Inspection·July 9, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few tear and a laceration to her head during a Hoyer lift transfer. Interventions included staff should use caution during transfers and bed mobility to prevent striking the resident's arms, legs, and hands against any sharp or hard surface. Review of the hospital records for Resident #19 dated 06/06/25 revealed the resident arrived in the ER with a head injury sustained when staff at the nursing home transported the resident to a recliner via Hoyer lift. Resident sustained a head injury without loss of consciousness when she was struck in the head with a metal pole from the left. Resident #19 had significant bleeding and receives Xarelto (a blood thinner) for treatment of atrial fibrillation. Lidocaine with epinephrine was applied to the injured area and the laceration was repaired with one suture applied. Review of the interdisciplinary team (IDT) investigation of the incident involving Resident #19 dated 06/09/25 revealed two aides assisted the resident to the recliner via Hoyer lift. During the transfer the legs of the Hoyer lift would not extend to the width of the recliner due to the size of the chair. The Hoyer device made contact with resident's head causing a laceration. Resident #19 was sent to the ER and returned with a suture to the laceration to the forehead. Resident #19 typically rested in a geri chair when out of bed but was in the process of getting a new chair from the hospice provider, and the recliner was used instead on 06/06/25. The facility follow up included to not utilize the recliner for Resident #19 because the Hoyer legs could not spread wide enough for the resident to safely transfer and to educate staff on the resident's care plan and appropriate Hoyer usage. Interview on 07/02/25 at 2:00 P.M. with the Director of Nursing (DON) confirmed on 06/06/25 two CNAs transferred Resident #19 to her recliner with a Hoyer that was too small to accommodate the width of the recliner. The DON confirmed staff continued with the transfer even when they became aware the Hoyer lift was not the correct size to complete the transfer. The DON confirmed as the staff lowered Resident #19 into the recliner, the bar of the Hoyer lift swung back and hit the resident in the head. Resident #19 sustained a laceration and bruising to the left forehead which resulted in the resident being sent to the ER for sutures. The DON confirmed the aides involved in the incident for Resident #19 on 06/06/25 were a hospice aide and a facility aide who was no longer employed with the facility. Review of the facility policy titled Activities of Daily Living dated September 2018 revealed staff should follow necessary precautions to ensure the safety of the residents during activities of daily living (ADLs). 2. Review of the medical record for Resident #25 revealed an admission date of 04/05/22 with diagnoses including type two diabetes mellitus, acquired absence of left leg below knee, acquired absence of right leg below knee, and chronic respiratory failure with hypoxia. Review of the progress note for Resident #25 dated 04/12/25 timed at 2:00 A.M. revealed the resident was on the floor laying on his right side between the window wall area and the bed. The bed was locked, and the side rails were up. Resident #25 complained of lower back pain and requested to go to the emergency room. Review of the fall report dated 04/12/25 at 2:00 A.M. revealed the resident was laying on the floor. Resident stated his arm was tired, so he let go of the side rail and then fell to the floor. Further review of the fall report revealed the event was not witnessed and resident did not go to the hospital. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 If continuation sheet Page 2 of 3 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 07/09/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few Review of the care plan for Resident #25 updated 04/12/25 revealed the resident had an actual fall with minor injury. Interventions included the following: educate resident on safety techniques with positioning and the use of assist bars, and encourage rest breaks when tired. Review of the MDS assessment for Resident #25 dated 05/06/25 revealed the resident was cognitively intact and required substantial assistance with bed mobility. Interview on 07/01/25 at 9:00 A.M. with Resident #25 confirmed he had fallen from his bed in April 2025. Resident #25 confirmed he was not interviewed about the incident, and when CNA #255 came into his room to change him, she shoved him over to the right side of the bed and he fell off the edge of the bed and onto the floor. Interview on 07/07/25 at 10:08 A.M. with Licensed Practical Nurse (LPN) Unit Manager #204 confirmed she documented Resident #25's fall on 04/12/25 in the progress notes, because the agency nurse who was working at the time of the fall didn't document anything about the fall. LPN #204 confirmed the facility did not interview Resident #25 about how the fall occurred. Interview on 07/07/25 at 11:38 A.M. with CNA #255 confirmed on 04/12/25 at approximately 2:00 A.M. she went into Resident #25's room to perform peri-care after trying to get another staff member to assist. CNA #255 confirmed she was not able to get another staff member to assist with Resident #25's peri-care, so she went into his room alone. Interview confirmed she rolled Resident #25 onto his right side, away from her, and the resident rolled out of bed onto the floor. CNA #255 confirmed the fall report was not accurate, and the fall was her fault because she rolled the resident away from her. CNA #25 confirmed the nurse didn't assess the resident or interview him. Interview on 07/07/25 at 2:25 P.M. with the Director of Nursing (DON) confirmed on 04/12/25 Resident #25 fell out of bed during routine care. The DON confirmed the fall investigation report dated 04/12/25 was not complete, and the resident was not interviewed after the fall. Review of the facility policy titled Managing Falls and Fall Risk undated revealed the staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. This deficiency represents noncompliance investigated under Complaint Number OH00166581 and Complaint Number OH00164646. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365437 If continuation sheet Page 3 of 3