Health inspection·May 6, 2021

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to obtain a resident's blood glucose levels as ordered by a physician. This affected one (#18) of five residents reviewed for unnecessary medications. The facility identified four residents with orders for blood glucose monitoring. The census was 37. Residents Affected - Few Findings include: Review of Resident #18's medical record revealed an admission date 03/17/20. Diagnoses included vascular dementia without behavioral disturbances, anxiety disorder, psychotic disorders, diabetes mellitus type I, cardiac arrhythmia, and essential hypertension. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had severely impaired cognitive skills for daily decision making and received insulin injections seven days during the seven day look back period. Review of a diabetic care plan date 03/17/20 revealed Resident #18 was at risk for hyper/hypoglycemic episodes episodes with and intervention dated 06/29/20 to monitor blood sugars and given insulin per sliding scale as ordered by the physician. Review of a physician order dated 01/10/21 revealed Resident #18 was ordered insulin lispro via sliding scale subcutaneously three times daily scheduled for 8:00 A.M., 12:00 P.M., and 5:00 P.M. Resident #18 sliding scale was ordered for blood glucose levels between zero and 200 milligrams per deciliter (mg/dL) administer four units of insulin; for blood glucose levels between 201 and 300 mg/dL given six units of insulin; and for blood glucose levels 301 and above given eight units of insulin and repeat blood glucose check in two hours and repeat sliding scale if the blood glucose level was above 200 mg/dL. Review of the January 2021 medication administration record (MAR) revealed on 01/16/21 at 12:00 P.M. Resident #18's blood glucose level was 346 mg/dL; on 01/21/21 at 12:00 P.M. Resident #18's blood glucose levels was 308 mg/dL; and on 01/22/21 at 12:00 P.M. Resident #18's blood glucose level was 343 mg/dL. There was no documentation on the MAR of Resident #18's blood glucose level being rechecked two hours after her blood glucose levels were 301 mg/dL or above. Review of the February 2021 MAR revealed on 02/01/21 at 12:00 P.M. Resident #18's blood glucose level was 322 mg/dL; on 02/03/21 at 12:00 P.M. Resident #18's blood glucose level was 339 mg/dL and on 02/13/21 at 12:00 P.M. Resident #18's blood glucose level was 346 mg/dL. There was no documentation on the MAR of Resident #18's blood glucose level being rechecked two hours after her blood glucose levels were 301 mg/dL or above. Review of Resident #18's nursing progress notes and blood glucose levels documented in the electronic health record under vital signs dated between 01/01/21 and 02/28/21 revealed no documentation of Resident #18's blood glucose levels being rechecked as ordered by the physician on 01/16/21, 01/21/21, 01/22/21, on 02/01/21, on 02/03/21, and on 02/13/21 after Resident #18's blood glucose levels were 301 mg/dL or above. Further review of the nursing progress notes revealed Resident #18 did not experience any changes in condition during this time frame and no additional medical interventions were implemented. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365680 If continuation sheet Page 2 of 9 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 365680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Hicksville 601 Defiance Avenue Hicksville, OH 43526 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 05/04/21 at 10:58 A.M., 1:23 P.M., and 4:17 P.M., and on 05/05/21 at 8:47 A.M., 11:40 A.M., and 2:03 P.M. revealed Resident #18 was free from any distress or discomfort. Resident #18 was not observed experiencing any outward signs or symptoms of hyperglycemia. Interview on 05/05/21 at 2:29 P.M. with Licensed Practical Nurse (LPN) #490 verified Resident #18's insulin lispro sliding scale order contained instructions if Resident #18's blood glucose level was 301 mg/dL or above the nurse was to recheck her blood glucose level two hours later and if the recheck blood glucose level was 200 mg/dL or above to restart the sliding scale. LPN #490 stated nurse usually documented the blood glucose levels on the MAR's but could also document them in a progress note or in the vital signs tab in the electronic health record. LPN #490 verified there was no documentation on the January or February 2021 MAR's or in nursing progress of Resident #18's blood glucose level being rechecked as ordered on 01/16/21, 01/21/21, 01/22/21, on 02/01/21, on 02/03/21, and on 02/13/21 after Resident #18's blood glucose levels were 301 mg/dL or above. Interview on 05/06/21 at 8:14 A.M. with Director of Nursing (DON) #1 verified there was no place for nurses to document on Resident #18's January and February 2021 MAR's when the blood glucose levels were to be rechecked if the level was 301 mg/dl or above. DON #1 verified there was no documentation for blood glucose level rechecks as ordered for Resident #1 on 01/16/21, 01/21/21, 01/22/21, on 02/01/21, on 02/03/21, and on 02/13/21. Review of an undated facility policy titled, Insulin Administration, revealed staff should check blood glucose per physician order or facility policy and document the resident's blood glucose result as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365680 If continuation sheet Page 3 of 9 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 365680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Hicksville 601 Defiance Avenue Hicksville, OH 43526 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 observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure fall interventions were in place as care planned and as ordered by a physician. This affected one (#234) of three residents reviewed for accidents. The facility identified four residents with orders for personal alarms. The census was 37. Findings include: Review of Resident #234's medical record revealed an admission date of 04/20/21. Diagnoses included unspecified severe protein malnutrition, chronic atrial fibrillation, chronic kidney disease, anxiety, and major depression. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #234 was cognitively impaired and required an extensive two-plus persons physical assistance for bed mobility and transfers. Review of an admission nursing assessment dated [DATE] revealed Resident #234 had an unsteady gait and poor balance and required staff assistance with bed mobility and transfers. Review of an admission fall risk assessment revealed Resident #234 was assessed at high risk for falls. Review of a fall risk care plan dated 04/30/21 revealed Resident #234 had a potential for falls related to a history of falling and a balance deficit. There was an intervention implemented on 05/04/21 for Resident #234 to have a clip alarm on when up in a chair. Review of a physician order dated 05/04/21 revealed Resident #234 was ordered a clip alarm when in a chair to alert staff of unassisted attempts to transfer. Observation on 05/04/21 at 2:43 P.M. revealed Resident #234 sitting in a wheelchair in the common area near the dining room on the Memory Lane hall. There was no clip alarm noted to Resident #234's body, clothing, or wheelchair. Further observation revealed two staff members sitting at a table in the common area within ten feet of Resident #234. Observation on 05/04/21 at approximately 2:55 P.M. revealed both staff members sitting at the table got up from the area and walked down the Memory Lane hall leaving Resident #234 unattended with no clip alarm on. There were no other staff members in the immediate area and Resident #234 was not visible to other staff members working further down the Memory Lane hall or on other halls of the facility. Observation on 05/04/21 at approximately 3:00 P.M. revealed a stated tested nurses aide (STNA) passing ice and water to residents on the Memory Lane further down the hallway away from Resident #234's location. From where the STNA was located in the hallway Resident #234 could not be seen. Interview on 05/04/21 at 3:02 P.M. with STNA #378 verified Resident #234 should have an alarm on when she was up in her wheelchair, and after walking down the hallway toward Resident #234's location, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365680 If continuation sheet Page 4 of 9 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 365680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Hicksville 601 Defiance Avenue Hicksville, OH 43526 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 STNA #378 verified Resident #234 did not have an alarm on her body, clothing, or wheelchair. Level of Harm - Minimal harm or potential for actual harm Review of an undated policy titled, Managing Falls and Fall Risk, revealed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The staff with input of the attending physician will identify appropriate interventions to reduce the risk of falls. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365680 If continuation sheet Page 5 of 9 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 365680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Hicksville 601 Defiance Avenue Hicksville, OH 43526 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to administer insulin as ordered by a physician. This affected one (#18) of five residents reviewed for unnecessary medications. The facility identified four residents with orders for insulin. The census was 37. Findings include: Review of Resident #18's medical record revealed an admission date 03/17/20. Diagnoses included vascular dementia without behavioral disturbances, anxiety disorder, psychotic disorders, diabetes mellitus type I, cardiac arrhythmia, and essential hypertension. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had severely impaired cognitive skills for daily decision making and received insulin injections seven days during the seven day look back period. Review of a diabetic care plan date 03/17/20 revealed Resident #18 was at risk for hyper/hypoglycemic episodes episodes with and intervention dated 06/29/20 to monitor blood sugars and given insulin per sliding scale as ordered by the physician. Review of a physician order dated 01/10/21 revealed Resident #18 was ordered insulin lispro via sliding scale subcutaneously three times daily scheduled for 8:00 A.M., 12:00 P.M., and 5:00 P.M. Resident #18 sliding scale was ordered for blood glucose levels between zero and 200 milligrams per deciliter (mg/dL) administer four units of insulin; for blood glucose levels between 201 and 300 mg/dL given six units of insulin; and for blood glucose levels 301 and above given eight units of insulin and repeat blood glucose check in two hours and repeat sliding scale if the blood glucose level was above 200 mg/dL. Review of the January 2021 medication administration record (MAR) revealed on 01/11/21 at 12:00 P.M. Resident #18's blood glucose level was 395 mg/dL. Review of Resident #18's vital signs in the electronic health record (EHR) revealed Resident #18's blood glucose level was rechecked on 01/11/21 at 2:09 P.M. and was 315 mg/dL. There was no documentation on the MAR of Resident #18 receiving any additional insulin with a rechecked blood glucose level above 200 mg/dL per the physician order. Review of the February 2021 MAR revealed on 02/13/21 at 8:00 A.M. Resident #18's blood glucose level was 307 mg/dL. Review of Resident #18's vital signs in the EHR revealed Resident #18's blood glucose level was rechecked at 10:00 A.M. and was 316 mg/dL. There was no documentation of additional units of insulin given to Resident #18 at this time. Further review of the February 2021 MAR revealed Resident #18's blood glucose level on 02/14/21 at 12:00 P.M. was 357 mg/dL. Review of Resident #18's vital signs in the EHR revealed Resident #18's blood glucose level was recheck at 1:30 P.M. and was 237 mg/dL. There was no documentation of Resident #18 receiving any additional units of insulin at this time as ordered. Review of the March 2021 MAR revealed on 03/04/21 at 12:00 P.M. Resident #18's blood glucose level was 331 mg/dL. Review of Resident #18's vital signs in the EHR revealed Resident #18's blood glucose level was rechecked at 1:45 P.M. and was 239 mg/dL. There was no documentation of additional units of insulin given to Resident #18 at this time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365680 If continuation sheet Page 6 of 9 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 365680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Hicksville 601 Defiance Avenue Hicksville, OH 43526 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 0755 Level of Harm - Minimal harm or potential for actual harm Review of the nursing progress notes dated between 01/01/21 and 03/31/21 revealed no documentation of Resident #18 receiving any additional units of insulin on 01/11/21, 02/13/21, 02/14/21, or 03/04/21 after Resident #18's initial blood glucose levels were 301 mg/dL or above, and after it was rechecked as ordered, Resident #18's blood glucose level was above 200 mg/dL. Resident #18 experienced no acute changes in condition and required no additional medical interventions during this time frame. Residents Affected - Few Observation on 05/04/21 at 10:58 A.M., 1:23 P.M., and 4:17 P.M., and on 05/05/21 at 8:47 A.M., 11:40 A.M., and 2:03 P.M. revealed Resident #18 was free from any distress or discomfort. Resident #18 was not observed experiencing any outward signs or symptoms of hyperglycemia. Interview on 05/05/21 at 2:29 P.M. with Licensed Practical Nurse (LPN) #490 verified Resident #18's insulin lispro sliding scale order contained instructions if Resident #18's blood glucose level was 301 mg/dL or above the nurse was to recheck her blood glucose level two hours later and if the recheck blood glucose level was 200 mg/dL or above to restart the sliding scale. LPN #490 stated nurse usually documented the blood glucose levels on the MAR's but could also document them in a progress note or in the vital signs tab in the electronic health record. LPN #490 verified there was no documentation on the January, February, or March 2021 MAR's or in nursing progress of Resident #18 receiving any additional insulin as ordered on 01/11/21, 02/13/21, 02/14/21, and 03/04/21 when her initial blood glucose levels were at or above 301 mg/dL and recheck blood glucose levels were above 200 mg/dL. Interview on 05/06/21 at 8:14 A.M. with Director of Nursing (DON) #1 verified there was no place for nurses to document on Resident #18's January, February, or March 2021 MAR's when the blood glucose levels were rechecked, and if the level was above 200 mg/dL, there was no place to document additional insulin doses given. DON #1 verified there was no documentation of additional insulin doses given per the physician ordered sliding scale when Resident #18's rechecked blood glucose levels were above 200 mg/dL on 01/11/21, 02/13/21, 02/14/21, and 03/04/21. Review of an undated facility policy titled, Insulin Administration, revealed the type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's orders. Staff should check blood glucose per physician order or facility policy and document the resident's blood glucose result as ordered and also document the dose of the insulin injection. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365680 If continuation sheet Page 7 of 9 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 365680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Hicksville 601 Defiance Avenue Hicksville, OH 43526 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 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. 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 facility policy review, the facility failed to monitor a residents laboratory levels per the physician orders. This affected one (#20) of five residents reviewed for unnecessary medications. The facility census was 37. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed she was admitted to the facility on [DATE] with diagnoses of psychosis, vascular dementia, hypothyroidism and osteoporosis. Review of Resident #20's current physician orders revealed Levothyroxine Sodium Tablet 100 micrograms (mcg) every morning for hypothyroidism ordered 02/09/21. Additionally, there was a physician order for laboratory testing for thyroid stimulating hormone (TSH) levels annually in April ordered 04/25/21. Further review of the medical record revealed the annual TSH levels ordered to be completed in April every year was not completed by the facility. Interview on 05/05/21 at 10:48 A.M. the Director of Nursing (DON) verified there was no TSH level completed as per the physician order for April, 2021. Review of the undated facility policy titled Medication Monitoring and Management revealed in order to optimize the therapeutic benefit of medication therapy and minimize or prevent adverse consequences the facility and the physician will perform ongoing monitoring for appropriate, effective and safe medication use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365680 If continuation sheet Page 8 of 9 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 365680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Hicksville 601 Defiance Avenue Hicksville, OH 43526 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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on document review, staff interview and facility policy review, the facility failed to have a Quality Assessment and Assurance Committee (QAA) meeting at least quarterly in the last 12 months. This had the potential to affect 37 of 37 facility residents. The facility census was 37. Residents Affected - Many Findings include: Review of the a document titled Class Attendance Record for Quality Assurance and Performance Improvement (QA/QAPI) dated 04/30/21 revealed the facility did hold one QAA meeting in the last 12 months. Interview on 05/05/21 at 11:44 A.M. with Director of Nursing (DON) she stated the facility held QAA meetings over the last year however the the prior Administrator never had anyone sign in. DON verified there were no QAA meeting sign in sheets and no evidence the facility had held the required minimum meetings. Interview on 05/06/21 at 11:54 A.M. with the current Administrator stated she was hired at the facility on 04/15/21. Administrator verified she held a QAA on 04/30/21. Administrator verified she was not able to locate any signature logs for staff who attended QAA/QAPI meetings held in the last year. Review of the facility policy titled Quality Assurance Performance Improvement Plan dated April 2021 revealed the QAA committee meets quarterly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365680 If continuation sheet Page 9 of 9