Health inspection·April 12, 2024

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, staff interview, and policy review, the facility failed to ensure care plans were person-centered to include all areas of concern. This affected three (Resident #14, #50, and #72) of 17 residents reviewed for care plans. The facility census was 67. Findings include: 1. Review of Resident #14's medical record revealed Resident #14 had an admission date of 09/12/19. Diagnoses included Alzheimer's disease, dementia, and age-related physical debility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 had severely cognitively impaired. Resident #14 was dependent on staff for toileting and was incontinent of bowel and bladder. Review of the plan of care dated 03/18/24 revealed that Resident #14 had no active care plan of incontinence care, wore incontinence briefs, and was dependent on staff for care. Resident #14 was at risk for nutrition and dehydration related to urinary tract infections. Interventions included monitor for signs and symptoms of dehydration, explain importance of adequate urinary output, monitor skin status, and obtain weight as resident allows. Interview on 04/11/24 at 1:38 P.M. with Quality Assurance Nurse (QAN) #122 verified Resident #14's care plan did not include areas to address Resident #14's incontinence care, wore incontinent briefs, and was dependent on staff for care. QAN #122 stated Resident #14 should have had this addressed at the beginning of her stay at the facility. 2. Review of the medical record for Resident #50 revealed an admission date of 01/07/23. Diagnoses included Alzheimer's disease, dementia, anxiety, and insomnia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had severe cognitive impairment and received an antidepressant. Review of the care plan dated 04/05/24 revealed the resident did not have an active care plan for psychotropic medications regarding antidepressant medications. Interview with the Director of Nursing on 04/12/24 at 10:15 A.M. confirmed the facility did not have a care plan for the resident's use of psychotropic medications. 3. Review of the medical record for Resident #72 revealed an admission date of 02/21/24. Diagnoses included metabolic encephalopathy, chronic kidney disease stage three, major depressive disorder, and adjustment disorder with anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was dependent on staff for toileting and was incontinent of bowel and bladder. Resident #72 had severe cognitive impairment. Review of the care plan dated 02/23/24 revealed no active care plan of incontinence care. (continued on next page) 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 04/12/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 04/11/24 at 1:24 P.M. with State Tested Nursing Assistant (STNA) #69 verified Resident #69 was incontinent of urine. STNA #69 verified the resident wore briefs and received incontinence care from staff. Interview on 04/11/24 at 1:24 P.M. with Quality Assurance Nurse (QAN) #122 verified Resident #72 did not have an active care plan for incontinence care. QAN #122 verified the resident was incontinent since admission into facility and should have a incontinence care plan. Review of the facility's policy titled Care Planning-Interdisciplinary Team, revised March 2022, revealed comprehensive, person-centered care plans are based on resident assessments and developed by and interdisciplinary team. 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 04/12/2024 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 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, review of the facility policy, review of the guidance from Medscape, and staff interview, the facility failed to ensure a resident had the proper diagnosis for administration of an antipsychotic medication. This affected one (Resident #3) of five residents reviewed for unnecessary medication use. The facility census was 67. Findings include: Review of the medical record for Resident #3 revealed she was admitted to the facility on [DATE] with a diagnosis of delirium due to known physiological condition, Alzheimer's disease, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had severe cognitive impairment. Review of Resident #3's physician orders for 04/2024 revealed an order for Zyprexa (antipsychotic) for delirium. Review of Resident #3's diagnoses revealed no schizophrenia or bipolar disorder diagnoses. The only diagnosis listed was delirium due to known psychological condition, but no psychological diagnoses was listed. Interview on 04/12/24 at 8:50 A.M. with the Director of Nursing verified Resident #3 was on Zyprexa for delirium and did not have a diagnoses of schizophrenia or bipolar disorder. Review of the guidance from Medscape at https://reference.medscape.com/drug/zyprexa-relprevv-olanzapine-342979 revealed Zyprexa is an antipsychotic medication commonly used to treat schizophrenia or bipolar disorder. In the geriatric population, Zyprexa is not approved for dementia-related psychosis, because of increased risk of cardiovascular or infection-related mortality. Review of the facility policy titled Antipsychotic Medication Use, dated 07/2022, revealed a resident will only receive antipsychotic medication when necessary to treat a specific condition for which they are indicated and effective. 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 04/12/2024 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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, completion of a test tray, review of resident council notes, observations, and resident and staff interviews, the facility failed to serve palatable meals to the residents. This affected five (Resident #19, #21, #22, #25, and #66) of 17 residents reviewed for dietary services. The facility census was 67. Residents Affected - Some Findings include: 1. Review of the medical record for Resident #19 revealed an admission date of 04/01/22. Diagnoses included congestive heart failure, hypertension, and anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact. Interview on 04/09/24 at 10:02 A.M. with Resident #19 revealed the food was often cold when she receives it. 2. Review of the medical record for Resident #66 revealed an admission date of 11/03/23. Diagnoses included chronic obstructive pulmonary disease, congestive heart failure, type two diabetes mellitus, and non-celiac gluten sensitivity. Review of the MDS assessment dated [DATE] revealed Resident #66 was cognitively intact. Interview on 04/11/24 at 9:19 A.M. with Resident #66 stated the chicken and dumplings served for lunch yesterday were dry. Resident #66 stated he did not eat very much of them. Resident #66 stated the problem was that some days the food was good but, on the other days, the food was terrible. 3. Review of the medical record for Resident #22 revealed an admission date 08/12/16. Diagnoses included acute respiratory failure. Review of the MDS assessment dated [DATE] revealed Resident #22 had moderately impaired cognition. Observation and interview on 04/09/24 at 12:35 P.M. with Resident #22's plate of food revealed she had cream dried beef gravy, toast, fruit, corn, and drinks. Resident #22 stated the chip beef gravy was not good. Resident #22 stated it did not look good and was tasteless. Resident #22 stated the food here can be terrible. 4. Review of the medical record for Resident #21 revealed an admission date of 12/04/17. Diagnoses included chronic obstructive pulmonary disease, type two diabetes mellitus, and atrial fibrillation. Review of the MDS assessment dated [DATE] revealed she was cognitively intact. Interview on 04/10/24 at 10:00 A.M. with Resident #21 stated her meal yesterday was cold, tasteless, and awful. Resident #21 stated she always gets carbohydrates, and she does not eat any carbohydrates. Subsequent interview on 04/11/24 at 9:50 A.M. with Resident #21 stated the meal yesterday for lunch and dinner was awful. Resident #21 stated she refused the lunch and dinner yesterday. Resident #21 who stated she was offered an alternative but also refused it. 5. Review of the medical record for Resident #25 revealed she was admitted to the facility on [DATE]. Diagnoses included paroxysmal atrial fibrillation and heart failure. Review of the MDS assessment (continued on next page) 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 04/12/2024 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 0804 dated [DATE] revealed Resident #25 was cognitively intact. Level of Harm - Minimal harm or potential for actual harm Interview with Resident #25 on 04/09/24 at 1:30 P.M. revealed the facility needed to do something about the food. She revealed the food was usually served cold and very tasteless. She stated she was the Resident Council President and has addressed this multiple times with the administration. Resident #25 revealed nothing has been done about the quality of the food. Residents Affected - Some Observation on 04/10/24 at 1:11 P.M. of test tray revealed one scoop of mashed potatoes, one scoop full of chicken and dumplings, and carrots. Mashed potatoes taste and texture were okay. Chicken and dumplings looked unrecognizable and in a clump on the tray. The dumplings were dry with a heavy texture and chewy. The dumplings tasted like flour. Chicken was tough and flavorless. Carrots were soggy and watered down. Interview on 04/11/24 at 12:43 P.M. with Dietary Manager (DM) #37 stated the chicken and dumplings that were prepared yesterday came frozen. DM #37 stated the dumplings were frozen and the chicken was shredded chicken that comes in frozen and they were cooked separately and then combined. DM #37 stated she believed the cook added cream of chicken soup to the chicken and dumplings. Review of the Resident Council notes for February, March, and April of 2024 revealed the residents expressed concerns regarding the food and menus. 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 04/12/2024 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 observations, policy review, and staff interview, the facility failed to date dry product when delivered to the facility, failed to discard expired foods, and failed to ensure staff changed gloves after touching surfaces before touching food while preparing food served to the residents. This had the potential to affect all 67 residents who received food from the kitchen. The facility census was 67. Findings include: 1. Observation on 04/09/24 at 8:20 A.M. of the dry food storage area revealed two bags of spiral noodles with expiration date of 06/17/23, seven bags of vanilla wafers with one bag open with no date, four bags of yellow cake mix, eight bags of powdered sugar, four bags of brown sugar, and three cans of three bean salad not dated with the date delivered to facility. Interview on 04/09/24 at 8:26 A.M. with Dietary Aide #27 verified the two bags of spiral noodles were expired. Dietary Aide #27 verified the vanilla wafers, yellow cake mix, powdered sugar, brown sugar, and cans of three been salad were not dated. Dietary Aide #27 stated the vanilla wafers were in a box that was dated yesterday and someone must have taken them from the box. Dietary Aide #27 verified the box with brown sugar, powdered sugar, and three bean salad was not dated as well. Interview on 04/09/24 at 11:25 A.M. with Dietary Manager (DM) #37 verified the undated brown sugar, powdered sugar, three bean salad, and the expired spiral noodles. DM #37 stated the yellow cake mix was dated however, the date was on the back of the package. DM #37 informed the yellow cake mix bags were inspected front and back and no date was present at the time of the observation. Review of the facility policy titled Food Receiving and Storage, revised November 2022, revealed dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date). Such foods are rotated using a first in - first out system. 2. Observation on 04/09/24 at 11:45 A.M. revealed Dietary Aide #22 was preparing a cheeseburger for a resident. Dietary Aide #22 touched the hamburger bun, hamburger, cheese, and spatula with the same gloved hands. Dietary Aide #22 then touched the fryer basket handle, prep table, and tongs before touching the sandwich again with the same gloved hands to move it over to put French fries into the container. Dietary Aide #22 did not change gloves or wash hands throughout the entire process. Interview on 04/09/24 at 11:55 A.M. with Dietary Aide #22 verified she did not change her gloves between touching surfaces and then touched food. Dietary Aide #22 verified that she was supposed to change gloves. 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 04/12/2024 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of the facility policy, and staff interview, the facility failed to ensure the residents were offered the pneumonia vaccine. This affected three (#19, #20, and #50) of five residents reviewed for pneomococcal immunization. The facility census was 67. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #19 revealed an admission date 04/01/22. The medical record revealed Resident #19 had the influenza vaccination on 10/03/23, and there was no evidence the resident was offered the pneumococcal immunization. Interview on 04/11/24 at 3:50 P.M. with the Director of Nursing (DON) confirmed Resident #19 did not get offered the pneumonia vaccination. 2. Review of the medical record for Resident #20 revealed an admission date of 11/27/23. There was no evidence Resident #20 was offered the pneumococcal immunization or received it in the past prior to admission. Interview on 04/11/24 at 9:50 A.M. with the Director of Nursing (DON) confirmed Resident #20 did not get offered the pneumonia vaccination. 3. Review of the medical record for Resident #50 revealed an admission date 01/07/23. There was no evidence Resident #50 was offered the pneumococcal immunization or received it in the past prior to admission. Interview on 04/11/24 at 9:50 A.M. with the Director of Nursing (DON) confirmed Resident #50 did not get offered the pneumonia vaccination. Review of the facility's undated policy titled Pneumococcal Vaccine Policy revealed all residents who were admitted to the facility were to be offered the pneumococcal vaccine. Residents were to have pneumococcal assessment within five working days of resident's admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 If continuation sheet Page 8 of 8