Health inspection·August 16, 2023

F 0622 Level of Harm - Minimal harm or potential for actual harm consistent with acute or life-threatening pathology. Resident #15 expressed he was upset about having to move rooms at the skilled facility, and that he smoked a bunch of cigarettes because he was upset, and threw a cigarette butt in a trash can. Resident #15 stated he felt bad about his actions and would not be smoking in his room anymore. Resident #15 was appropriate for discharge with an estimated arrival for an ambulance to take Resident #15 back to facility at 12:45 A.M on 08/01/23. Residents Affected - Few Review of Resident #15's facility nursing progress note dated 07/31/23 at 10:30 P.M. revealed LPN #149 received a call from the ED reporting Resident #15's pink slip was not valid. The ED nurse explained the ED would monitor Resident #15 and evaluate him after his medication wore off, but there was nothing medically wrong with Resident #15 and he would be returning to the facility. LPN #149 indicated it was not safe for Resident #15 to return to the facility because of a threat to resident and staff safety. LPN #149 indicated she would call the Administrator due to policies and procedures in accepting Resident #15 back to the facility who was pink slipped, and Resident #15 was not to return to the facility. LPN #149 reached out to the Administrator about the phone call she had with the ED staff and left a voicemail for Physician #210 with no return call received. Review of the ED nursing progress notes revealed a discharge report was called into the facility at 1:34 A.M. on 08/10/23 and received by LPN #110. Review of Resident #15's facility nursing progress notes on 08/01/23 at 2:00 A.M. revealed Social Services Designee (SSD) #120 received notification Resident #15 was was returning to the facility, so he called the ED staff and was told the pink slip was invalid, and they felt Resident #15 was cleared to return to the facility. There was no additional documented information in Resident #15's facility medical record about him arriving at the facility after being sent to the hospital on [DATE], and the facility instructing the transport personnel to take Resident #15 back to the hospital as the facility would not readmitted the resident to the facility. Review of the ED nursing progress report dated 08/01/23 at 1:44 A.M. revealed a male called from the facility, and identified as the Director of Nursing (DON), and spoke with the ED nurse. The DON wanted to know why Resident #15 was sent back to the facility and why the pink slip was not valid. The DON was accusing Resident #15 of intentionally starting a fire in the bathroom, and he continued to be upset after an explanation was given. Review of Resident #15's ED medical record revealed on 08/01/23 at 2:15 A.M., Resident #15 returned to the hospital and was readmitted . Further review revealed the nursing home refused to accept Resident #15 back into the facility after he was medically cleared, discharged from ED, and report was given to facility nurse before Resident #15 left the ED. At the time of the report, the facility nurse did not refuse to take Resident #15 back. The legal team of the hospital was contacted and decided to have Resident #15 admitted after he was cleared by psychiatry, and will be placed in another nursing facility because the current facility was not willing to accept him back. Review of Resident #15's hospital record on 08/01/23 at 7:39 A.M. revealed a hospital case manager sent clinical documentation to the facility, and at 9:25 A.M. on 08/10/23 the case manager attempted to call the facility's social services designee with no answer. An email was also sent with no response received. At 9:49 A.M. on 08/01/23, the hospital case manager spoke with the facility's Ombudsman about the situation, and at 11:35 A.M. someone from the nursing home stated they should be willing to accept Resident #15 back if they had a bed available. At 11:40 A.M. on 08/01/23, all clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 If continuation sheet Page 2 of 7 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 08/16/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm documentation was sent to the facility, and at 2:54 P.M. the case manager received a call from Ombudsman #399 who explained the facility was refusing to allow Resident #15 to return to the facility. Ombudsman #399 and the case manager continued working on alternative placement in case the facility refused to allow Resident #15 to return. Resident #15 was discharged from the hospital on [DATE] to another long-term care facility. Residents Affected - Few Interview on 08/15/23 at 11:00 A.M. with the Administrator and the Director of Nursing (DON) occurred. The Administrator explained on 07/31/23 they were notified Resident #15 was caught smoking in his room and a few minutes later there was a fire in his bathroom waste basket. The residents were evacuated, the fire was put out, and Resident #15 was placed in a private room. Facility staff believed earlier in the day during a leave of absence Resident #15 obtained cigarettes and a lighter, and the facility was a non-smoking facility. Facility staff found an empty bottle of alcohol in his room. Physician #210 was notified of the incident and informed Resident #15 was not acting like himself as he was laughing at staff and residents during the evacuation. Physician #210 ordered to pink slip Resident #15 for an evaluation, and Social Service Designee (SSD) #120 notified a local behavior hospital with no return call. Three hours later, per Physician #210, Resident #15 was sent to the local ED with a pink slip. Interview on 08/15/23 at 11:30 A.M. with Physician #210 stated he did not see Resident #15 on 07/31/23. Physician #210 stated he did not need to as the staff explained the situation, and he verified he ordered Resident #15 be pink-slipped to the hospital. Physician #210 confirmed he received a call from the facility's nurse on 08/01/23 explaining the ED physician called and was sending Resident #15 back to the facility. Physician #210 called the ED and spoke to someone and told the ED staff they could not send Resident #15 back to the facility as he wanted a psychological evaluation completed on Resident #15. Physician #210 reported that he assumed Resident #15 would return to the facility after having a psychological evaluation. Interview on 08/15/23 at 11:30 A.M., with SSD #120, who handles facility admissions, confirmed he was called back into the facility at 6:00 P.M. on 07/31/23 because of a fire. When he spoke to Resident #15 he was belligerent, and not remorseful for his actions or the safety risk caused to facility or residents. SSD #120 confirmed he worked with LPN #149 to obtain a pink slip for Resident #15. SSD #120 confirmed Resident #15 did not return to the facility, and he was told by the Administrator not to follow up on Resident #15 during the day on 08/01/23 for readmission. Interview on 08/15/23 at 11:45 A.M., with LPN #149 confirmed she was called back into the facility on [DATE] at 6:50 P.M. and was working with the SSD #120 to obtain a pink slip to send Resident #15 out for a psychological evaluation. Interview on 08/15/23 at 11:55 A.M., with the Administrator confirmed she instructed the SSD #120 not to contact the ED to find out a status report on Resident #15. The Administrator stated per Physician #210, the ED staff member hung up the phone with Physician #210 while discussing the case around 2:00 A.M. on 08/01/23; therefore, it was no longer their responsibility where Resident #15 was or how he was doing. The Administrator placed a call to Ombudsman #399 and explained the situation and stated they would not take Resident #15 back because he did not have a psychological evaluation done. The Administrator stated Ombudsman #399 told her he would call the hospital to explain the situation, and she did not have to take Resident #15 back to the facility. The Administrator knew nothing about Resident #15 until she received facsimile (fax) documentation from another facility requesting Resident #15's medical records. The Administrator was adamant they never discharged Resident #15 from the facility. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 If continuation sheet Page 3 of 7 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 08/16/2023 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 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A telephone interview was completed on 08/15/23 at 12:15 P.M., with Ombudsman #399 who clarified he did not tell the Administrator not to take Resident #15 back. Ombudsman #399 reported he explained to the Administrator why they would have to take Resident #15 back and the process of issuing a proper 30-day discharge. Interview on 08/16/23 at 9:30 A.M with the Director of Nursing (DON) stated she was new to the facility, and she was not at the facility while a pink slip was being obtained for Resident #15. DON stated she was called in and arrived at the facility and found Resident #15 sitting in the hallway unattended. DON stated she instructed staff to start one-on-one observations while they determine where Resident #15 would be sent. DON stated she observed Resident #15 to be calm and non-threatening. After Resident #15 was transferred out of the facility she left for the night, and she was not contacted when Resident #15 was discharged from the hospital and returned to the facility during the early morning on 08/01/23. DON stated she later found out the Administrator did not allow Resident #15 to come into the building when he was initially discharged from the ED and returned to the facility. DON stated facility staff refused Resident #15 admittance back into the facility. Interview on 08/16/23 at 10:40 A.M., with SSD #120 confirmed Resident #15 was discharged from the ED and was transported to the facility. SSD #120 stated when he arrived facility staff instructed the EMS staff to transport Resident #15 back to the hospital. Interview on 08/16/23 at 3:45 P.M. with the ED Physician #400 confirmed his documentation in Resident #15's hospital medical record, and stated he discharged Resident #15 back to the facility. ED Physician #400 stated the facility sent Resident #15 back to the ED and did not readmit him to the facility. ED Physician #400 stated he spoke to the hospital legal team and was instructed to readmit Resident #15 to the ED in order to find another place for him to be discharged to. Review of the facility's transfer and discharge policy dated November 2017 revealed before a resident was discharged , appropriate notice will be provided to the resident and/or their legal representative. This deficiency represents non-compliance investigated under Complaint Number OH00145095. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 If continuation sheet Page 4 of 7 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 08/16/2023 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of emails sent to the State Long-Term Care Ombudsman, and review of a facility policy, the facility failed to notify the Office of the State Long-Term Care Ombudsman when residents were discharged from the facility. This affected two (#15 and #24) of four reviewed for discharge. The facility census was 71. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 04/08/23. Diagnoses included atrial fibrillation, hypertensive heart disease with heart failure, chronic systolic (congestive heart failure), chronic obstructive pulmonary disease, cerebral vascular disease, and depression. Further review of the medical record revealed Resident #15 was sent to the hospital on [DATE] and was discharged to the hospital on [DATE]. There was no documentation the Office of the State Long-Term Care Ombudsman was notified. 2. Review of Resident #24's medical record revealed an admission date of 04/23/23. Diagnosis included displaced fracture of the lateral malleolus of the right tibia. Resident #24 was discharged home on [DATE] and return to the facility was not anticipated. There was no documentation the Office of the State Long-Term Care Ombudsman was notified. Review of email documentation sent to the Office of the State Long-Term Care Ombudsman office in May, June and July 2023 regarding resident transfers and discharges from the facility did not include documentation or notification of Resident #15 and Resident #24 being discharged from the facility. Interview on 08/16/23 at 4:15 P.M. with Social Service Designee (SSD) #120 stated he did not notify the Office of the State Long-Term Care Ombudsman when residents are discharged from the facility, including Resident #15 and Resident #24, and it was his understanding the Ombudsman was to be notified for transfers from the facility only. Interview on 08/16/23 at 4:20 P.M., with the Administrator stated it was not facility policy to notify the Office of the State Long-Term Care Ombudsman when residents are discharged from the facility. Review of the facility's transfer and discharge policy dated November 2017 revealed no indication the Ombudsman should be notified when a resident was discharged from the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 If continuation sheet Page 5 of 7 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 08/16/2023 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 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on medical record review, staff interview, and review of a facility policy, the facility failed to provide a discharge summary when residents were discharged from the facility. This affected one (#22) of four residents reviewed for discharge. The census was 71. Findings include: Review of Resident #22's medical record revealed an admission date of 07/28/23. Diagnoses included transient ischemic attack, cerebral infarction, and bone density and structure disorder. Resident #22 was discharged on 08/12/23. Review of Resident #22 medical record revealed there was no discharge summary completed when Resident #22 was discharged on 08/12/23. Interview on 08/16/23 at 2:00 P.M. with Social Service Designee (SSD) #120 stated Resident #22 was discharged to an assisted living facility, therefore, Resident #22 did not require a discharge recapitulation of her stay. SSD #120 stated the facility sent documentation by facsimile (fax) to the assisted living facility. Interview on 08/16/23 at 2:05 P.M. with Licensed Practical Nurse (LPN) #149 confirmed Resident #22 did not receive written discharge summary when she was discharged to her home at an assisted living facility, and confirmed the assisted living facility was not part of the nursing home. Review of a blank discharge instruction packet provided by LPN #149 revealed a recapitulation of a resident's stay while receiving services by the facility. Each resident being discharged or their representative were to sign an acknowledgement of receipt of their discharge instructions for care. Review of the facility's transfer and discharge policy dated November 2017 revealed it did not include information related to a discharge summary was to be provided when a resident was discharged to the community. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 If continuation sheet Page 6 of 7 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 08/16/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on medical record review and staff interview, the facility failed to have physician visits or progress notes available in resident medical records. This effected three (#15, #18, and #22) of four resident's medical records reviewed for reviewed for discharge. The census was 71. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 04/08/23. Diagnoses included atrial fibrillation, hypertensive heart disease with heart failure, chronic systolic (congestive heart failure), chronic obstructive pulmonary disease, cerebral vascular disease, and depression. Further review of the medical record did not have physician progress notes or visit noted available for review. 2. Review of Resident #18's medical record revealed an admission date of 06/20/23. Diagnoses included chronic gout, hypertension, hyperlipidemia, and chronic kidney disease. Further review of the medical record did not have physician progress notes or visit notes available for review. 3. Review of Resident #22's medical record revealed an admission date of 07/28/23. Diagnoses included transient ischemic attack, cerebral infarction, and bone density and structure disorder. Further review of the medical record did not have physician progress notes or visit notes available for review. Interview on 8/15/23 at 11:00 A.M. with the Administrator confirmed the Director of Nursing had to contact the physician's office to send the progress notes or visit notes for residents that were seen in order to have the notes for review. The Administrator confirmed she called Resident #15 physician's office to have them facsimile (fax) all his visit notes to the facility. Interview on 08/15/23 at 1:00 P.M., with Social Service Designee #120 revealed physician progress notes for Resident #15 dated 05/08/23, 05/16/27, 05/27/23, 06/16/23 and 06/27/23 were received through the fax machine on 08/15/23. Interview on 08/16/23 at 2:15 P.M. with the Director of Nursing revealed physician visits notes dated 4/10/23, 4/22/23 and 04/27/23 for Resident #15 were received by the facility from the fax machine on 08/16/23. Interview on 08/16/23 at 2:25 P.M. with the Director of Nursing confirmed Resident #18's and Resident #22's physician progress notes were not available in their medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 If continuation sheet Page 7 of 7