Health inspection·October 26, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on record review, staff interview, and review of facility policy, the facility failed to ensure implementation of their abuse policy and obtain an employee background check was completed for State Tested Nurse Aide (STNA) #432 prior to working with residents. This had the potential to affect 30 (#2, #4, #13, #14, #16, #18, #19, #20, #21, #24, #25, #27, #30, #31, #32, #35, #36, #38, #40, #42, #46, #47, #49, #54, #62, #63, #71, #74, #131, and #132) residents identified as residing on the 2 North Hallway in the facility and received care from STNA #432. The facility census was 81. Residents Affected - Some Findings include: Review of State Tested Nurse Aide (STNA) #432's personnel file revealed a hire date of 09/26/23. Further review revealed no evidence of the completion, or attempt to complete, a background check prior to employment. Review of the staffing schedules from 09/26/23 through 10/24/23 revealed STNA #432 was assigned to provide care to 30 (#2, #4, #13, #14, #16, #18, #19, #20, #21, #24, #25, #27, #30, #31, #32, #35, #36, #38, #40, #42, #46, #47, #49, #54, #62, #63, #71, #74, #131, and #132) residents on the 2 North Hallway during the night shift on 10/2/23, 10/4/23, 10/5/23, 10/9/23, 10/10/23, 10/13/23, 10/15/23, 10/18/23, 10/19/23, 10/23/23, and 10/24/23. Interview on 10/26/23 at 2:14 P.M. with Business Manager (BM) #476 confirmed the facility did not have STNA #432's background check. Follow-up interview on 10/26/23 at 3:40 P.M. with BM #476 revealed BM #476 called the sheriff's department and verified STNA #432 had not been in for a background check. Interview on 10/26/23 at 3:54 P.M. with the Administrator revealed she thought they had 30 days to get the background check completed and back to the facility. Review of facility policy titled Vancrest: Abuse: Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, undated, revealed it was the policy to undertake background checks of all employees and to retain on file applicable records of current employees regarding such checks. Additionally, the policy stated prior to hiring a new employee, the facility would conduct a criminal background check in accordance with Ohio law and Vancrest's policy;. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 2 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on record review, review of the facility self-reported incidents, staff interview, and review of the facility policy on abuse, the facility failed to ensure an allegation of physical abuse was reported to the state agency as required. This affected one (#55) of 19 residents screened for abuse. The facility census was 81. Findings include: Review of the medical record for Resident #55 revealed an admission date of 09/26/18. Medical diagnoses included cerebral infarction (stroke), vascular dementia, and depression. Resident #55 resided on the secured memory care unit. Review of the Minimum Data Set (MDS) quarterly assessment, dated 09/06/23, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 04 which indicated severely impaired cognition. Resident #55 had no hallucinations, delusions, or behaviors. Resident #55 was coded to have adequate hearing with no hearing aid or other appliance used. The assessment further identified Resident #55 to need extensive assistance from one to two staff members for transferring, dressing, and personal hygiene. Review of the progress note dated 09/26/23 and timed 9:20 P.M. revealed an incident between Resident #55 and Agency State Tested Nursing Assistant (STNA) #495. Resident #55 called out help me, and a staff STNA responded to take over care of Resident #55. The note described Resident #55 as fearful after Agency STNA #495 had began to start evening care without making Resident #55 aware of the plan. The progress note was authored by Licensed Practical Nurse #418 and was created on 09/27/23 at 10:33 A.M., thirteen hours after the event occurred. Interviews conducted on 10/25/23 between 6:20 A.M. and 7:24 A.M. with Licensed Practical Nurse (LPN) #418 revealed she was the night shift nurse for the memory care unit on 09/26/23. Agency STNA #495 worked in the memory care unit for a twelve hour shift with one other staff STNA. LPN #418 did not directly witness the event, but based her charting on the STNA's account of the event. LPN #418 stated she initially wrote a progress note that described the interaction between Resident #55 and Agency STNA #495 as an attack, but was called back in to the facility the next morning to meet with the Activities Director (AD) #479 and the Director of Nursing (DON), after which meeting she changed her documentation. LPN #418 stated she inactivated her original documentation and re-phrased her progress note. LPN #418 stated she did not directly notify a supervisor about the event that night, but may have mentioned it to the DON during a phone call about another situation. LPN #418 stated both she and the staff STNA she worked with that night provided a written statement. Review of Ohio Department of Health's Certification and Licensure System on 10/26/23 at 10:00 A.M. revealed no self-reported incident had been filed by the facility related to the allegation of physical abuse by Resident #55 on 09/26/23. Review of the daily staffing schedule, dated 09/26/23, revealed STNA #460 was mandated to work from 7:00 P.M. to 11:00 P.M. in the memory care unit with Agency STNA #495. An interview on 10/25/23 at 3:24 P.M. with STNA #460 revealed she works day shift from 7:00 A.M. to 7:00 P.M., but on 09/26/23 was mandated to work an additional four hours. STNA #460 stated 09/26/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 3 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was the first time she had worked with Agency STNA #495. Agency STNA #495 entered Resident #55's room to provide care. STNA #460 walked down the hall when she heard Resident #55 yell help me. STNA #460 stated she knocked quickly but immediately entered the room and found Resident #55 with a hold on Agency STNA's arms. STNA #460 stated Resident #55 recognized her and asked you saw him attack me, right?. STNA #460 sent Agency STNA #495 out of the room and provided care to Resident #55. Resident #55 was upset, fearful, and continued to ask STNA #460 you saw him attack me, right. After care was completed for Resident #55, STNA #460 reported the event to LPN #418. STNA #460 stated she was called back in to the facility the next morning to discuss the incident and provide a written statement. Interview on 10/26/23 at 10:08 A.M. with the Administrator revealed she had no knowledge the incident with Resident #55 on 09/26/23. The Administrator verified she had not reported any self-reported incidents in September 2023, and confirmed the Administrator should be made aware of any and all abuse allegations and investigations of abuse. Interview on 10/26/23 at 10:15 A.M. with the DON and the Administrator revealed the DON was familiar with the incident. The DON stated she was aware of the situation, the facility had investigated the incident, and it was not an abuse situation. Interview on 10/26/23 at 10:35 A.M. with AD #479 revealed she also functioned as the Memory Support Manager and oversaw care of the residents who lived in the memory care unit. On 09/27/23, she saw LPN #418's progress note describing the event, and was concerned. AD#479 and the DON reached out to LPN #418 and STNA #460 and asked them to come in to discuss the situation. Both LPN #418 and STNA #460 provided a written statement. AD #479 stated there was no statement from Agency STNA #495, and the DON had the investigation in her office. AD #479 verified that Resident #55 had severely impaired cognition and a BIMS score of 04 seemed accurate for him. Interview on 10/26/23 at 11:02 A.M. with the DON revealed she discussed the incident with LPN #418 and STNA #460. The DON stated she asked LPN #418 to modify her statement, but figured she would add an addendum, not strike out and completely re-write the narrative. The DON provided a copy of the investigation which included two witness statements and two pages of printed-off progress notes from Resident #55's electronic medical record. The DON verified the four pages were the full investigation the facility completed. Review of witness statement authored by LPN #418, dated 09/27/23, referenced event that occurred 09/26/23 around 9:20 P.M. Agency STNA #495 went into Resident #495's room and did not ask for Resident #55's permission to perform care. Resident #55 yelled help, and STNA#460 entered the room. STNA #460 reported to LPN #418 that Agency STNA #495 attacked me. LPN #418 asked Resident #55 about the incident, and he reported he felt attacked and unsafe. LPN #418 asked Resident #55 why he felt that way, to which he stated Agency STNA #495 entered his room and just started touching and grabbing at him, and that the nurse needed to do something about him, referring to Agency STNA #495. The statement further indicated that LPN #418 asked Agency STNA #495 to not enter Resident #55's room the rest of the night and to communicate with residents before care was attempted. Review of witness statement authored by STNA #460, dated 09/27/23, revealed she entered Resident #55's room after she heard him call for help. Resident #55 was in bed, had a hold on Agency STNA #495's arm. Resident #55 recognized STNA #460 and stated she was his friend. STNA #460 took over the care of Resident #55 and asked him what had happened. Resident #55 asked if STNA #460 had seen Agency STNA #495 attack him. STNA #460 stated she had not witnessed anything firsthand. Resident #55 said nothing further other than he was glad STNA #460 was there. STNA #460 then reported the incident to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 4 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 0609 nurse. Level of Harm - Minimal harm or potential for actual harm Interview on 10/26/23 at 12:28 with the Administrator and DON revealed the provided witness statements from LPN #418 and STNA #460 and the progress notes documented in Resident #55's medical record were the only components of the facility's investigative file for the incident. The Administrator and DON verified there had been no interviews or assessments attempted of like residents, no recent abuse education or in-servicing for staff, and Agency STNA #495 completed his twelve hour shift, and was not immediately removed from the patient care area. The Administrator indicated she had not read the two staff witness statements until 10/26/23 and verified both statements used the term attacked. Residents Affected - Few Review of the policy Resident Rights, revised August 2022, revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Employees shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of lift, recognizing each resident's individuality. The facility will protect and promote the rights of the resident. Review of the policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 2017, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). If a staff member is accused or suspected of Abuse, they should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. The policy additionally notes that nursing home staff includes employees, consultants, contractors, volunteers, and any other caregivers who provide care and services to residents on behalf of the facility. Documentation in the nurses' notes should include the result of the resident's assessment, notification of the physician and the Resident Representative, and any treatment provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 5 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on record review, review of the facility self-reported incidents, staff interview, and review of the facility policy on abuse, the facility failed to conduct a thorogh investigation of alleged physical abuse. This affected one (#55) of 19 residents screened for abuse. The facility census was 81. Residents Affected - Few Findings include: Review of the medical record for Resident #55 revealed an admission date of 09/26/18. Medical diagnoses included cerebral infarction (stroke), vascular dementia, and depression. Resident #55 resided on the secured memory care unit. Review of the Minimum Data Set (MDS) quarterly assessment, dated 09/06/23, revealed Resident #55 had a Brief Interview for Mental Status (BIMS) score of 04 which indicated severely impaired cognition. Resident #55 had no hallucinations, delusions, or behaviors. Resident #55 was coded to have adequate hearing with no hearing aid or other appliance used. The assessment further identified Resident #55 to need extensive assistance from one to two staff members for transferring, dressing, and personal hygiene. Review of the progress note dated 09/26/23 and timed 9:20 P.M. revealed an incident between Resident #55 and Agency State Tested Nursing Assistant (STNA) #495. Resident #55 called out help me, and a staff STNA responded to take over care of Resident #55. The note described Resident #55 as fearful after Agency STNA #495 had began to start evening care without making Resident #55 aware of the plan. The progress note was authored by Licensed Practical Nurse #418 and was created on 09/27/23 at 10:33 A.M., thirteen hours after the event occurred. Interviews conducted on 10/25/23 between 6:20 A.M. and 7:24 A.M. with Licensed Practical Nurse (LPN) #418 revealed she was the night shift nurse for the memory care unit on 09/26/23. Agency STNA #495 worked in the memory care unit for a twelve hour shift with one other staff STNA. LPN #418 did not directly witness the event, but based her charting on the STNA's account of the event. LPN #418 stated she initially wrote a progress note that described the interaction between Resident #55 and Agency STNA #495 as an attack, but was called back in to the facility the next morning to meet with the Activities Director (AD) #479 and the Director of Nursing (DON), after which meeting she changed her documentation. LPN #418 stated she inactivated her original documentation and re-phrased her progress note. LPN #418 stated she did not directly notify a supervisor about the event that night, but may have mentioned it to the DON during a phone call about another situation. LPN #418 stated both she and the staff STNA she worked with that night provided a written statement. Review of Ohio Department of Health's Certification and Licensure System on 10/26/23 at 10:00 A.M. revealed no self-reported incident had been filed by the facility related to the allegation of physical abuse by Resident #55 on 09/26/23. Review of the daily staffing schedule, dated 09/26/23, revealed STNA #460 was mandated to work from 7:00 P.M. to 11:00 P.M. in the memory care unit with Agency STNA #495. An interview on 10/25/23 at 3:24 P.M. with STNA #460 revealed she works day shift from 7:00 A.M. to 7:00 P.M., but on 09/26/23 was mandated to work an additional four hours. STNA #460 stated 09/26/23 was the first time she had worked with Agency STNA #495. Agency STNA #495 entered Resident #55's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 6 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few room to provide care. STNA #460 walked down the hall when she heard Resident #55 yell help me. STNA #460 stated she knocked quickly but immediately entered the room and found Resident #55 with a hold on Agency STNA's arms. STNA #460 stated Resident #55 recognized her and asked you saw him attack me, right?. STNA #460 sent Agency STNA #495 out of the room and provided care to Resident #55. Resident #55 was upset, fearful, and continued to ask STNA #460 you saw him attack me, right. After care was completed for Resident #55, STNA #460 reported the event to LPN #418. STNA #460 stated she was called back in to the facility the next morning to discuss the incident and provide a written statement. An interview on 10/26/23 at 10:08 A.M. with the Administrator revealed she had no knowledge the incident with Resident #55 on 09/26/23. The administrator verified she had not reported any self-reported incidents in September 2023, but the Administrator should be made aware of any and all abuse allegations and investigations of abuse. An interview on 10/26/23 at 10:15 A.M. with the DON and the Administrator revealed the DON was familiar with the incident. The DON stated she was aware of the situation, the facility had investigated the incident, and it was not an abuse situation. An interview on 10/26/23 at 10:35 with AD #479 revealed she also functions as the Memory Support Manager and oversaw care of the residents who lived in the memory care unit. On 09/27/23, she saw LPN #418's progress note describing the event, and was concerned. AD#479 and the DON reached out to LPN #418 and STNA #460 and asked them to come in to discuss the situation. Both LPN #418 and STNA #460 provided a written statement. AD #479 stated there was no statement from Agency STNA #495, and the DON had the investigation in her office. AD #479 verified that Resident #55 had severely impaired cognition and a BIMS score of 04 seemed accurate for him. An interview on 10/26/23 at 11:02 A.M. with the DON revealed she discussed the incident with LPN #418 and STNA #460. The DON stated she asked LPN #418 to modify her statement, but figured she would add an addendum, not strike out and completely re-write the narrative. The DON provided a copy of the investigation which included two witness statements and two pages of printed-off progress notes from Resident #55's electronic medical record. The DON verified the four pages were the full investigation the facility completed. Review of witness statement authored by LPN #418, dated 09/27/23, referenced event that occurred 09/26/23 around 9:20 P.M. Agency STNA #495 went into Resident #495's room and did not ask for Resident #55's permission to perform care. Resident #55 yelled help, and STNA#460 entered the room. STNA #460 reported to LPN #418 that Agency STNA #495 attacked me. LPN #418 asked Resident #55 about the incident, and he reported he felt attacked and unsafe. LPN #418 asked Resident #55 why he felt that way, to which he stated Agency STNA #495 entered his room and just started touching and grabbing at him, and that the nurse needed to do something about him, referring to Agency STNA #495. The statement further indicated that LPN #418 asked Agency STNA #495 to not enter Resident #55's room the rest of the night and to communicate with residents before care was attempted. Review of witness statement authored by STNA #460, dated 09/27/23, revealed she entered Resident #55's room after she heard him call for help. Resident #55 was in bed, had a hold on Agency STNA #495's arm. Resident #55 recognized STNA #460 and stated she was his friend. STNA #460 took over the care of Resident #55 and asked him what had happened. Resident #55 asked if STNA #460 had seen Agency STNA #495 attack him. STNA #460 stated she had not witnessed anything firsthand. Resident #55 said nothing further other than he was glad STNA #460 was there. STNA #460 then reported the incident to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 7 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 0610 nurse. Level of Harm - Minimal harm or potential for actual harm An interview on 10/26/23 at 12:28 with the Administrator and DON revealed the provided witness statements from LPN #418 and STNA #460 and the progress notes documented in Resident #55's medical record were the only components of the facility's investigative file for the incident. The Administrator and DON verified there had been no interviews or assessments attempted of like residents, no recent abuse education or in-servicing for staff, and Agency STNA #495 completed his twelve hour shift, and was not immediately removed from the patient care area. The Administrator indicated she had not read the two staff witness statements until 10/26/23 and verified both statements used the term attacked. Residents Affected - Few Review of the policy Resident Rights, revised August 2022, revealed The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Employees shall treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of lift, recognizing each resident's individuality. The facility will protect and promote the rights of the resident. Review of the policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, dated 2017, revealed residents have the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. It is the facility's policy to investigate all alleged violations involving abuse. Facility staff should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). If a staff member is accused or suspected of Abuse, they should immediately remove that staff member from the facility and the schedule pending the outcome of the investigation. The policy additionally notes that nursing home staff includes employees, consultants, contractors, volunteers, and any other caregivers who provide care and services to residents on behalf of the facility. Documentation in the nurses' notes should include the result of the resident's assessment, notification of the physician and the Resident Representative, and any treatment provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 8 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to implement appropriate fall interventions for Resident #69. This affected one (#69) of two residents reviewed for falls. The facility census was 81. Findings include: Review of the medical record for Resident #69 revealed an admission date of 09/23/21. Medical diagnoses included dementia, anxiety, osteoarthritis, and closed left hip fracture with surgical repair. Resident #69 resided on the secured memory care unit. Review of the Minimum Data Set (MDS) quarterly assessment, dated 09/01/23 revealed Resident #69 had a Brief Interview for Mental Status (BIMS) score of 03, which indicated severely impaired cognition. Resident #69 required extensive assistance of one to two staff members with activities of daily living (ADLs). Review of the plan of care, initiated 09/24/21, revealed Resident #69 to be at high risk for falls and injury due to arthritis, dementia, cardiac disease, confusion, incontinence, poor balance and safety awareness and an unsteady gait. The care plan was updated on 07/14/23 and indicated Resident #69 sustained a left hip fracture and was sent to the hospital on [DATE]. Review of Resident #69's Fall Risk Assessment, dated 07/13/23, revealed a score of a 13. Review of the Fall Risk Assessment, dated 09/23/23, revealed a score of 16. Each assessment score indicated Resident #69 was at high risk for falls. Review of interdisciplinary progress notes revealed Resident #69 had falls at the facility on 07/13/23, 08/03/23, 09/21/23 and 09/23/23. The documentation did not identify interventions placed to prevent fall reoccurrence. Further review revealed no documented falls in the year prior to the fall on 07/13/23. Review of the Nurse Root Cause Analysis form, dated 07/13/23 and timed 6:40 A.M., completed by Licensed Practical Nurse (LPN) #418, revealed Resident #69 was found on the floor lying on her left side in front of her wheelchair. Resident #69 was in pain and was transferred to the local hospital for evaluation. There was no intervention listed on the root cause analysis form with a statement of there has been no implementations, I suggest a fall mat and a pendant. Review of Resident #69's hospital records dated 07/13/23 and 07/14/23 revealed Resident #69 sustained a closed left hip fracture as a result of a fall that occurred at the facility on 07/13/23. Resident #69 had her hip surgically repaired at the hospital on [DATE] and returned to the facility on [DATE]. Review of the Nurse Root Cause Analysis form, dated 08/03/23 and timed 3:15 P.M., completed by LPN #415, revealed Resident #69 sustained a fall in her bathroom after an attempted self-transfer. Resident #69 was not injured. The listed intervention was to encourage Resident #69 to use her call light. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 9 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 - Minimal harm or potential for actual harm Residents Affected - Few Review of the Nurse Root Cause Analysis form, dated 09/21/23 and timed 6:50 P.M., completed by Registered Nurse (RN) #405, revealed Resident #69 was observed on the floor in the lounge area seated on her buttocks. Resident #69 was not injured. There was no listed intervention implemented to prevent future fall occurrences. Review of the Nurse Root Cause Analysis form, dated 09/23/23 and timed 9:45 A.M., completed by LPN #412, revealed Resident #69 sustained a fall when she was attempting to transfer from wheelchair to bed, but the wheelchair brakes were not locked. Resident #69 was observed on the ground near her bed and wheelchair. Resident #69 was not injured. The listed intervention was to reinforce the need for Resident #69 to use her call light for assistance. Interview on 10/24/23 at 4:44 P.M. with LPN #411 revealed Resident #69 was independently mobile in her wheelchair, confused, and extremely forgetful. Interview on 10/26/23 at 10:35 A.M. with Activities Director (AD) #479 revealed she also functioned as the Memory Support Manager and oversaw care of the residents who lived in the memory care unit. AD #479 stated the nurse on duty should have assessed Resident #69 after each fall, completed the notifications to the provider and responsible party, completed the incident report and implemented a fall intervention. AD #479 stated she then gave completed fall reports to the Director of Nursing (DON). Falls were routinely discussed in morning meeting where the root cause was identified. AD #479 stated all falls should have an intervention placed to prevent fall recurrence. AD #479 verified Resident #69 had severely impaired cognition and education on the use of a call light would not be appropriate or effective. AD #479 verified the fall reports dated 07/13/23 and 09/21/23 listed no intervention and that fall reports dated 08/03/23 and 09/23/23 listed an inappropriate and ineffective intervention. Interview on 10/26/23 at 11:11 A.M. with the Director of Nursing (DON) verified Resident #69 had impaired cognition. The DON verified no interventions were placed for Resident #69 following falls sustained on 07/13/23 and 09/21/23. The DON stated the fall interventions placed following falls on 08/03/23 and 09/23/23 of reminders or education for Resident #69 to utilize her call light to call for assistance were not appropriate for her cognition. Review of the policy Fall Risk Assessment Policy and Incident and Accident Reporting, revised 10/01/14, revealed a Fall Risk Assessment with a score of 10 or greater indicates the resident is at high risk for falls and appropriate interventions should be put into place. Additionally, an immediate intervention to prevent reoccurrence must be instituted for all falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 10 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on staff interview, medical record review, and review of facility policy, the facility failed to ensure the pharmacy recommendations were completed on a monthly basis and were timely addressed by the physician. This affected one (Resident #34) of five reviewed for unnecessary medications. The facility census was 81. Findings include: Review of the medical record for Resident #34 revealed an admission date of 01/31/23. Medical diagnoses included cerebral infarction (stroke) affecting left non-dominant side, vascular dementia, and insomnia. Resident #34 resided in the secured memory care unit. Review of the Minimum Data Set (MDS) quarterly assessment, dated 08/10/23, revealed a Brief Interview for Mental Status (BIMS) of 00, indicating severely impaired cognition. The resident was noted to have verbal behaviors directed towards others and other behavioral symptoms not directed towards others on one to three days during the seven-day lookback period. Resident #34 required extensive assistance of one to two staff members for activities of daily living (ADLs). Resident #34 was identified to have received antipsychotic medications on a routine basis during the seven-day lookback period. Review of consultant pharmacist recommendations revealed no evidence that a medication regimen review was completed by the consultant pharmacist in April 2023. Additionally, the facility was unable to locate the recommendation completed by the consultant pharmacist dated 05/23/23. An interview on 10/25/23 at 3:43 P.M. with the Director of Nursing (DON) verified she was unable to locate the physician-signed pharmacy recommendation sheet from 05/23/23 for Resident #34. Follow-up interview on 10/26/23 at 11:02 A.M. with the DON verified there was no evidence of a medication regimen review completed in April 2023. The DON verified there was no evidence of a medication regimen review conducted between 03/01/23 and 05/23/23. Additionally, the DON stated she was still unable to locate the physician-signed pharmacy recommendation sheet from 05/23/23 and it was unknown what recommendation was made. The DON stated the facility had three different pharmacies over the past year and believed that was where the breakdown occurred. Review of the policy titled Medication Regimen Reviews, revised May 2019, revealed the consultant pharmacist performs a medication regimen review for every resident in the facility receiving medication. Medication regimen reviews are done upon admission and at least monthly thereafter, or more frequently if indicated. The consultant pharmacist provides the director of nursing services and medical director with a written, signed and dated copy of all medication regimen reports. Copies of medication regimen reports, including physician responses, are maintained as part of the permanent medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 11 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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. Based on staff interview, medical record review, and review of facility policy, the facility failed to ensure an as needed medication order for a psychotropic medication was limited to a 14 day duration and instructions for use were followed. This affected one (Resident #61) of five reviewed for unnecessary medications. The facility census was 81. Findings include: Review of the medical record for Resident #61 revealed an admission date of 08/02/23. Medical diagnoses included Alzheimer's disease, depression, cognitive communication deficit, and anxiety. Resident #61 resided on the secured memory care unit. Review of Resident #61's Minimum Data Set (MDS) admission assessment, dated 08/09/23, revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. Resident #61 required extensive assistance of one to two staff members for activities of daily living (ADLs). Review of Resident#61's physician's order, dated 09/19/23 revealed a medication order for Lorazepam (Ativan, an anti-anxiety medication) 0.25 milligrams (mg) by mouth twice daily routinely for anxiety. Review of Resident #61's physician's order, dated 09/19/23, revealed an as needed medication order, for Ativan 0.25 mg by mouth as needed for anxiety at 2 P.M. The order was open-ended with no end date listed. Review of Resident #61's Medication Administration Record (MAR) for September 2023 revealed Resident #61 received an as needed dose of Ativan on 09/22/23 at 5:00 A.M. An interview on 10/26/23 at 12:40 P.M. with the Director of Nursing (DON) verified Resident #61's open-ended as needed Ativan order and stated the order should be limited to 14 days duration. The DON verified the dose administered to Resident #61 on 09/22/23 at 5:00 A.M. was not given within the order parameters and should not have been administered. Review of the policy Tapering Medications and Gradual Dose Reductions, Revised July 2022, revealed the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 12 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 0851 Level of Harm - Minimal harm or potential for actual harm Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Residents Affected - Many Based on the review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, staffing schedule, posted daily staffing sheets, staff time sheets, and staff interview, the facility failed to submit accurate information in the PBJ in the third quarter of 2022. This had the potential to affect all residents. The facility census was 81. Findings Include: Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed the facility triggered for excessively low weekend staffing and not having licensed nursing coverage 24 hours a day in the third quarter of 2022. The specific days identified were Saturday 04/02/22, Sunday 04/03/22, Saturday 04/30/22, Saturday 05/14/22, Sunday 05/15/22, Saturday 06/11/22, and Saturday 06/25/22. Review of the Staffing Schedule and Posted Daily Staffing sheets for Saturday 04/02/22, Sunday 04/03/22, Saturday 04/30/22, Saturday 05/14/22, Sunday 05/15/22, Saturday 06/11/22, and Saturday 06/25/22 revealed the nursing staff worked 12 hour shifts, 7:00 A.M. to 7:30 P.M. and 7:00 P.M. to 7:30 A.M. On Saturday 04/02/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Sunday 04/03/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Saturday 04/30/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Saturday 05/14/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Sunday 05/15/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Saturday 06/11/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. On Saturday 06/25/22 there were four nurses working 7:00 A.M. to 7:30 P.M. and four nurses working in the facility from 7:00 P.M. to 7:30 A.M. The Staffing Schedules did not match the information entered into the PBJ as there was sufficient nurse staffing for 24 hours on each of the days identified as deficient in the PBJ. Reconciliation of the staff time sheets for Saturday 04/02/22, Sunday 04/03/22, Saturday 04/30/22, Saturday 05/14/22, Sunday 05/15/22, Saturday 06/11/22, and Saturday 06/25/22 verified the data on the Staffing Schedule and Posted Daily Staffing sheets were accurate. Interview on 10/25/23 at 10:53 A.M. with the Administrator verified the data entered into the PBJ for the third quarter of 2022 was not entered accurately. The Administrator reviewed the staffing schedule for each day indicated as not having sufficient 24 hour nursing staff and verified there were four nurses in the facility 24 hours a day on those days. The Administrator reported some of the shifts were split between two nurses but there were no gaps. The deficient practice was corrected on 06/01/23 when the facility implemented the following corrective action: • (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 13 of 14 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 365478 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/26/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Upper Sandusky 850 Marseilles Avenue Upper Sandusky, OH 43351 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many On 06/01/23, new ownership assumed responsibility of the facility and implemented a new PBJ data reporting procedure. • On 06/01/23, corporate support began staff data collection, review of facility staffing, and submission of data for the PBJ. • Since the implementation of the new procedure, no additional concerns had been identified related to PBJ data reporting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 14 of 14