Inspection·January 15, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medical record review and staff interview, the facility failed to ensure comprehensive care plans were developed to address residents' needs. This affected four (#2, #64, #84 and #10) of four residents reviewed for care plans. The facility census was 89. Findings include:1. Review of the medical record for Resident #2 revealed she was admitted on [DATE]. Her diagnoses included dementia, hypertension, glaucoma, malnutrition, and a stage three pressure ulcer to her upper back. Her Braden assessment (used to predict the risk for pressure ulcers) revealed she was at risk for pressure ulcers. Review of the Minimum Data Set (MDS) assessment, dated 12/12/25, revealed Resident #2 was cognitively impaired and did not experience behaviors at the time of the assessment. Resident #2 was incontinent and dependent on staff for bed mobility and transfers. Resident #2 was at risk for pressure ulcers. Review of Resident #2's current care plan revealed turning and repositioning was not implemented as an intervention for the prevention of pressure ulcers. Interview on 01/14/26 at 9:20 A.M. with the Director of Nursing (DON) revealed turning and repositioning every two hours was a standard of care for the prevention of pressure ulcers and should be a care plan intervention for residents at risk for pressure ulcer development. The DON verified turning and repositioning was not a care planned intervention for Resident #2 and should have been. 2. Review of the medical record for Resident #64 revealed she was admitted on [DATE]. Her diagnoses included intracerebral hemorrhage, dysphagia, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, hemiplegia and hemiparesis to the left side, hyperlipidemia, depression, and anxiety. Her Braden assessment revealed she was at risk for pressure ulcers. Review of the MDS assessment, dated 10/18/25, revealed Resident #64 was cognitively intact and did not display any behaviors at the time of the assessment. She experienced functional range of motion (ROM) limitations to her left upper extremity and to her bilateral lower extremities. She utilized a wheelchair and was dependent for transfers. Resident #64 required substantial assistance with bed mobility and activities of daily living (ADLs) and was at risk for pressure ulcers. Review of Resident #64's current care plan revealed turning and repositioning was not implemented as an intervention for the prevention of pressure ulcers. Interview on 01/14/26 at 9:20 A.M. with the DON revealed turning and repositioning every two hours was a standard of care for the prevention of pressure ulcers and should be a care plan intervention for residents at risk for pressure ulcer development. The DON verified turning and repositioning was not a care planned intervention for Resident #64 and should have been. 3. Review of the medical record for Resident #84 revealed he was admitted on [DATE]. His diagnoses included heart disease, deep vein thrombosis, hypertension, obstructive sleep apnea, basal cell carcinoma, dementia, difficulty walking, and cerebral infarction (stroke). His Braden assessment revealed he was at risk for pressure ulcers. Review of the MDS assessment, dated 12/16/25, revealed Resident #84 was mildly cognitively impaired and did not exhibit behaviors at the time of the assessment. Resident #84 was incontinent, required substantial assistance with bed mobility and transfers, and was at risk for pressure ulcers. Review of Resident #84's current care plan revealed turning and repositioning was not implemented (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 2 of 17 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 01/15/2026 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 0656 as an intervention for the prevention of pressure ulcers. Level of Harm - Minimal harm or potential for actual harm Interview on 01/14/26 at 9:20 A.M. with the DON revealed turning and repositioning every two hours was a standard of care for the prevention of pressure ulcers and should be a care plan intervention for residents at risk for pressure ulcer development. The DON verified turning and repositioning was not a care planned intervention for Resident #84 and should have been. Residents Affected - Some 4. Review of the medical record for Resident #10 revealed an admission date of 09/20/25 with diagnoses including, but not limited to, dementia with other behavioral disturbance, cognitive communication deficit, and anxiety. Review of the MDS assessment, dated 11/18/25, revealed the resident had severe cognitive impairment with inattention behaviors that fluctuated. Resident #10 had physical and verbal behaviors directed towards others one to three days of the seven-day look-back period. Review of current physician orders revealed the resident was on Seroquel (antipsychotic medication) 25 milligrams (mg) for anxiety twice daily. Review of care plan dated 06/13/25 revealed no care plan was initiated or implemented related to Resident #10's use of antipsychotic/psychotropic medication. Interview on 01/14/26 at 7:43 A.M. with the DON confirmed Resident #10 did not have a care plan for psychotropic medication usage. The DON further verified Resident #10 should have had a care plan focus area, with interventions, in place for the use of psychotropic medications. Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed the comprehensive, person-centered care plan included measurable objectives and timeframes, described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, and reflected currently recognized standards of practice for problem areas and conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 3 of 17 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 01/15/2026 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 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the activity calendars, staff interview, and review of facility policy, the facility failed to ensure an adequate activities program on the memory care unit. This had the potential to affect 12 (#13, #14, #47, #53, #57, #60, #63, #68, #78, #80, #82, and #89) residents identified by the facility as residing on the memory care unit and regularly participating in activities. The facility census was 89.Findings include:Review of the Activity Calendar for 01/12/26 revealed the following scheduled activities on the memory care unit: 9:30 A.M. morning music, 10:30 A.M. just you and me, 1:00 P.M. hydration station, and 3:00 P.M. piano with Resident Council President.Observation on 01/12/26 from 9:00 A.M. through 10:40 A.M. of the memory care unit revealed no activities were occurring. Residents were observed in the dining room for breakfast or sitting in the common area in front of the television (TV) sleeping.Observation on 01/12/26 at 1:25 P.M. of the memory care unit revealed no activities were occurring on the unit. Review of the Activity Calendar for 01/13/26 revealed the following activities: 10:30 A.M. greet the day, 11:00 A.M. lunch friends, 1:00 P.M. refreshment time, 2:00 P.M. let's get moving, 2:30 P.M. music with [NAME], and 4:00 P.M. winter memories.Observation on 01/13/26 at 10:06 A.M. of the memory care unit revealed six residents were sitting in the back common area watching TV. Two of those residents were sleeping, with one resident asleep in her wheelchair with her head bobbing back and then back to the front toward her chest. Continued observation revealed one resident was asleep in front of the TV in the front hall common area. No staff were observed to be interacting with the residents in the common areas.Observation on 01/13/26 at 10:24 A.M. revealed Activities Aide (AA) #212 was in the back common area of the memory care unit. AA #212 cleared off the table, which had magazines and puzzles on it. AA #212 was observed with an activity cart.Observation on 01/13/26 at 10:39 A.M. of the memory care unit revealed no scheduled activity was occurring. Continued observation revealed activities staff gathered hot water to make tea for residents. One resident was observed to be sitting at the table. Four residents were sitting around the TV. At 10:44 A.M., a total of three residents were sitting at the table for tea. A visitor arrived to the unit with their dog and visited with the residents, allowing them to pet the dog. Several residents were observed petting the dog and talking about the pets they used to have. Staff were observed to begin taking residents to the dining room for lunch. Interview on 01/13/26 at 11:28 A.M. with AA #12 revealed that within the past month, different activities had been done at the kitchen table, including music, snacks, crafts, and exercise. AA #212 stated greet the day was everyday, which included one-on-ones in resident rooms. AA #212 stated they no longer had a pastor that came regularly for church services. AA #212 stated that she did inspirational corner, where she sings hymns for the residents.Interview on 01/13/26 at 1:39 P.M. with AA #212 revealed she was on another unit in the facility on 01/12/26, so no activities were completed on the memory care unit. AA #212 stated that she went to the memory care unit around noon and talked to a few residents. AA #212 stated they only had two activity aides and verified no activities were done on the memory care unit on 01/12/26. Observation on 01/13/26 at 1:54 P.M. of the front common area revealed residents were being brought down for an exercise activity scheduled at 2:00 P.M. Three residents were present for the activity. AA #212 proceeded to turn on music and lead the residents through stretches and exercises. Interview with AA #212 revealed the 2:30 P.M. activity, music with [NAME], would not be occurring as he no longer came to the facility. AA #212 stated the activity had not been replaced yet and she had to be on another unit at 2:30 P.M. to lead a music activity. Continued observation revealed two additional residents and family members came to the common area for the 2:30 P.M. music activity and AA #212 informed them he was no longer coming and the activity would not Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 4 of 17 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 01/15/2026 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 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete take place. The residents and family members were observed leaving the common area. After the exercises, all but one resident left the area. Review of the Activity Calendar for 01/14/26 revealed the following activities: 10:30 A.M. greet the day, 11:00 A.M. lunch friends, and 1:00 P.M. refreshment time.Observation on 01/14/26 at 10:39 A.M. of the memory care unit common area revealed two residents in wheelchairs were sleeping in front of the TV, one resident was observed sitting at the table asleep, and one resident was drinking fluids. No activity was observed to be occurring and no staff were observed interacting with the residents in the common area. Interview on 01/14/26 at 10:49 A.M. with Licensed Practical Nurse (LPN) #232 revealed that AA #212 would not be on the memory care unit until 1:00 P.M. as it was her late night. LPN #232 confirmed the scheduled activities did not occur that morning and none would be done until AA #212 came in. LPN #232 stated Activities Director (AD) #278 would help with activities. Interview on 01/14/26 at 10:58 A.M. with AD #278 verified no activities occurred on the memory care unit on 01/12/26. AD #278 stated she talked to the residents all the time, but confirmed talking to residents was not an activity. Review of the facility policy titled, Activity Programs, revised June 2018, revealed the activities program was provided to support the well-being of residents and to encourage both independence and community interaction. Activities offered were based on the comprehensive resident-centered assessment and the preferences of each resident. Activities were scheduled seven days a week and residents were given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. Event ID: Facility ID: 365478 If continuation sheet Page 5 of 17 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 01/15/2026 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observation, and resident and staff interview, the facility failed to ensure timely follow-up on hearing needs. This affected one (#28) of one resident reviewed for hearing services. The facility census was 89.Findings include:Review of the medical record for Resident #28 revealed an admission date of 12/10/19 and a re-admission date of 11/03/23. Diagnoses included diabetes mellitus Type II, chronic obstructive pulmonary disease (COPD), and major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment, dated 11/21/25, revealed Resident #28 had moderate cognitive impairment. Further review of the MDS revealed Resident #28 had moderate difficulty with hearing and wore hearing aids. Review of the care plan dated 11/03/23 revealed Resident #28 had a communication problem related to hearing deficit. Interventions included bilateral hearing aids. Review of the physician orders dated 06/25/25 revealed Resident #28 had an order to offer to put hearing aids in the morning and document Resident #28's wishes. Further review revealed an order dated 06/25/25 to remove Resident #28's hearing aids at night and store in the medication cart.Review of the audiology progress report dated 08/25/25 revealed Resident #28 was seen for a hearing evaluation. Findings from the audiology appointment included bilateral moderate hearing loss. New orders included continued use of the right hearing aid, turn volume of the hearing aid all the way up.Review of the Medication Administration Record (MAR) for January 2026 revealed from 01/01/26 through 01/13/26, staff documented Resident #28 wore his hearing aids and they were placed in the medication cart at nighttime.Review of the nurse progress notes from 01/01/26 through 01/13/26 revealed no documentation of Resident #28's right hearing aid missing.Observation on 01/13/26 at 8:47 A.M. revealed Resident #28 sitting in his recliner chair with his feet elevated. Resident #28 had a hearing aid in the left ear. Concurrent interview with Resident #28 revealed the resident had difficulty understanding what was said to him by the surveyor as he was not able to hear. Resident #28 stated his right hearing aid had been missing for an extended period, adding he placed the hearing aid on his bedside table months ago and it came up missing.Interview on 01/13/26 at 10:21 A.M. with Licensed Practical Nurse (LPN) #317 confirmed Resident #28's right hearing aid was lost. LPN #317 stated staff searched for months for the right hearing aid, without success in locating it. LPN #317 stated she reported the missing hearing aid to management, but did not specify who was notified. LPN #317 was unable to recall how long the right hearing aid had been missing; however, LPN #317 stated the right hearing aid was not functioning properly at the time it came up missing.Interview on 01/13/26 at 11:58 A.M. with the Director of Nursing (DON) confirmed she was unaware Resident #28's right hearing aid was missing and denied management was notified of the missing hearing aid. The DON verified that staff should have made her aware so that an appointment could have been scheduled to have it replaced. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 6 of 17 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 01/15/2026 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure sanitary practice while caring for a urinary catheter. This affected one (#45) of two residents reviewed for urinary catheters. The facility census was 89.Findings include:Review of the medical record for Resident #45 revealed an admission date of 08/22/14 and a readmission date of 01/12/24. Diagnoses included Arnold Chiari Syndrome with spina bifida, paraplegia, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy, unspecified. Review of the annual Minimum Data Set (MDS) assessment, dated 11/30/25, revealed Resident #45 was cognitively intact. Further review of the MDS revealed Resident #45 was dependent on staff for activities of daily living (ADLs). Review of the care plan dated 01/13/24 revealed Resident #45 was at risk for urinary tract infections (UTIs) related to neurogenic bladder, obstructive uropathy, and intermittent catheterization. Interventions included encourage fluids, laboratory (lab) draws, medications, and notify the provider of signs and symptoms of a UTI. Additionally, Resident #45 had potential for complications related to catheter related to paraplegia, neurogenic dysfunction of bladder, obstructive uropathy, and neurogenic bowel. Interventions included staff to provide perineal care and catheter care to site care as needed. Review of the physician orders dated 01/07/26 revealed Resident #45 had an order for gentamicin sulfate injection solution (antibiotic), 480 milligrams (mg) via irrigation every day shift for bladder irrigation, 60 milliliters (ml) by bladder. Gentamicin 480 mg in one liter of 0.9 percent (%) normal saline. Instill 60 ml into the bladder, clamp off catheter for one hour, then drain.Observation on 01/14/26 at 9:39 A.M. revealed Licensed Practical Nurse (LPN) #302 cleansed around the skin of Resident #45's urinary catheter site with a wet wipe. LPN #302 did not clean the catheter tubing. Further observation revealed LPN #302 placed a 60 ml syringe into the gentamycin and normal saline solution, withdrawing 60 mls. LPN #302 then removed the urinary catheter bag and attached the 60 ml syringe to the catheter. LPN #302 pushed the gentamycin and normal saline solution into Resident #45's urinary catheter tubing and left the syringe connected to the urinary catheter tubing. LPN #302 then walked into Resident #45's bathroom. Continued observation revealed Resident #45 began coughing. While Resident #45 was coughing, fluid pushed from the urinary catheter back into the syringe, with notable sediment present. Resident #45 coughed again, expelling 60 mls total from the urinary catheter into the syringe. After the surveyor made LPN #302 aware that fluid was present in the syringe, LPN #302 pushed the fluid back into Resident #45's bladder and walked out of the room.Interview on 01/14/26 at 9:41 A.M. with LPN #302 confirmed that Resident #45's catheter care should be completed with warm soapy water, cleaning the catheter insertion site and down the tubing. LPN #302 confirmed she did not clean Resident #45's catheter with warm soapy water and further stated, Sometimes I do. LPN #302 verified she left the medication syringe connected to the urinary catheter tubing instead of clamping it because the clamp to the catheter did not work properly. LPN #302 stated she was unsure if it was sanitary to push the fluid that was expelled into the syringe when Resident #45 was coughing back into the resident's bladder.Interview on 01/14/26 at 11:15 A.M. with the Director of Nursing (DON) confirmed staff should clean around the urinary catheter site with warm soapy water, including going down the catheter tubing. The DON further confirmed Resident #45's catheter should have been clamped off and the syringe removed following the administration of the gentamicin and normal saline solution. The DON stated the fluid that was expelled into the syringe should not have been pushed back into Resident #45's bladder as it could cause obstruction or infection.Review of the facility policy titled, Catheter Care Policy, undated, revealed staff should inspect the suprapubic insertion (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 7 of 17 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 01/15/2026 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 0690 Level of Harm - Minimal harm or potential for actual harm site each shift for redness, swelling, drainage, or signs of infection. Cleanse the site daily with mild soap and water.Review of the facility policy titled, Urinary Catheter Irrigation Policy, undated, revealed catheter irrigation would be completed using aseptic technique to maintain a closed drainage system whenever possible and to minimize the risk of catheter-associated UTIs. Staff should clamp the drainage tubing, then unclamp tubing at ordered time to allow drainage into the collection bad. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 8 of 17 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 01/15/2026 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on medical record review and staff interview, the facility failed to ensure respiratory assessments were completed following a change in condition. This affected one (#60) of one resident reviewed for respiratory care. The facility census was 89.Findings include:Review of the medical record for Resident #60 revealed an admission date of 06/19/24 with diagnoses including, but not limited to, type two diabetes, hypertension, major depressive disorder, chronic obstructive pulmonary disease (COPD), dementia, anxiety, and mild cognitive impairment.Review of the Minimum Data Set (MDS) assessment, dated 10/28/25, revealed the resident had severe cognitive impairment. Review of care plan dated 06/14/24 revealed Resident #60 had emphysema/COPD related to smoking. Resident #60 was noted to have lung nodules. Interventions included administer medications as ordered, apply oxygen as ordered, head of bed elevated, observe as needed for signs and symptoms of respiratory infection, and monitor respiratory rate, depth, and effort.Review of the physician orders dated 01/11/26 revealed Resident #60 was ordered azithromycin (antibiotic) 250 milligrams (mg) daily until 01/15/26 for cough/congestion, oxygen at two liters per minute (lpm), prednisone 20 mg daily for five days, and oxygen tubing- change, date, and initial weekly on Sunday. Review of the Respiratory Assessments revealed Resident #60 had assessments completed at least daily until 01/11/26. Further review revealed no assessments were completed after 01/11/26.Interview on 01/14/26 at 9:11 A.M. with the Director of Nursing (DON) revealed that if a resident had a history of respiratory disease or any new respiratory issues, the Respiratory Assessment was to be completed every shift. The DON verified the last Respiratory Assessment for Resident #60 was completed on 01/11/26 and they should have been completed on each shift. A follow-up interview on 01/14/26 at 11:20 A.M. with the DON revealed the protocol for residents receiving antibiotics, steroids, oxygen, and breathing treatments would be to complete an assessment, to include lung sounds, cough, and vital signs. The DON verified there was no documentation in Resident #60's medical record that the resident's respiratory issues, such as lung sounds, antibiotic use, and cough were assessed from 01/12/26 through 01/14/26. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 9 of 17 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 01/15/2026 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **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 ensure parameters were in place for the safe administration of as needed (PRN) pain medications. This affected two (#71 and #8) of five residents reviewed for unnecessary medications. The facility census was 89.Findings include:1. Review of the medical record for Resident #71 revealed she was admitted on [DATE]. Diagnoses included cirrhosis of the liver, bipolar disorder, anxiety, depression, acquired absence of parts of the digestive tract, malnutrition, sacroiliitis, low back pain, fibromyalgia, migraine, lesion of the right sciatic nerve, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 12/31/25, revealed Resident #71 was cognitively intact and did not display any behaviors at the time of the assessment. Resident #71 utilized a walker and was either independent or required minimal assistance with activities of daily living (ADLs). She received scheduled and as-needed pain medication to manage frequent pain that affected her sleep and day-to-day activities. Residents Affected - Few Review of the physician orders revealed Resident #71 had an order dated 12/11/23 for five milligrams (mg) of oxycodone hydrochloride (HCI) every 24 hours PRN for pain, an order dated 06/15/25 for a fentanyl transdermal patch, 12 micrograms (mcg) per hour to be changed every 72 hours for pain, an order dated 10/03/25 for butalbital-aspirin-caffeine 50-325-40 mg every six hours PRN for migraine pain, and an order dated 09/16/25 for five mg of oxycodone HCI twice daily for pain. The PRN pain medication orders did not include parameters for the administration of the medications. Review of the December 2025 Medication Administration Record (MAR) revealed Resident #71 was administered butalbital-ASA-caffeine oral capsule twice on 12/05/25, once on 12/06/25, once on 12/07/25, once on 12/10/25, once on 12/11/25, once on 12/20/25, and once on 12/21/25 for an assessed pain level of zero. Further review revealed additional butalbital-ASA-caffeine oral capsule doses were administered at least daily, with assessed pain levels ranging from one to 10 upon administration. Additionally, oxycodone HCI five mg oral tablet was administered on 12/02/25, 12/05/25, 12/06/25, 12/07/25, 12/18/25, 12/20/25, and 12/21/25 for an assessed pain level of zero. Further review revealed oxycodone HCI was administered 18 additional times during the month of December with assessed pain levels ranging from two to nine. Review of the January 2026 MAR, from 01/01/25 through 01/14/25, revealed butalbital-ASA-caffeine oral capsule was administered at least daily for assessed pain levels ranging from two to nine. Oxycodone HCI was administered 12 of the 14 days for assessed pain levels of two to eight. Interview on 01/14/26 at 3:30 P.M. with Registered Nurse (RN) #500 confirmed Resident #71 had PRN orders for butalbital-ASA-caffeine oral capsule and oxycodone HCI without parameters for the administration of the medications. RN #500 verified PRN pain medication orders should include parameters for the administration of the medication. 2. Review of the medical record for Resident #8 revealed an admission date of 12/08/25 with diagnoses including, but not limited to, cerebral infarction (stroke), cognitive communication deficit, localized edema, major depressive disorder, anxiety, and pain. Review of the MDS assessment, dated 12/12/25, revealed the resident had moderate cognitive impairment. Review of the care plan dated 12/15/25 revealed Resident #8 had complaints of pain related to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 10 of 17 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 01/15/2026 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 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few osteoarthritis of the knee and rhabdomyolysis. Interventions included administering medications per orders, anticipate the resident's need for pain relief and respond immediately to any complaints of pain, assess for pain as ordered and as needed, and monitor for side effects of pain medications. Review of the physician orders revealed Resident #8 had an order dated 12/08/25 for Tylenol eight hour extended release (ER) 650 mg give two tablets every eight hours PRN for pain and an order dated 12/25/25 for tramadol 50 mg give one tablet twice daily PRN for pain. Neither order had parameters for the administration of the pain medications. Review of the MAR for December 2025 revealed Tylenol was given on the following dates: 12/09/25 for an assessed pain level of one, 12/17/25 for an assessed pain level of six, 12/18/25 twice for assessed pain levels of five and eight, 12/21/25 for an assessed pain level of five, and 12/24/25 for an assessed pain level of four. Further review revealed tramadol was given on the following dates: 12/27/25 twice for assessed pain levels of five and eight and 12/28/25 twice for assessed pain levels of eight and six. Review of the MAR for January 2026 revealed Tylenol was not administered through the survey date. Tramadol was administered on the following dates: 01/04/26 for an assessed pain level of eight, 01/11/26 for an assessed pain level of two, 01/12/26 twice for assessed pain levels of eight and five, and 01/13/26 for an assessed pain level of eight. Interview on 01/14/26 at 1:08 P.M. with the Director of Nursing (DON) verified there were no parameters to indicate when to administer Tylenol or tramadol to Resident #8. The DON confirmed parameters should be in place for PRN pain medication orders. Review of the facility policy titled, Administering Medications, dated April 2019, revealed the facility would administer medications in a safe manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 11 of 17 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 01/15/2026 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, staff interviews, review of facility policy, and review of a medication reference guide, the facility failed to ensure medications were properly labeled with an open date to determine expiration dates and further failed to ensure expired medications were disposed of. This had the potential to affect all 89 residents residing in the facility. The facility census was 89.Findings include: 1. Observation on 01/13/26 at 9:22 A.M. of the Buckeye Hall medication cart revealed a bottle of GenTeal tears (for dry eyes) for Resident #90, with a delivery date of 10/18/25 and no open date. Concurrent interview with Registered Nurse (RN) #123 verified there was no open date on Resident #90's GenTeal tears to indicate when they should be discarded. 2. Observation on 01/13/25 at 9:41 A.M. of the Stepping Stones Hall medication cart revealed the following: a Lantus SoloStar 100 units/milliliters (u/ml) insulin pen , with a delivery date of 11/01/25 and no open date for Resident #38; an insulin degludec FlexTouch 100 u/ml insulin pen, with a delivery date of 11/24/25 and no open date for Resident #7; a bottle of artificial tears 0.5 fl oz with no open date for Resident #87; and a bottle of Refresh Tears lubricant eye drops 0.5 fl oz with no open date for Resident #77. Concurrent interview with RN #140 verified the medications were not labeled with the date they were opened. 3. Observation on 01/13/25 at 9:15 A.M. of the Stepping Stone Hall storage unit revealed a vial of Aplisol (tuberculin purified protein derivative solution used in the standard Mantoux tuberculosis [TB] skin test). The label on the vial stated, Do not use 30 days after above date, with an open date of 11/26/25. Concurrent interview with RN #140 verified the Aplisol was past the 30-day expiration date and further confirmed it was available for any resident who required TB testing.4. Observation on 01/14/25 at 8:20 A.M. of the west medication cart revealed three unidentified pills (one white pill, one black pill, and one small lavender pill) in a medication cup sitting in the second drawer of the medication cart. Further observation revealed multiple bottles of Refresh Tears lubricant eye drops 0.5 fl oz. that did not have a resident name or open dates; two Lantus SoloStar insulin pens for Resident #45 with no open date; a bottle of Pataday (eye drops for allergies) with no open date for Resident #58; a bottle of latanoprost 0.005% eye drops, with a delivery date of 12/02/25 and no open date for Resident #45; and a bottle of Systane lubrication eye drops with no resident name and an open date of 11/27/25. Concurrent interview with Licensed Practical Nurse (LPN) #307 verified the findings.5. Observation on 01/14/25 at 8:35 A.M. of the north medication cart revealed an albuterol sulfate inhalation aerosol 90 microgram (mcg) per actuation inhaler with an open date of 08/28/25. Further observation of the label revealed the inhaler expired 90 days after opening (90 days from opening was 11/26/25). Concurrent interview with LPN #317 verified the albuterol sulfate inhaler was expired.Review of the medical reference, The International Pharmacopoeia-Thirteenth Edition, dated 2025, revealed multidose ophthalmic drop preparations may be used for up to four weeks after the container was initially opened.Review of the Lantus SoloStar pharmaceutical safety information, dated 2022, revealed to throw away an opened Lantus SoloStar pen, even if it still had insulin in it, after 28 days.Review of the insulin degludec FlexTouch injection pen pharmaceutical safety information, dated 2024, revealed to dispose of the pen after eight weeks, even if there was insulin left in the pen or vial and the expiration date had not passed.Review of the facility policy titled, Medication Labeling and Storage, dated February 2023, revealed if the facility had discontinued or outdated medication, the dispensing pharmacy was contacted for instructions regarding returning or destroying these items. Over the counter (OTC) medications should have a label that contained the medication names, strength, quality, accessory instructions, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 12 of 17 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 01/15/2026 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 0761 Level of Harm - Minimal harm or potential for actual harm lot number and expiration date. Multi-dose vials that had been opened or accessed were dated and discarded within 28 days unless the manufacturer specified a shorter or longer date.Review of the facility policy titled, Administering Medications, dated April 2019, revealed when opening a multi-dose container, the date opened was recorded on the container. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 13 of 17 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 01/15/2026 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, and review of facility policy, the facility failed to ensure mechanically altered meals were stored in a manner to prevent contamination. This affected six (#2, #8, #16, #51, #74, #79, and #84) of six residents identified by the facility as receiving pureed foods. Additionally, the facility failed to ensure the kitchenette was maintained in a clean and sanitary manner. This affected 37 (#4, #5, #6, #9, #12, #16, #20, #22, #27, #28, #31, #33, #34, #37, #39, #40, #41, #44, #46, #50, #51, #56, #58, #61, #67, #70, #71, #75, #79, #85, #86, #88, #90, #91, #92, #94, and #100) of 37 residents who received food from the second floor kitchenette. The facility census was 89.Findings include:1. Observation on 01/12/26 at 9:30 A.M. revealed [NAME] #210 prepared puree meals, consisting of breaded fish and broccoli, for the lunch meal. [NAME] #210 placed the pureed foods into twelve single-serve bowls, covered the bowls with lids, labeled and dated the lids, then placed them on a room temperature preparation (prep) table. Interview on 01/12/26 at 9:45 A.M. with [NAME] #210 confirmed the prepared pureed foods were placed on the prep table and further stated the foods were neither refrigerated nor warmed until lunch service at 11:30 A.M. (two hours after preparation). Interview on 01/12/26 at 9:55 A.M. with Dietary Manager (DM) #233 verified prepared foods should be refrigerated after preparation. Review of the facility policy titled, General Food Preparation and Handling, dated 2005, revealed foods would be refrigerated to below 40 degrees Fahrenheit (F) immediately after preparation. 2. Observation on 01/14/26 at 10:37 A.M. of the second-floor kitchenette revealed a drying towel hanging over the sink. Further observation of the kitchenette revealed a dried, clear, sticky substance on the ice machine, an unknown dried white substance scattered on the cupboards under the sink, and a large amount of food debris in the reach in refrigerator. Additional observation of the kitchenette revealed a large amount of food debris built up in the microwave. Interview on 01/14/26 at 10:45 A.M. with Dietary Aide (DA) #242 revealed the drying towel hanging over the sink was used for the clean dishes that came out of the dish washer. DA #242 confirmed that the towel was to be changed after each meal, however the towel drying over the sink was the same towel used 01/13/26. DA #242 verified the sticky substance on the ice machine, the white substance on the cupboards under the sink, and the food debris in the refrigerator and microwave. Review of the facility policy titled, General Sanitation of Kitchen, dated 2005, revealed the staff shall maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 14 of 17 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 01/15/2026 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, family and staff interview, review of facility policy, and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to perform hand hygiene during medication administration and further failed to ensure nebulizer tubing was stored in a sanitary manner. This affected one (#5) of 13 residents observed for medication administration. Additionally, the facility failed to ensure residents with respiratory illness were placed on transmission-based precautions (TBP). This affected one (#64) of one resident reviewed for respiratory illness. The facility census was 89. Findings include:1. Review of the medical record for Resident #5 revealed an admission date of 03/26/18. Diagnoses included contusion, laceration, and hemorrhage of brainstem with loss of consciousness of unspecified duration, aphasia, nontraumatic intracerebral hemorrhage, hemiplegia, and hemiparesis following cerebral infarction (stroke) affecting left non-dominant side. Residents Affected - Some Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/25/25, revealed Resident #5 had severe cognitive impairment and was dependent on staff for daily care. Further review of the MDS revealed Resident #5 required tracheostomy care and required a feeding tube for nutrition. Review of the current care plan revealed Resident #5 received nourishment via a percutaneous endoscopic gastrostomy (peg) tube (feeding tube surgically placed through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medication) related to the inability to take nourishment by mouth due to traumatic brain injury (TBI) and tracheostomy. Additionally, Resident #5 was in enhanced barrier precautions (EBP-infection control measures, including the use of gowns and gloves during high-contact care, to reduce the spread of multidrug-resistant organisms [MDROs]). Observation on 01/14/26 at 11:24 A.M. of medication administration revealed Licensed Practical Nurse (LPN) #307 prepared medications for administration to Resident #5. LPN #307 did not complete hand hygiene before medication preparation or after administering Resident #5's medication. Further observation of Resident #5's room revealed a nebulizer machine, with the tubing hanging off the bedside table onto the floor, and the breathing tube on a paper towel on the bedside table. Interview on 01/14/26 at 11:32 A.M. with LPN #307 verified she did not perform hand hygiene prior to preparing and administering Resident #5's medications, or after she completed administration. Additionally, LPN #307 verified the resident's nebulizer tubing was laying on the floor, with the breathing tube placed on a paper towel on the bedside table. LPN #307 confirmed the tubing should have been placed in a bag to ensure sanitary storage. LPN #307 verified there was no bag in Resident #5's room for the storage of the resident's nebulizer tubing and stated she would get one to ensure it was properly stored. Review of the facility policy titled, Standard Precautions, dated September 2022, revealed hand hygiene was performed with alcohol-based hand rub (ABHR) or soap and water before and after contact with a resident and after the removal of gloves. Review of facility policy titled, Breathing Treatment Machine Cleaning and Storage Policy, undated, revealed clean nebulizer components and tubing shall be stored in a clean, labeled container or bag. 2. Review of the medical record for Resident #64 revealed she was admitted on [DATE]. Her diagnoses included intracerebral hemorrhage, dysphagia, chronic obstructive pulmonary disease (COPD), (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 15 of 17 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 01/15/2026 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some cognitive communication deficit, hemiplegia and hemiparesis to the left side, hyperlipidemia, depression, and anxiety. Review of the MDS assessment, dated 10/18/25, revealed Resident #64 was cognitively intact and did not display any behaviors at the time of the assessment. She experienced functional range of motion (ROM) limitations to her left upper extremity and to bilateral lower extremities. She utilized a wheelchair and was (staff) dependent for transfers. Resident #64 required substantial assistance with bed mobility and activities of daily living (ADLs). Review of a progress note for Resident #64 revealed on 01/09/26 at 12:49 P.M., the resident had congestion and a dry barking cough. Her lung sounds were coarse and wheezy and she required oxygen supplementation. At 1:57 P.M. a progress note revealed new medications were ordered due to abnormal lung sounds and shortness of breath. Review of a nursing respiratory assessment dated [DATE] for Resident #64 revealed abnormal breath sounds of wheezing and rhonchi (low-pitched rattling lung sounds) in all lung fields. Resident #64 also experienced shortness of breath and a non-productive cough. Review of the physician orders dated 01/09/26 for Resident #64 revealed an order for a one time chest X-ray, an order for ipratropium-albuterol inhalation solution 0.5-2.5 three milligrams (mg) per milliliter (mL) to be administered three times a day for three days for wheezing, and an order for 20 mg of prednisone to be administered daily at bedtime for five days for wheezes and rhonchi. Additionally, there was an order dated 01/13/25 to re-start the ipratropium-albuterol inhalation solution 0.5-2.5 three mg per mL to be administered three times a day for five days for wheezing. Review of a physician note for Resident #64, dated 01/12/26, revealed a diagnosis of acute bronchitis, shortness of breath, wheezing, and acute unspecified upper respiratory infection. Further review revealed prolonged isolation and limited contact with family and friends, increase fluids and COVID protocol per policy. Interview on 01/12/26 at 10:30 A.M. with Resident #64's spouse revealed Resident #64 had an unspecified respiratory infection. Concurrent observation revealed no signage or other evidence Resident #64 was on TBP. Observations on 01/13/26 at 9:20 A.M., 01/14/26 at 8:42 A.M., and 01/15/26 at 10:45 A.M. of Resident #64's room revealed no signage or other evidence Resident #64 was on TBP. Interview on 01/14/26 at approximately 3:00 P.M. with the Director of Nursing (DON) confirmed Resident #64 was not placed on TBP due to respiratory illness. Interview on 01/15/26 at 10:50 A.M. with Certified Nursing Assistant (CNA) #295 confirmed Resident #64 was not on TBP, nor had she been recently. Review of the facility policy titled, Respiratory Illness: Screening and Management, dated 11/09/23, revealed the facility would place residents with confirmed or suspected respiratory illness in TBP in a manner consistent with the CDC to prevent the transmission of communicable respiratory infections. Further review of this policy revealed symptoms that warranted following the above noted procedure included new cough and shortness of breath. Review of the CDC guidelines titled, Transmission-Based Precautions, dated 04/03/24, revealed to use droplet precautions for patients known or suspected to be infected with pathogens transmitted by (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 16 of 17 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 01/15/2026 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 0880 Level of Harm - Minimal harm or potential for actual harm respiratory droplets that are generated by a patient who was coughing, sneezing, or talking. Further review revealed to use personal protective equipment (PPE) by donning a mask upon entry to the patient's room or patient's space. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365478 If continuation sheet Page 17 of 17