Inspection·August 22, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Observation on 08/22/19 at 9:19 A.M. revealed the resident was lying in bed awake eating breakfast. Resident #323's urinary catheter bag was observed visible from the hallway into the resident's room. Interview on 08/22/19 at 9:22 A.M. with Registered Nurse (RN) #187 verified Resident #323's catheter bag was visible from the hallway. Per the RN, the facility was to cover the bags for dignity of the residents. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 0569 Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident accounts, staff interview and review of facility policy, the facility failed to notify Medicaid Residents/Representatives, when their account was $200.00 less than the Supplemental Security Income (SSI) limit of $2,250, and the facility failed to return a resident funds to the State after his death. This affected four (Resident #27, #54, #101 and #177) of five residents accounts reviewed. The facility census was 120. Residents Affected - Few Findings include: 1. Review of Resident #27's personal funds account revealed a copy of a letter of notification, dated [DATE], sent to the resident's representative that the residents funds account balance was $4905.00. On [DATE], review of the residents account balance revealed a balance of $5195.93. 2. Review of Resident #54's personal funds account revealed a copy of a letter of notification, dated [DATE], sent to the resident's representative that the residents funds account balance was $2490.93. On [DATE], review of the residents account balance revealed a balance of $3207.61. 3. Review of Resident #101's personal funds account revealed a copy of a letter of notification, dated [DATE], sent to the resident's representative that the residents funds account balance was $5467.10. On [DATE], review of the residents account balance revealed a balance of $4465.84. 4. Review of Resident #177's personal funds account revealed the resident expired on [DATE]. The residents account summary on [DATE] revealed a balance of $1975.08. On [DATE] at 2:22 P.M., during an interview Receptionist #56 revealed she manages the resident accounts and confirmed the resident representatives were not notified when the resident account balances were within $200.00 of the SSI limit for notification, and confirmed Resident #177's funds have not been returned to the State. Review of the facility policy titled Resident Trust, dated [DATE], revealed number seven was regarding monitoring balances: per Omnibus Budget Reconciliation Act (OBRA) regulations, a resident on medical assistance must be notified whenever their funds are within $200.00 of their resource asset limit. The Resident Trust Custodian is responsible for sending a notification letter to the resident/responsible party whenever their funds are within $200.00 of their resource limit. Number nine was regarding deceased residents/closed accounts: in the event of a resident's death while a resident of the facility, any funds remaining, after financial obligation to the facility shall be disbursed within 30 days FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and staff interview, the facility failed to ensure resident's advance directives were accurate. This affected two (#22 and #112) of 32 residents reviewed for advance directives. The facility census was 120. Findings include: 1. Review of Resident #112's medical record revealed an admission date of [DATE]. Medical diagnoses included abnormal levels of serum enzymes, chronic atrial fibrillation, chronic obstructive pulmonary disease, dysphagia, hypertension, and hypothyroidism. Review of the resident's Minimum Data Set (MDS) assessment, dated [DATE], revealed no impairment in cognition. Review of the resident's electronic medical record physician's orders and face sheet revealed no evidence of the resident's code status. Review of the resident's paper chart revealed no physician's orders to clarify the resident's code status. The front of the resident's chart contained a full code form with a blank space for resident/representative signature and the nurse signature. The front of the chart also contained a blank do not resuscitate advance directives form. Interview with Registered Nurse #181 on [DATE] at 11:03 A.M. verified the resident's record did not contain clarification of what the resident's code status was. She stated she would assume the resident was a full code. She verified the full code form and do not resuscitate form were in the front of the chart and blank. She stated they should have been completed on admission. 2. Review of the medical record for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses included weakness, sepsis, atrial fibrillation, muscle weakness, depression, lymphoma and dementia. Review of the comprehensive MDS assessment, dated [DATE], revealed the resident had intact cognition. Review of the care plans, dated 02/2019, revealed the resident had a focus for code status as Do Not Resuscitate Comfort Care (DNRCC). Review of the physician orders for Resident #22 revealed an order dated [DATE] for a DNRCC code status. Further review of the care conference note, dated [DATE] and [DATE], documented the resident as being a Full Code status. Interview on [DATE] at 10:40 A.M. with Licensed Practical Nurse (LPN) #185 revealed the nurse's report for Resident #22 documented as the resident being a 'Full Code'. Per LPN #185, the nurse's would check the report for code status and then the chart if there was an issue with care. LPN #185 then verified there was a DNRCC order, dated [DATE], in Resident #22's paper chart. Review of a facility policy titled Full Code (CPR) Policy, last revised 01/2019, revealed in the case of cardiac and/or pulmonary arrest, the resident's chart is checked to determine code status. Code status is located in the front of the medical record, and a valid do not resuscitate comfort care (DNRCC) or do not resuscitate comfort care arrest (DNRCCA) has a physician signature. If the state (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 0578 of Ohio sheet is not signed in the chart, CPR is initiated immediately and may include all measures to prevent and/or reverse death. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Potential for minimal harm Based on review of personnel files, staff interview and review of a facility policy, the facility failed to implement their abuse policy by ensuring reference checks were completed upon hire. This affected seven of seven newly hired personnel files reviewed. This had the potential to affect all 120 residents residing in the facility. Residents Affected - Many Findings include: Review of the following personnel files revealed no evidence of reference checks completed prior to hire for the following staff members: • The Director of Nursing was hired on 07/29/19 • The Administrator was hired on 03/18/19 • Registered Nurse (RN) #190 was hired on 07/10/19 • Director of Sales #191 was hired on 06/18/19 • Social Services Director #189 was hired on 05/24/19 • State Tested Nursing Aide (STNA) #191 was hired on 07/11/19 • STNA #192 was hired on 08/05/19 Interview with Staff Development Nurse #178 on 08/22/19 at 3:29 P.M. verified the facility did not have reference checks for any of the new employees. She stated the staff person who performed reference checks was no longer employed and the facility was unable to locate any reference checks. Review of a facility policy titled Resident Abuse Policy, revised on 08/2018, revealed persons applying for employment with the facility will be screened for a history of abuse, neglect or mistreating resident to include: references from previous or current employers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 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, record review and resident and staff interview, the facility failed to monitor an open wound on a resident. This affected one (Resident #22) of three residents reviewed for skin conditions. The facility census was 120. Residents Affected - Few Findings include. Review of the medical record for Resident #22 revealed the resident was re-admitted to the facility on [DATE] with an original admission of 10/08/18. Diagnoses included weakness, sepsis, atrial fibrillation, muscle weakness, depression, lymphoma, arthritis and dementia. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/06/19, revealed the resident had intact cognition and was at risk for skin breakdown. Review of the care plans, dated 10/08/18 and revised on 04/25/19, revealed a focus for skin breakdown. One intervention for the focus included monitor left lower leg skin integrity for breakdown. Review of the weekly skin assessments, dated 06/04/19, revealed the resident had intact skin and no open areas to bilateral arms were resolved. Review of the weekly skin assessment, dated 08/02/19, revealed the resident had an open wound to the left lower leg and was documented as being four centimeters (cm.) in length by 1.5 cm. wide by 0.1 cm. depth. with green sloth and odor. No other weekly skin assessment were noted in the record between 06/04/19 and 08/02/19. On 08/21/19 at 2:15 P.M., a weekly assessment was completed by wound team. Per the assessment, the area to the left lower leg was 1.5 cm. by 0.9. cm by 0.9 cm depth. Observation on 08/20/19 at 9:58 A.M. of Resident #22's left lower leg revealed a dressing dated 08/20/19 was in place, no drainage was noted on the dressing and the wound appeared to be healing. Interview on 08/21/19 at 11:00 A.M. with Registered Nurse, (RN), #182 revealed she was the wound nurse and was to be notified of all wounds the residents had. RN #182 stated Resident #22 did have a history of vascular wounds to her legs and was to have a weekly skin assessment completed to ensure no new areas developed. RN #182 stated she was unaware of the left lower leg wound on Resident #22. RN #182 stated she would assess the wound and notify the physician for treatment. RN #22 verified there was no weekly skin assessments for Resident #22 in the chart from 06/04/19 to 08/02/19. Interview on 08/22/19 at 11:03 A.M. with Resident #22 revealed she was aware there was an open wound on her left lower leg. Per Resident #22, she had no pain associated with the wound and stated the nurses were treating the wound by changing the dressing daily. Resident #22 was unable to remember the day the wound started but stated she had told the nurse who started to put a dressing on the wound. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #112's medical record revealed an admission date of 07/24/19. Diagnoses included abnormal levels of serum enzymes, chronic atrial fibrillation and chronic obstructive pulmonary disease. Review of the resident's Minimum Data Set (MDS) assessment, dated 07/31/19, revealed the resident had no impairment in cognition and was always incontinent of urine and bowel. She required extensive assistance of one staff member for bed mobility and dressing. She required extensive assistance with two staff members for transfers. She was at risk for pressure ulcer, with no unhealed pressure ulcers. She had a pressure reducing device for her bed. Residents Affected - Few Review of the resident's care plan, initiated on 07/25/19 and revised on 08/02/19, revealed the resident was at risk for skin breakdown, skin tears, bruising and pressure ulcers due to weakness, fragile skin, decreased mobility and incontinence. Interventions included to apply a protective barrier cream as ordered, assess and record changes in skin status, report pertinent changes to physician, minimize pressure over bony prominence, provide/monitor effectiveness of pressure relieving or reduction device(s) (pressure reduction mattress to bed), treatments per Treatment Administration Record (TAR), and weekly skin assessments by nurse. Review of the resident's admission nursing assessment, dated 07/24/19, revealed the only skin impairment the resident had was a spine abrasion. It measured 5.0 centimeters (cm) in length by 3.0 cm wide. There was no further description of the area. Review of the physician's order, dated 07/25/19, revealed to apply bordered foam daily to mid back spine area until healed for abrasion. This order was discontinued on 08/19/19. Review of the resident's TAR revealed bordered foam daily to mid back spine area was signed off daily as completed. Further review of the physician's orders, dated 08/07/19, revealed to apply skin prep (a liquid that when applied to the skin forms a protective film or barrier) to tips of bilateral great toes due to redness. On 08/09/19, an order was written to apply a foot cradle (a device that attaches to the bed to keep sheets and blankets from touching and rubbing your legs or feet) to the end of the bed. The resident's TAR had multiple blank entries noted for the resident's bed cradle. Continued review of the medical record revealed no further documentation of the resident's skin impairment to the mid back area until 08/06/19. The note indicated redness to area, skin intact. No further description was documented. The next entry for the resident's mid back area was dated 08/19/19 and indicated the physician wanted to discontinue the foam border to the reddened area on her back and a new order was obtained to apply skin prep to reddened area to mid upper back daily. There was no documentation regarding the impairment to the resident's toes. Observation of the resident on 08/19/19 at 10:02 A.M. revealed she had a bed cradle on her bed. The resident's sheet and blanket were under the bed cradle, touching her feet and legs. Observation of care and interview with State Tested Nursing Assistant (STNA) #180 on 08/19/19 at 10:05 A.M. verified the bed cradle was not being used properly. Observation during care also revealed a dressing to the resident's mid back dated 08/13/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 0686 Level of Harm - Actual harm Residents Affected - Few Observation and interview on 08/19/19 at 10:56 A.M. with Registered Nurse (RN) #181 revealed the resident's right great toe was red, but blanchable. She verified there was a large bandage on the resident's back dated 08/13/19. Further observations of the resident on 08/21/19 at 8:35 A.M. and 9:02 A.M. revealed she was in bed with her sheet and blankets resting on her feet and legs. The bed cradle was on the bed but not being used properly. Observation of the resident on 08/21/19 at 10:05 A.M. with Licensed Practical Nurse (LPN) #177 revealed the resident had a large foam dressing on her mid back dated 08/19/19. LPN #177 verified the order for a dressing to the resident's back had been discontinued. She stated the order was changed to skin prep on 08/21/19. The reddened area on the resident's mid-back spine area was measured at 7.0 cm by 1.0 cm and was red and not blanchable per LPN #177. She stated the area was a Stage I pressure area. The resident's right great toe was also observed to be red and not blanchable. It measured 1.0 cm by 1.5 cm with skin starting to flake off the middle portion of the reddened area. LPN #177 stated this area was also a Stage I pressure area. Interview with RN Wound Nurse #182 on 08/21/19 at 12:22 P.M. revealed LPNs were not permitted to stage pressure areas at their facility. She stated she assessed the resident and the area to the resident's back was a Stage I, but the right great toe was red and blanchable per her assessment, and therefore, not a Stage I pressure ulcer. She verified there was no documentation indicating the resident's toes were being monitored and there was no additional documentation on the resident's back impairment. Interview with the Director of Nursing on 08/22/19 at 11:06 A.M. verified there were multiple blank entries on the TAR for the resident's bed cradle. She also verified nurses had signed they were placing a dressing on the resident's back from 08/13/19 through 08/19/19 when it had not been changed since 08/13/19. Review of the facility policy titled Pressure Prevention Policy, revised on 01/05/17, revealed the geriatric population is at risk for skin breakdown. The risk becomes greater with co-morbidities, and during times of acute illness. The facility will ensure the nursing staff are providing preventative practices which help decrease the risk of skin breakdown. Procedures included: assessing skin daily during activities of daily living, weekly skin checks by nursing staff, protect skin against friction and shearing force. Based on observation, medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure staff provided ongoing monitoring of a resident's left heel pressure ulcer and failed to notify the physician when the wound deteriorated/began draining. This resulted in Actual Harm to one resident (#75) when facility staff did not provide ongoing monitoring of Resident #75's left heel pressure ulcer including measuring/staging the wound, did not notify the physician when the wound began to drain and Resident #75's left heel ulcer subsequently deteriorated into an unstageable pressure ulcer (the area could not be staged due to presence of slough and/or eschar). Additionally, the facility failed to ensure preventative measures were in place and treatments were completed as ordered by the physician for a second resident's (#112) pressure ulcer, which placed the resident at risk for potential harm. This affected two (#75 and #112) of six residents reviewed for pressure ulcers. The facility identified 10 residents with pressure ulcers. The facility census was 120. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 0686 Findings include: Level of Harm - Actual harm 1. Review of medical record of Resident #75 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, arthritis, pressure ulcer Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed), muscle weakness, depression, psychotic disorder, anemia and heart disease. Residents Affected - Few Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/12/19, revealed the resident had intact cognition and had unhealed pressure ulcers. Review of the care plan, dated 06/10/19, revealed a focus for skin breakdown related to pressure ulcers. Interventions for the focus included to monitor the skin, treatments per order, notify physician of changes in skin and to complete weekly skin assessments. Review of the physician orders, dated 06/20/19, revealed an order to wash the left heel with normal saline, pat dry, apply Medihoney and calcium alginate. Cover with heel protector then wrap with Kerlix every evening shift for wound care and every 24 hours as needed for wound care. Review of the skin assessment to the resident's left heel, dated 06/26/19, revealed the left heel wound was measured at five centimeters (cm) in length by five cm in width and noted as a pressure wound. This was the first measurement of the resident's wound to her left heel since admission. There was no other description of the wound and no staging of the pressure ulcer. Review of the physician's progress notes, dated 07/16/19, revealed when Resident #75 was admitted to the facility, the resident had bilateral heel wounds, large sacral decubitus ulcer, and myositis of the left gluteal maximus with osteomyelitis to the left iliac bone and sacrum. Foot wounds were noted to be healing after skin grafts applied. Further review of Resident #75's weekly skin assessments revealed there was no documentation on the left heel from 06/26/19 until 08/14/19. On 08/14/19, the left heel was documented as the area continued, treatment was in place and there was moderate amount of drainage from the wound. There were no measurements of the wound, description of the wound and what stage the pressure ulcer was. Interview on 08/20/19 at 8:53 A.M. with Resident #75 revealed she had to go to the hospital when she had a wound on her backside. Resident #75 stated she had wounds on her feet which caused her to lay down more which caused the wound on her coccyx. The resident stated she felt the wounds were improving but was unsure of the wound on her left heel. Resident #75 stated she didn't have any pain associated with the left heel wound. Observation on 08/22/19 at 9:37 A.M. of Resident #75's dressing change, with Registered Nurse (RN) #182 and Physician Assistant (PA) #200, revealed the PA was measuring and ordering treatments for the resident's coccyx wound but not the left heel wound. Interview on 08/22/19 at 10:29 A.M. with PA #200 revealed she does care for all the pressure ulcers for all the residents residing in the facility. The PA stated she was not aware Resident #75 had skin breakdown on her left heel and verified she was not currently caring for Resident #75's heel wound and was unaware if it was a pressure ulcer. Observation and interview with Licensed Practical Nurse (LPN) #183 and LPN #186 on 08/22/19 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 0686 Level of Harm - Actual harm Residents Affected - Few 11:30 A.M. of Resident #75's left heel wound revealed the wound appeared to be an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar). The heel was covered with a heel protector and Kerlix. Upon removal of the dressing, dated 08/21/19, the wound bed was not visible, there was moderate amount of drainage noted on the dressing, and the tissue covering the wound appeared to be necrotic. LPN #186 measured the wound to be 8.5 cm by 7.5 cm. Interview on 08/22/19 at 11:30 A.M. with LPN #186 and LPN #183 revealed the evening shift nurses do all dressing changes not associated with the wound team and the nurses were to document all findings in the weekly skin assessments. Per LPN #186, all wounds appearing to be pressure related were to be reported to the wound nurse, RN #182. Interview on 08/22/19 at 11:35 A.M. with RN #182 verified Resident #75 had an unstageable pressure wound on her left heel. Per RN #182, the LPNs at the facility do not stage pressure ulcers per facility policy. RN #182 stated as the wound nurse she was to be notified of all skin issues once discovered by nurses and aides to be assessed for treatment by the wound team. RN #182 verified the left heel wound was measured on 06/26/19 to be five cm by five cm. The RN verified LPN #186 measured the wound to be increasing in size. RN #182 stated she had not been notified of the wound and had not assessed the wound herself. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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** 2. Medical record review for Resident #54 revealed an admission date of 09/28/15. Diagnoses included Alzheimer's disease, dementia without behavioral disturbance, hypothyroidism, diabetes mellitus type two, chronic kidney disease, hyperlipidemia, cerebral infarction, osteoporosis, unspecified psychosis not due to substance or known physiological, atherosclerotic heart disease, acute gastric ulcer without hemorrhage, osteoarthritis and hypertensive heart disease. Residents Affected - Some Review of the current physician orders revealed the resident was to receive a Synthroid 50 micrograms (mcg.) daily to control hypothyroidism. In addition, there were lab orders which consisted of complete blood count (CBC), complete metabolic panel (CMP) and thyroid stimulating hormones (TSH) and lipid levels to be drawn every six months, September and March. Further review of the medical record found labs which consisted of CBC,CMP, TSH and lipid levels which had been drawn on 08/28/18. The medical record was silent to any labs drawn in March 2019. Interview with the Director of Nursing (DON) on 08/22/19 at 11:30 A.M. verified the labs ordered to be drawn in March 2019 were not done as ordered. 3. Review of Resident #84's medical record revealed an admission date of 06/14/19. Diagnoses included dementia, chronic obstructive pulmonary disease and rheumatoid arthritis. Review of the resident's nursing notes revealed an entry dated 07/13/19 at 3:46 P.M. indicating the resident's urine was dark amber in color with a foul odor. Review of the resident's physician's orders revealed an order dated 07/13/19 for a one time urinalysis with culture and sensitivity. Review of the resident's laboratory results revealed a urinalysis was collected on 07/13/19. The results of the urine culture were completed on 07/17/19 at 2:37 P.M. with evidence of Escherichia coli. The facility did not receive fax results of the culture until 07/20/19 at 4:49 P.M. and did not receive orders to treat the resident's urinary tract infection (UTI) until 07/21/19 at 8:00 A.M. Continued review of the physician's orders revealed an order dated 07/21/19 for Macrobid (antibiotic) twice daily for seven days. Interview with the Director of Nursing (DON) on 08/21/19 at 11:08 A.M. verified there was a delay in treatment for the resident's urinary tract infection (UTI). She verified the results of the urine culture were completed on 07/17/19 and the facility did not receive results until 07/20/19, with no physician's orders to treat the resident until 07/21/19. 4. Review of Resident #112's medical record revealed an admission date of 07/24/19. Diagnoses included chronic obstructive pulmonary disease and hypothyroidism. Review of the resident's Minimum Data Set assessment dated [DATE] revealed no impairment in cognition. Review of the resident's nursing notes revealed an entry dated 08/14/19 at 10:51 A.M. indicating the resident complained of pain with urination and fluids were encouraged. Continued review of the nursing notes revealed an entry dated 08/15/19 at 11:19 A.M. indicating the resident complained of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 Level of Harm - Minimal harm or potential for actual harm burning and pain while urinating. Urine was greenish/yellow in color with foul odor noted and the physician was notified. Review of the resident's physician's orders revealed an order dated 08/15/19 for a one time urinalysis with culture and sensitivity. Residents Affected - Some Review of the resident's laboratory results revealed a urinalysis was collected on 08/15/19. The results of the urine culture were completed on 08/17/19 at 10:46 A.M. with evidence of Escherichia coli. The facility did not receive results of the culture until 08/20/19 at 4:24 P.M. and received orders to treat the resident's UTI on 08/20/19. Interview with the Director of Nursing (DON) on 08/21/19 at 11:08 A.M. verified there was a delay in treatment for the resident's urinary tract infection (UTI). She verified the results of the urine culture were completed on 08/17/19 and the facility did not receive results or orders to treat the UTI until 08/20/19. Review of the facility policy titled Lab Policy, revised 04/2016, revealed each resident will have laboratory services performed as ordered by the attending physician. Procedures included to obtain order from the resident's physician, or on-call physician. Complete requisition for the lab, obtain specimen, notify the physician when results are available. Non-life threatening labs will be reported to the physician via Tiger Text, paging system or during physician visits. Based on record review, review of facility policy and staff interview, the facility failed to ensure laboratory values were obtained per physcian orders and/or the results provided to the facility timely for four (Resident #3, #54, #84 and #112) of five residents reviewed for unnecessary medications. The facility census was 120. Findings include: 1. Review of Resident #3's medical record revealed an admission date of 09/14/17. Diagnoses included coronary artery disease, chronic atrial fibrillation and hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/01/19, revealed Resident #3 was cognitively impaired and indicated the resident received an anticoagulant medication daily. Review of the resident's care plan, dated 09/14/17, revealed the resident was at risk for bleeding related to Coumadin (blood thinning medication). Interventions included to monitor labs as ordered and report abnormal findings to physician. Review of the physician orders for April 2019 and May 2019 revealed Resident #3 received 2.5 milligrams (mg.) of Coumadin daily and was ordered laboratory blood tests, to be done monthly, for Prothrombin Time/International Normalized Ratio (PT/INR) to monitor the effectiveness of Coumadin. Further review of Resident #3's medical record revealed an absence of laboratory results for PT/INR for April 2019 and May 2019. On 08/22/19 at 9:12 A.M., during an interview the Director of Nursing (DON) confirmed Resident #3's ordered lab tests for PT/INR for April 2019 and May 2019 were not completed as ordered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 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 365735 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest-Upper Valley 3232 North County Road 25a Troy, OH 45373 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 a facility policy, the facility failed to ensure pneumococcal vaccinations were offered. This affected one (Resident #92) of five residents reviewed for pneumococcal vaccinations. The facility census was 120. Residents Affected - Few Findings include: Review of Resident #92's medical record revealed she was admitted to the facility on [DATE]. There was no evidence in the medical record the resident was screened for the necessity of a pneumococcal vaccination upon admission or annually thereafter. Interview with the Director of Nursing on 08/20/19 at 3:00 P.M. verified Resident #92 did not have a pneumonia consent completed upon admission or annually thereafter. She verified the facility had no documentation the resident had received a pneumonia vaccine. Review of the facility policy titled Pneumococcal Policy, revised in 04/2019, revealed residents admitted to the facility will be given the opportunity to receive the pneumococcal vaccine per physician order. The nurse will research the medical record and resident history to determine if pneumococcal has been given. After determining that the vaccine has not been given within five years, the nurse will obtain an order for the vaccine from the attending physician, and consent from the resident or responsible party. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365735 If continuation sheet Page 14 of 14