral heel boots on at all times while in bed, skin prep to bilateral heels and buttocks and administer treatments as ordered and monitor for effectiveness. No additional focus was made for the actual non pressure wounds present on admission. Interview on 10/11/22 at 1:51 P.M., with the LPN #252 verified there was no care plan for Resident #259's actual non pressure wounds. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 8 of 21 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 10/13/2022 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 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 medical record review, staff, resident, and hospital staff interview, observation, and policy review, the facility failed to ensure a resident was prepared for a colonoscopy and endoscopy as scheduled. This affected one resident (#26) out of one resident reviewed for medical appointments. In addition, the facility failed to ensure existing skin conditions were assessed, measured and referrals were made. This affected two (#07 and #259) out of 24 Residents reviewed. The facility census was 57. Residents Affected - Few Findings include: 1. Review of Resident #26's medical record revealed an admission date of 06/24/22. Diagnoses included muscle weakness, difficulty walking, major depression, diabetes mellitus type II, essential hypertension, chronic kidney disease, and unspecified intellectual disabilities. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was assessed with intact cognition. Review of a physician order dated 08/12/22 revealed Resident #26 was scheduled for an appointment with a physician for a possible colonoscopy (examination of the large bowel and the distal part of the small bowel with a camera on a flexible tube passed through the anus) due to anemia. Review of a physician visit dated 08/12/22 revealed Resident #26 visited with the physician to discuss a colonoscopy. Resident #26 was assessed during the physician visit to have iron deficiency anemia and given the nature of the anemia the physician would perform a colonoscopy and esophagogastroduodenoscopy (EGD, which is using a flexible camera to view the upper part of the gastrointestinal tract). The procedure was explained in detail per the physician visit note and orders were placed for diagnostic colonoscopy and diagnostic upper endoscopy. Review of a monthly physician visit note dated 09/06/22 revealed the practitioner noted in Resident #26's assessment and plan that Resident #26 was getting scopes due to anemia. Review of a physician order dated 09/26/22 revealed Resident #26 had an appointment for the colonoscopy and upper endoscopy on 09/26/22 at 1:00 P.M. Further review of the physician orders between 09/25/22 and 09/26/22 revealed no orders for Resident #26 to prepare for the colonoscopy or upper endoscopy. There was no documentation in the medical record of Resident #26's colonoscopy or upper endoscopy being completed on 09/26/22 as scheduled. Review of a nursing progress note dated 09/27/22 revealed Resident #26's colonoscopy and upper endoscopy were rescheduled for 11/14/22. Interview on 10/06/22 at 12:46 P.M. with Licensed Practical Nurse (LPN) #118 stated Resident #26 received orders for the colonoscopy and upper endoscopy when she was on the rehabilitation hall of the facility and was later transferred to the long-term care hall were LPN #118 worked. LPN #118 stated Resident #26 before coming to the long-term care hall Resident #26 never had orders for preparation for the colonoscopy and upper endoscopy and no one caught it. LPN #118 stated when Resident #26 left for her appointment on 09/26/22 no one knew it was for an actual procedure and verified Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 9 of 21 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 10/13/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few #26 was not properly prepared for the colonoscopy and upper endoscopy, so it was not done on the scheduled day and needed to be rescheduled. A telephone interview was completed on 10/06/22 at 12:55 P.M. with Hospital Medical Records Clerk #163. Hospital Medical Records Clerk #163 verified Resident #26 was scheduled for a colonoscopy and upper endoscopy on 09/26/22 but the procedures were canceled due to Resident #26 not being prepared for them. Hospital Medical Records Clerk #163 could not provide any additional information related to Resident #26's appointment on 09/26/22. Hospital Medical Records Clerk #163 verified Resident #26's procedures were rescheduled for 11/14/22. 2. Review of the medical record for Resident #07 revealed an admission date of 06/10/19. Diagnoses included congested heart failure (CHF), hypertension (HTN), and chronic kidney disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #07 had intact cognition and required extensive one person assistance for bed mobility, transfers, and toilet use. Review of the care plan for potential for impairment of skin integrity listed betadine to the right ear for proactive skin health and scabs to bilateral feet. Interventions included assess areas over bony prominences, encourage to remove shoes when resting in the chair and betadine as per order and monitor for effectiveness (03/30/22). Review of subsequent care plans dated 05/07/22 and 07/14/22 revealed no change regarding the intervention for the right ear to apply betadine and monitor for its effectiveness. Observation and interview on 10/06/22 at 2:20 P.M., with the Director of Nursing (DON) of Resident #07's ear revealed the DON believed the scab may be larger than she remembered. She further shared Resident #07 had been seen by the wound nurse for her feet and was unsure if she saw her for her ear, or if any follow-up assessments of the area were completed by the nurses of the area. Resident #07 said she had not been seen by the wound nurse for her chronic right ear skin condition. Review of the physician orders for Resident #07 revealed weekly skin assessments were ordered with a start date of 11/08/21. Review of the audiology appointment dated 08/30/22 for Resident #7 revealed the physician addressed the scab to the right ear as being present on the 04/2022 appointment and recommended a referral to a dermatologist due to the chronic non-healing nature of the scab. Interview on 10/11/22 at 10:20 A.M., the DON revealed she was unaware of a referral to the dermatologist, and later set the appointment for 12/20/22. She then acknowledged staff had been documenting no new areas on the skin assessments and not assessing the current wound to the right ear, and it would be her expectation to do so. 3. Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 10 of 21 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 10/13/2022 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the physician orders for Resident #259 revealed weekly skin assessments were ordered with a start date of 09/26/22. Review of the care plan for Resident #259 revealed pressure ulcer or potential for pressure ulcer related to decreased mobility and extensive assistance with bed mobility with interventions including bilateral heel boots on at all times while in bed, skin prep to bilateral heels and buttocks and administer treatments as ordered and monitor for effectiveness. Interview on 10/11/22 at 11:05 A.M., with the DON revealed Resident #259 was admitted to the facility with documented wounds, followed by an outside physician and had an appointment previously scheduled for 09/29/22. However, due to the steady decline of Resident #259, her family opted for hospice care. She was admitted to hospice on 10/1/22 and the family no longer wanted the resident followed by the outside physician and opted for the facility wound nurse to follow the resident. The DON further shared the wound nurse saw residents weekly on Thursdays and was unable to verify if Resident #259 had been seen yet. The DON also verified there had not been any further assessments or measurements of the wounds since admission. Record review of the policy titled Managing Skin Integrity, undated revealed nursing, in collaboration with the interdisciplinary team, will assess and manage skin integrity for all residents throughout the stay and provide close monitoring of the response to treatment and a referral to additional resources when indicated. The plan of care will be developed to consider the current state of skin integrity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 11 of 21 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 10/13/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interview, the facility failed to ensure pressure ulcer care planned and ordered interventions were implemented. This affected one resident (#259) out of 24 residents reviewed. The facility census was 57. Residents Affected - Few Findings include: Review of medical record for Resident #259 revealed admission date of 09/20/22. Diagnoses included local infection of the skin, diabetes, non-pressure chronic ulcer of left foot, peripheral vascular disease (PVD) and protein deficient malnutrition. The resident was admitted to hospice on 10/01/22 and remained in the facility. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #259 required extensive two-person assistance for bed mobility, toilet use, limited assistance for transfers and eating. The skin section of the MDS documented three, stage one pressure injuries. There was no further documentation of skin conditions. Review of the progress notes of the admission skin assessment for Resident #259 revealed her buttocks was red and non-blanchable, the left great toe wound measured 3.5 centimeters (cm) by 4.5 cm by unable to determine the depth due to black eschar tissue, a second left toe measurement of 2.5 cm by 2.0 cm by unable to determine the depth due to black eschar tissue, the third left toe measurement of 1.0 cm by 1.3 cm by unable to determine the depth due to black eschar tissue, the right great toe measurement of 2.0 cm by 1.5 cm scarring, the second right toe amputation with black tissue scarring, three scabs noted to the third right toe, the fifth right toe amputation noted, and bilateral heels were soft and mushy. It was also documented Resident #259 was followed by the physician for bilateral feet due to the peripheral vascular disease and the next visit was scheduled 09/29/22. Review of the comprehensive care plan for Resident #259 revealed an added focus for pressure ulcer or potential for pressure ulcer related to decreased mobility and extensive assistance with bed mobility with interventions which included but were not limited to, bilateral heel boots on at all times while in bed, skin prep to bilateral heels and buttocks and administer treatments as ordered and monitor for effectiveness. No additional focus was made for the actual non pressure wounds present on admission. Review of the physician orders for Resident #259 revealed an order for bilateral heel protectors on at all times while in bed, with a start date of 09/29/22. Observation on 10/04/22 at 9:05 A.M. revealed Resident #259 was lying in bed with her left heel boot off. At the time of the observation the State Tested Nursing Assistant (STNA) #125 verified the boot was off and retrieved the boot from the chair beside the bed and applied it to Resident #259's left foot. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 12 of 21 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 10/13/2022 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and family interview, review of the hospital documentation, and policy review, the facility failed to ensure falls were investigated to determine the root cause analysis to reduce hazards, implement resident-specific interventions, and to reduce/eliminate falls and falls with major injury. This resulted in Actual Harm when Resident #16 experienced repeated falls resulting in a fractured left wrist on one event and a fractured left femur on another event with surgical repair without investigating and/or determining the cause of each fall. In between the two falls with fractures, Resident #16 fell and suffered a contusion to the left knee and the hip area. This affected one resident (#16) out of two residents reviewed for falls. Additionally, the facility failed to ensure resident safety when beds were left in the high position without staff present in the room. This had the potential for Harm but no Actual Harm occurred for two residents (#25 and #52) out of 24 residents sampled. The facility census was 57. Findings include: 1. Review of the medical record of Resident #16 revealed an admission date of 07/11/22. Diagnoses included orthopedic aftercare, fracture of unspecified part of neck of left femur, cognitive communication deficit, difficulty in walking, type II diabetes mellitus without complications, major depressive disorder, anemia, and sleep apnea. Review of the admission Minimum data set (MDS) assessment, dated 07/18/22, revealed Resident #16 had moderate impaired cognition. The resident required extensive assistance of two staff for bed mobility, and extensive assistance of one staff for transfers, walking in the room, locomotion on the unit, dressing, toilet use and for personal hygiene. Resident #16 required limited assistance of one staff for locomotion in the corridor. The assessment indicated she had fallen in the month prior to admission, but indicated no fractures in the six months prior to admission. Review of the fall risk assessment, dated 07/11/22, revealed Resident #16 was a low risk for falls, however, all sections of the assessment were not completed, as the section titled Systolic Blood Pressure was unmarked. Fall risk assessments, dated 08/10/22 and 09/19/22, revealed Resident #16 was a high risk for falls. Review of the initial care plan, dated 07/12/22, revealed a potential for/at risk for injuries/falls related to unsteadiness with various transfers, and a fall history. No interventions were initiated until 07/22/22, and the intervention was to instruct the resident not to get up without assistance. Interventions initiated on 07/26/22 included half assist rail/transfer enabler to both sides of the bed to enhance independent bed mobility, assist in positioning for comfort as needed, anticipate needs as able, maintain uncluttered environment, monitor safety/preventative devices for application, instruct on the use of adaptive equipment as needed, observe for signs and symptoms of pain, medicate per physician orders, pharmacy medication review as needed, refer to therapy services as needed, and physical and occupational therapy evaluation and treat as ordered or as needed. No new interventions were added after the fall on 08/04/22 or on 08/08/22. Interview on 10/05/22 at 2:30 P.M. with Licensed Practical Nurse (LPN) #159 provided verification of the lack of interventions for fall precautions in the initial care plan, and no new interventions following falls on 08/04/22 or 08/08/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 13 of 21 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 10/13/2022 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of the progress note, dated 07/22/22 and timed 9:34 P.M., revealed a temporary nurse (agency) was alerted at 8:40 P.M. Resident #16 was on the floor, face down. Resident stated she hit her head, a hematoma was noted on her left face. The resident complained of pain in her left wrist upon palpation and movement. She was sent to the emergency room and returned approximately three hours later with a diagnosis of a left wrist fracture. Review of the emergency department notes, dated 07/22/22, revealed a splint was applied to the left wrist. Review of the progress note, dated 07/23/22 at 12:47 A.M., revealed Resident #16 returned to the facility with a splint to the left wrist. Review of the progress note, dated 08/04/22 at 10:55 A.M., revealed Resident #16 was found on the floor on her belly with her left arm tucked under her body and her left leg slightly under her right leg. The left side of her head was lying flat on the floor. She had non-skid socks on both feet and the call light was attached to the bed rail. Resident #16 was complaining of pain to the left side of her head and the left hip and was asked to remain still until the emergency squad arrived. No visual injuries were observed. Resident #16 returned from the emergency department at 2:15 P.M. with a diagnosis of contusion to the knee and the hip. Review of the progress note, dated 08/08/22 at 3:49 A.M., revealed Resident #16 was found on the floor, sitting next to her bed with her left leg crossed under her right leg. She had complaints of pain to the left leg. Resident was sent to the emergency department. A follow-up progress note, dated 08/08/22 at 6:54 A.M., revealed the emergency department called to inform the facility Resident #16 was being admitted with a left lower femur fracture and surgical repair would be initiated. Interview on 10/04/22 at 2:15 P.M., with Resident #16's husband revealed he was aware of all the falls. He stated the facility had tried to avoid the falls to the best of his knowledge, but had not noticed any new interventions after each fall. Interview on 10/06/22 at 2:00 P.M., with the Director of Nursing (DON) revealed the facility could not produce fall investigations for any of the falls experienced by Resident #16. Review of the facility policy titled Fall and Fall Risk, Managing, undated, revealed based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent future falls and to minimize complications from falls. 2. Review of the medical record of Resident #52 revealed an admission date of 05/16/22. Diagnoses included cerebral infarction due to thrombosis of other precerebral artery, hemiplegia and hemiparesis affecting left non-dominant side. Review of the quarterly minimum data set (MDS), dated [DATE], revealed Resident #52 had moderate impaired cognition and required extensive assistance of two staff for bed mobility. Observation on 10/03/22 at 9:50 A.M. revealed Resident #52 was lying in bed and the bed was in the high position. The side rails were in the raised position on both sides of the bed extending approximately two feet from the headboard to two feet from the foot board. Interview on 10/03/22 at 9:50 A.M., with the Administrator verified the bed of Resident #52 was in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 14 of 21 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 10/13/2022 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 0689 the high position and no staff were in the room. He said the side rails were enablers. Level of Harm - Actual harm Subsequent observations throughout 10/03/22 and 10/04/22 revealed the bed of Resident #52 remained in the high position and the side rails raised on both sides of the bed when the resident was in the bed. Residents Affected - Few 3. Review of the medical record of Resident #25 revealed an admission date of 06/08/22. Diagnoses included nontraumatic intracerebral hemorrhage, hemiplegia affecting right dominant side and cognitive deficit. Review of the quarterly MDS assessment, dated 08/08/22, revealed Resident #25 required extensive assistance of two staff for bed mobility. The MDS indicated one fall with non-major injury during the look back period. Review of the care plan revealed Resident #25 had a risk for falls/injuries. Interventions included bilateral half assist rails to better enhance independent bed mobility, and the bed against the wall in the low position. Observation on 10/04/22 at 4:19 P.M. revealed Resident #25 was lying in her bed. The bed was not in its lowest position. Upon returning to the room with staff, Resident #25's family was sitting on the side of the bed, assisting Resident #25 with her meal. The bed was noted to be in the low position and Resident #25's daughter acknowledged she lowered the bed when she came into the room. Observation on 10/05/22 at 3:06 P.M. revealed Resident #25 was lying her bed. The bed was not in the lowest position. State Tested Nursing Assistant (STNA) #124 verified Resident #25's bed was not in the lowest position as ordered and did lower the bed. Review of the physician orders for Resident #25 revealed the bed was to be in the lowest position when Resident #25 was in bed. The order had a start date of 07/12/22. Review of the policy titled Falls and Fall Risk, Managing, undated, revealed staff will identify and implement relevant interventions to try to minimize the serious consequences of falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 15 of 21 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 10/13/2022 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, policy review, the facility failed to accurately assess residents and obtain consent for assist rails/transfer enablers. This affected 10 residents (#02, #06, #10, #18, #24, #30, #34. #37, #50, and #52) and had the potential to affect all residents in the facility. The facility census was 57. Findings include: Observation on 10/04/22 at 10:20 A.M. with State Tested Nursing Assistant (STNA) #124 revealed the side rails on the beds of seven residents (#02, #06, #18, #34, #37, #50, and #52) were in the raised position and extended approximately two foot from the head board to two foot from the foot board on both sides of the bed. Interviews from 10:20 A.M. to 10:30 A.M. with Resident #10, Resident #30, and Resident #34 revealed they did not use the side rails and would like them removed. 1. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #02 had severe cognitive impairment and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #02 was not ambulatory, had no history of falls, no decrease of consciousness, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated without any indication. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown, promoting independence and sense of accomplishment and independent function. Safety risks without use included reduced bed mobility, anxiety/fear, fall from bed, and decreased functional ability. The assessment was not signed by the resident or a representative. 2. Review of the annual MDS assessment dated [DATE] revealed Resident #06 had severe cognitive impairment and required extensive assistance of one staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #06 was not ambulatory, no decrease of consciousness, had history of falls, and did have poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated without any indication. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown, promoting independence and sense of accomplishment and independent function. Safety risks without use included reduced bed mobility, anxiety/fear, fall from bed, total dependence on staff for bed mobility, and decreased functional ability. The assessment was not signed by the resident or a representative. 3. Review of the quarterly MDS assessment dated [DATE] revealed Resident #10 had intact cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #10 was not ambulatory, no decrease of consciousness, had no history of falls, and had poor bed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 16 of 21 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 10/13/2022 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mobility/positioning, received medications that impaired safety and did not use the rails for positioning. The assessment indicated two rails were indicated without any indication. No benefit of use was indicated. Safety risks without use included anxiety/fear, and fall from the bed. The assessment was not signed by the resident or a representative 4. Review of the quarterly MDS assessment dated [DATE] revealed Resident #18 had moderate impaired cognition and required extensive assistance of one staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #18 was ambulatory, had no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated without any indication. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown, promoting independence and sense of accomplishment and independent function. Safety risks without use included reduced bed mobility, anxiety/fear, and decreased functional ability. The assessment was not signed by the resident or a representative 5. Review of the quarterly MDS assessment dated [DATE] revealed Resident #24 had moderate impaired cognition and required extensive assistance of one staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #24 was not ambulatory, no decrease of consciousness, had no history of falls, and did not have poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated one transfer enabler was indicated to enhance independent bed mobility. The benefits of use included improved independent bed mobility, promoting independence and sense of accomplishment and independent function. Safety risks without use included reduced bed mobility and decreased functional ability. The assessment was not signed by the resident or a representative. 6. Review of the quarterly MDS assessment dated [DATE] revealed Resident #30 had intact cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #30 was not ambulatory, had no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated with an indication to allow the resident to participate in turning and repositioning. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown promoting independence and sense of accomplishment and independent function. No safety risks without or with use were indicated. The assessment was not signed by the resident or a representative. 7. Review of the quarterly MDS assessment dated [DATE] revealed Resident #34 had intact cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #34 was not ambulatory, had no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated with an indication to allow resident to participate in turning and repositioning. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown, promoting independence and sense of accomplishment and independent function. No safety risks without or with use were indicated. The assessment was not signed by the resident or a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 17 of 21 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 10/13/2022 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 0700 representative. Level of Harm - Minimal harm or potential for actual harm 8. Review of the quarterly MDS assessment dated [DATE] revealed Resident #37 had intact cognition and required extensive assistance of two staff for bed mobility. Residents Affected - Some Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #37 was not ambulatory, had no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received no medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated with an indication to allow resident to participate in turning and repositioning. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown promoting independence and sense of accomplishment. No safety risks without or with use were indicated. The assessment was not signed by the resident or a representative. 9. Review of the quarterly MDS assessment dated [DATE] revealed Resident #50 had intact cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #50 was not ambulatory, had no decrease of consciousness, had no history of falls, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated with no indication for use. The benefits of use included improved independent bed mobility, decreased risk of skin breakdown, promoting independence and sense of accomplishment and independent function. Safety risks without use were reduced bed mobility, total dependence on staff for bed mobility and decreased functional ability. The assessment was not signed by the resident or a representative. 10. Review of the quarterly MDS assessment dated [DATE] revealed Resident #52 had moderate impaired cognition and required extensive assistance of two staff for bed mobility. Review of the assist rail/transfer enabler assessment dated [DATE] revealed Resident #52 was not ambulatory, had no history of falls, no decrease of consciousness, and had poor bed mobility/positioning, received medications that impaired safety and used the rails for positioning. The assessment indicated two rails were indicated to allow resident to participate with turning and repositioning. The benefits of use included improved independent bed mobility, decreased risk of sin breakdown, promoting independence and sense of accomplishment and independent function. No safety risks were indicated with or without use. The assessment was not signed by the resident or a representative. Interview on 10/05/22 at 10:00 A.M., with the Director of Nursing verified the incomplete assist rail/transfer enablers forms for the above residents. Review of the facility policy titled Bed Safety, dated 12/07 revealed resident sleeping environment shall be assessed by an interdisciplinary team, considering a resident's safety, medical conditions, comfort, and freedom of movement and will get input from resident and family. The facility shall obtain consent for the use of side rails from the resident or their representative prior to use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 18 of 21 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 10/13/2022 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **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 with orders for as needed psychotropic medications had not extended the order beyond 14 days without physician rationale. This affected one resident (#26) out of five residents reviewed for unnecessary medications. The facility census was 57. Findings include: Review of Resident #26's medical record revealed an admission date of 06/24/22. Diagnoses included muscle weakness, difficulty walking, major depression, diabetes mellitus type II, essential hypertension, chronic kidney disease, and unspecified intellectual disabilities. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #26 was assessed with intact cognition. Review of a nursing communication document dated 07/22/22 revealed Resident #26 had increased anxiety with behaviors from being in COVID-19 quarantine as evidence by hitting bed rails, yelling out, refusing therapy, and attempting to harm the therapy staff. Review of a physician order dated 07/22/22 revealed Resident #26 was ordered the anti-anxiety medication Ativan 0.5 milligrams (mg) by mouth every six hours as needed. Further review of the physician order gave no indication of a stop date or rationale for continued use beyond 14 days. Review of the July and August 2022 medication administration records (MARs) revealed Resident #26 received as needed Ativan on 07/27/22, 08/04/22, 08/05/22, and 08/11/22 with each dose documented as effective. Review of the September and October 2022 MARs revealed Resident #26 received no doses of Ativan in either month. Review of a physician order dated 10/05/22 revealed Resident #26's as needed Ativan was discontinued. Review of a nursing progress note dated 10/05/22 revealed Resident #26's order for as needed Ativan was discontinued due to non-use. Interview on 10/06/22 at 2:55 P.M., with the Director of Nursing (DON) #100 verified Resident #26 was ordered as needed Ativan on 07/22/22 and the order continued beyond 14 days without a documented rationale for continued use. Review of the facility policy titled Antipsychotic Medication Use, revised December 2016 revealed the need to continue as needed orders for psychotropic medications beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the as needed order will be indicated in the order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 19 of 21 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 10/13/2022 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, medical record review, staff interview, and policy review the facility failed to ensure medications were administered without error. There were three errors out of 34 opportunities for a calculated medication error rate of 8.82 percent. This affected one resident (#03) out of three residents observed for medication administration. The facility census was 57. Residents Affected - Few Findings include: Observation on 10/05/22 at 7:44 A.M. with Licensed Practical Nurse (LPN) #110 revealed he prepared and administered 12 medications for Resident #03, which included isosorbide mononitrate (anti angina medication) extended release tablet 30 milligrams (mg), Lasix (a diuretic medication) 40 mg, and Xarelto (an anticoagulant medication) tablet 15 mg. Review of the current physician orders revealed there was no order for the isosorbide mononitrate, Lasix, or Xarelto. The medications had been discontinued on 07/24/22. Interview on 10/05/22 at 9:14 A.M., with LPN #110 verified the medication error. LPN #110 added he normally removes those three medications when administering to Resident #03, but forgot to remove them today. Review of the facility policy titled Administering Medications, dated 12/2012 revealed medications must be administered as ordered. The individual administering must check the label three times to verify the right resident, right medication, right dosage, right time and right method before giving the medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 20 of 21 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 10/13/2022 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, staff and resident interview, and policy review, the facility failed to ensure infection control procedures were implemented. This affected two residents (#24 and #57) out of two residents reviewed for transmission based precaution. The facility census was 57. Residents Affected - Few Findings include: 1. Observation on 10/03/22 at 11:55 A.M. revealed State Tested Nursing Assistant (STNA) #124 entering Resident #24's room after donning a cloth gown that had been hanging on the outside of his door, an N95 mask, with only one strap that had been stored in a cloth pocket of a hanging organizer, and gloves. STNA #124 entered the room with a lunch tray with Styrofoam containers, and exited a short time later. STNA #124 removed the gown, inside out, and hung it back on the hook on the outside of the door, removed the N95 mask and replaced it in the pocket of the organizer and proceeded down hall. The gown was touching items in a yellow pocket organizer, hanging slightly to the right of the gown. No disinfectant wipes were observed in the organizer. Interview at 11:57 A.M., with the STNA #124 verified she had not donned any eye protection, performed hand hygiene, and the N95 had broken one strap off. She added she wore the same gown all day long, turning it right side out before donning it and not performing hand hygiene after doing so. She added Resident #24 had been in isolation for a long time related to COVID but was supposed to come out tomorrow (10/04/22). Observation on 10/04/22 at 7:00 A.M. revealed a green cloth gown hanging on the outside of door of Resident #24's room, and the resident was in isolation for COVID. The yellow pocket organizer was hanging slightly to the right of the gown and the gown was touching the organizer. 2. Observation and interview on 10/04/22 at 9:45 A.M., with Licensed Practical Nurse (LPN) #117 revealed Resident #57 was in contact isolation for extended spectrum beta-lactamase (ESBL) and if not touching her or soiled clothing, there was no need for gown or gloves. Observation of the yellow pocket organizer hanging from the door of Resident #57's room revealed no gowns were present. Observation and interview on 10/04/22 at 9:50 A.M., with Resident #57 revealed she had been incontinent of urine since before breakfast and had been told she had to wait. She would not name the person who told her that. Her call light had been activated and her pants were darker between her legs where she had soiled herself. Observation and interview on 10/04/22 at 10:02 A.M. revealed STNA #128 preparing to enter the room of Resident #57, STNA #128 had on a surgical mask and gloves. The STNA #128 stated she was preparing to assist the resident with perineal care. STNA #128, when questioned about a gown, she said she did not have to wear a gown and proceeded into the room. Interview on 10/04/22 at 10:05 A.M., with LPN #158 revealed when providing direct care to Resident #57, staff should wear a gown. Review of the facility policy titled Isolation - Categories of Transmission-Based Precautions revised 01/2012, revealed when a resident is in contact isolation a disposable gown was to be worn when entering the room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365254 If continuation sheet Page 21 of 21