Inspection·April 2, 2025

F 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Based on observation, medical record review and staff interview, the facility failed to ensure residents received meal textures as physician ordered. This affected two (#37 and #38) of three residents reviewed for altered food textures. The facility census was 56. Findings include: 1. Review of the medical record for Resident #37 revealed an admission date of 07/11/24 with a diagnosis of dementia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 02/14/25, revealed Resident #37 had impaired cognition and required set-up or clean-up assistance for eating. Review of a physician order, dated 10/31/24, revealed Resident #37 received a regular diet with mechanical soft textures and ground meats, with regular texture liquids. Also noted in the physician's order was Resident #37 should receive gravy or sauce on all foods, and should receive no skins, seeds, or nuts. Observation on 04/02/25 at 12:10 P.M. revealed Resident #37 seated in the dining room during the noon meal. Resident #37 received ground Salisbury steak, mashed potatoes, and whole peas with diced carrots on his plate. Resident #37 ate his meal without assistance. Observation and interview on 04/02/25 at 12:12 P.M. with Certified Nursing Assistant (CNA) #101 confirmed Resident #37 received peas and was eating them. 2. Review of the medical record for Resident #38 revealed an admission date of 9/19/24 with diagnoses of dementia and dysphagia (difficulty swallowing). Review of the quarterly MDS assessment, dated 02/13/25, revealed Resident #38 was rarely/never understood and required set-up or clean-up assistance for eating. Review of a physician order, dated 11/11/24, revealed Resident #38 received a regular diet with mechanical soft textures and ground meats, with regular texture liquids. Also noted in the physician's order was Resident #38 should receive gravy or sauce on all foods, and should receive no skins, seeds, or nuts. Observation on 04/02/25 at 12:18 P.M., in the dining room, revealed Resident #38 was served a plate (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365680 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 04/02/2025 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)