Inspection·January 23, 2020

F 0623 Level of Harm - Minimal harm or potential for actual harm Review of the nurse's note dated 10/18/19 revealed the resident was re-admitted to the facility from the hospital on [DATE]. Review of the medical record revealed no evidence the Ombudsman was provided a copy of the transfer notice for Resident #21's transfer to the hospital on [DATE]. Residents Affected - Few Interview with Social Service Manager #237 on 01/22/20 at 1:49 P.M. verified the Ombudsman was not provided a copy of the transfer notice for Resident #21's transfer to the hospital on [DATE]. Review of the policy titled Transfer and Discharge, dated November 2017, revealed providing the Ombudsman with a copy of the transfer or discharge notice was not addressed in the policy. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 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 365437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Urbana, Inc 2380 St Rt 68 S Urbana, OH 43078 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 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the resident/resident representative of the bed hold and reserve bed payment policy upon transfer to the hospital. This affected one (#63) of five resident's reviewed for hospitalization. The census was 70. Findings include: Review of the medical record for Resident #63 revealed the resident was admitted to the facility on [DATE]. Diagnoses include congestive heart failure, diabetes mellitus type two, major depressive disorder, cellulitis, morbid obesity, chronic kidney disease, cellulitis of left lower limb, hypertension, and osteoporosis. Review of a progress note dated 11/20/19 at 12:16 P.M. revealed Resident #63 had an unwitnessed fall at the facility on 11/20/19. Documentation revealed the physician was at the facility and gave orders to sent the resident to the hospital for evaluation and treatment. The resident was admitted to the hospital. Review of a progress note dated 11/26/19 at 9:43 P.M. revealed Resident #63 was readmitted to the facility from the hospital. Review of the medical record for Resident #63 revealed no evidence the resident or resident representative was provided the bed hold and reserve bed payment policy upon transfer to the hospital. Interview on 01/22/20 at 2:10 P.M. with social service manager (SSM) #237 verified Resident #63 or the resident's representative was not given the bed hold and reserve bed payment policy upon transfer to the hospital on [DATE]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 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 365437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Urbana, Inc 2380 St Rt 68 S Urbana, OH 43078 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 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** 4. Closed medical record review for Resident #73 found an admission dated of 10/24/19 with diagnoses: aftercare following joint replacement surgery, major depressive disorder, congestive heart failure, restless leg syndrome, diabetes mellitus type two with diabetic neuropathy, hypertensive heart disease with heart failure, obstructive sleep apnea, pulmonary hypertension, morbid obesity due to excessive calories, presence of left artificial knee joint, long term use of insulin, asthma, osteoarthritis, gastro-esophageal reflux disease, and muscle weakness. Residents Affected - Some Review of Resident #73's medical record revealed the resident was discharged home on [DATE] after skilled therapy was cut. Review of MDS assessments was conducted. A Discharge Return Not Anticipated/End of Prospective Payment System (PPS) Part A stay noted the resident was discharged to the community on 11/08/19. An MDS dated [DATE] Discharge Return Not Anticipated stated the resident was discharged to an acute hospital. An interview with DON on 01/22/2020 at 11:15 A.M. confirmed Resident #73's MDS was inaccurate coded. The DON confirmed Resident #73 was discharged home; however, the MDS identified the resident was discharged to the acute care hospital. Based on medical record review, observation, and resident and staff interviews, the facility failed to ensure minimum data set (MDS) assessments were accurate. This affected four (#68, #73, #21, and #22) of 16 residents reviewed for accuracy of the assessment. The census was 70. Findings include: 1. Review of the medical record for Resident #68 revealed the resident was admitted to the facility on [DATE]. Diagnoses include diabetes mellitus type two, hyperlipidemia, congestive heart failure, chronic obstructive pulmonary disease, muscle weakness, insomnia, chronic pain, osteoporosis, cognitive communication deficit, hypertension, chronic respiratory failure, and hyponatremia. Review of an admission minimum data set (MDS) assessment dated [DATE], revealed Resident #68 had no natural teeth or tooth fragments (edentulous). Review of a quarterly MDS assessment dated [DATE], revealed the resident had intact cognition. Review of Resident #68's plan of care dated 06/19, revealed the resident was at risk for oral discomfort due to the use of full upper and lower dentures. Interventions include assist with oral care as needed and assist with referrals as needed. Interview on 01/21/20 at 8:44 A.M. with Resident #68 revealed the resident utilized a full upper denture and partial bottom denture. Interview with the resident revealed the resident had no upper teeth and two bottom teeth. Observation during the interview verified Resident #68 had no upper teeth and two bottom teeth. Interview on 01/22/20 at 1:22 P.M. with licensed practical nurse (LPN) #236 revealed the nurse reported Resident #68 utilized a full upper and lower denture because the resident had no upper or lower teeth. Observation (during the interview) of Resident #68's oral cavity, with LPN #236, verified Resident #68 had two bottom teeth. Further interview with LPN #236 verified the quarterly MDS assessment dated [DATE] for Resident #68 was not accurate. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 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 365437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Urbana, Inc 2380 St Rt 68 S Urbana, OH 43078 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Review of the medical record for Resident #21 revealed an admission date of 10/27/09 with diagnoses including dementia with behavioral disturbance, Alzheimer's disease, and chronic obstructive pulmonary disease. Review of the physician orders for Resident #21 revealed a gradual dose reduction (GDR) was completed on 03/04/19 when Resident #21's Seroquel was decreased from 50 milligrams by mouth two times a day to 25 milligrams by mouth one time a day in the morning and 50 milligrams by mouth one time a day in the evening. Review of the Significant Change MDS assessment dated [DATE] revealed Resident #21 was coded as receiving anti-psychotics on a routine basis only. Further review of the Significant Change MDS assessment dated [DATE] revealed the last GDR attempt was completed on 01/09/18. Interview with Director of Nursing on 01/23/20 at 9:01 A.M. verified Resident #21's last GDR attempt was completed on 03/04/19 and the Significant Change MDS assessment dated [DATE] was incorrect. 3. Review of the medical record for Resident #22 revealed an admission date of 12/04/17 with diagnoses including diabetes mellitus type two, depression, and hypertension. Review of the physician orders for Resident #22 revealed an order dated 09/14/19 for Novolin 70/30 Suspension 100 unit/milliliter, a diabetes medication, inject 15 units subcutaneously two times a day. Review of the October Insulin Administration Record for Resident #22 revealed Resident #22 received an injection of 15 units of Novolin two times a day every day in October. Review of the Annual MDS assessment dated [DATE] revealed Resident #22 was coded as having received zero injections in the seven day look back period. Interview with MDS Coordinator #236 on 01/22/20 at 2:19 P.M. verified Resident #22 received seven injections in the look back period and the Annual MDS assessment dated [DATE] coded the number of injections incorrectly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 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 365437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Urbana, Inc 2380 St Rt 68 S Urbana, OH 43078 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** 2. Review of the medical record for Resident #21 revealed an admission date of 10/27/09 with diagnoses including dementia with behavioral disturbance, Alzheimer's disease, and generalized muscle weakness. Review of the comprehensive care plan revealed a care plan focus of Resident #21 had potential for injuries/falls related to cognitive deficits, does not wait for assistance, wandering, incontinence, and per x-ray has osteopenia which increases risk of injury with falls. The care plan had a goals of safety will be maintained through next review, and will have minimal risk of injury from falls through next review. The care plan had fall interventions which included call light within reach while in the room, encourage non-skid footwear at all times, encourage to rest throughout the day, ensure blanket corner is tucked on left side of the bed, frequent orientation to room, bathroom, call light and facility, keep needed items within reach, left side of bed against the wall, maintain uncluttered environment, non-skid strips to right side of bed, physical therapy and occupational therapy evaluation and treatment as ordered and as needed, shoes on feet when up ambulating, wake resident and toilet at 2:00 A.M. every night and State Tested Nurse Aides to start rounds with this resident. The care plan did not include a fall intervention for a fall mat on the right side of the bed while the resident was in bed. Observation of Resident #21 and her room on 01/22/20 at 10:18 A.M. revealed Resident #21 was lying in bed with a fall mat on the right side of the bed. Interview with Director of Nursing on 01/22/20 at 10:18 A.M. revealed Resident #21 was to have a fall mat to the right side of the bed while she was in the bed. The interview further revealed the fall mat was added as an intervention when the resident became less ambulatory. The interview verified the care plan was not updated to include the fall intervention of a fall mat to the right side of the bed while in bed. Review of the policy titled Fall Risk Assessment, last revised 10/01/14 revealed, interventions established for those residents identified to be at risk must be documented in the residents care plans. Based on medical record review, resident and staff interviews, and policy review; the facility failed to ensure a resident was included in the care planning process. This affected one (#68) of two residents review for care planning. Additionally, the facility failed to revise a plan of care to include updated fall interventions. This affected one (#21) of two resident reviewed for falls. The census was 70. Findings include: 1. Review of the medical record for Resident #68 revealed the resident was admitted to the facility on [DATE]. Diagnoses include diabetes mellitus type two, hyperlipidemia, congestive heart failure, chronic obstructive pulmonary disease, muscle weakness, insomnia, chronic pain, osteoporosis, cognitive communication deficit, hypertension, chronic respiratory failure, and hyponatremia. Review of a quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #68 had intact cognition. Continued review of the medical record revealed a quarterly MDS assessment was also (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 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 365437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Urbana, Inc 2380 St Rt 68 S Urbana, OH 43078 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 completed on 12/23/19. The resident continued to have intact cognition. Level of Harm - Minimal harm or potential for actual harm Review of Resident #68's medical record from 10/01/19 to 01/22/20 revealed the medical record had no evidence of a care conference or of the resident being included in the care planning process for the assessments dated 10/09/19 and 12/23/19. Residents Affected - Few Interview on 01/21/20 at 8:44 A.M. with Resident #68 revealed the resident had not been invited to a care conference or been asked to participate in the care planning process. Interview on 01/22/20 at 11:41 A.M. with social service manager (SSM) #237 revealed care conference are to be held quarterly. SSM #237 verified there was no care conference for Resident #68 during the fourth quarter of 2019. SSM #237 further verified the facility failed to include Resident #68 in the care planning process. Review of an undated policy titled, Care Conferences revealed the intention of care planning is to meet the resident needs in a manner conductive to obtaining the best outcome for the individual. Care conferences are a part of this process. Conferences are done in a variety of ways using various methods at various times. Conferences may be face to face, telecommunication and written communication. An interdisciplinary care conference will be held to coordinate and plan the care of each resident within five days of admission, quarterly, and whenever requested by a member of the team, resident, or family. Social service will coordinate meetings. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 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 365437 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/23/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Urbana, Inc 2380 St Rt 68 S Urbana, OH 43078 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and policy review, the facility failed to maintain the kitchen in a clean and sanitary manner. This had the potential to affect all 70 residents who receive meals from the kitchen. The census was 70. Findings include: 1. Observation of the kitchen on 01/21/20 at 9:05 A.M. revealed a grayish fuzzy like substance on the light fixture above the food preparation table. Interview with Dietary Aide #143 on 01/21/20 at 9:05 A.M. verified there was a grayish fuzzy like substance on the light fixture above the food preparation table. 2. Observation of the kitchen on 01/22/20 at 11:13 A.M. revealed a grayish fuzzy like substance on the light fixture above the food preparation table. Interview with Dietary Manager #152 on 01/22/20 at 11:13 A.M. verified there was a grayish fuzzy like substance on the light fixture above the food preparation table. 3. Observation of the kitchen on 01/22/20 at 12:10 P.M. revealed a grayish fuzzy like substance on the piping along the ceiling above the tray line area. Interview with Dietary Manager #152 on 01/22/20 at 12:10 P.M. verified there was a grayish fuzzy like substance on the piping along the ceiling above the tray line area. The facility confirmed all 70 residents receive their meals from the kitchen. 4. Observation of the kitchen on 01/23/20 at 1:32 P.M. revealed there was still a grayish fuzzy like substance on the light fixture above the food preparation table and the piping along the ceiling above the tray line area. Review of the daily cleaning schedule form dated January 20 through January 26 revealed cleaning of the light fixture above the food preparation table and the piping along the ceiling above the tray line area were not addressed on the daily cleaning schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 If continuation sheet Page 8 of 8