Inspection·October 3, 2019

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few were notified of the residents varying BP while in therapy. Review of a physical therapy progress note dated 07/09/19 revealed Resident #66 was very lethargic and unable to participate fully with the treatment session. Documentation revealed the resident's nurse was to assess the resident's BP. Review of the nurse progress notes dated 07/04/19 revealed no evidence of nursing assessing Resident #66 or of the physician being notified of the residents varying BP during physical therapy. Review of the nurse progress notes dated 07/05/19, 07/07/19 and 07/08/19 revealed no evidence of physician notification for the low BP readings. Review of the nurse progress notes dated 07/09/19 at 3:17 P.M. revealed the residents BP was 80/50. Resident #66 was assessed with shortness of breath, cough, and increased weakness. Documentation revealed the cardiologist was notified of the residents change of condition and faxed a medication list, vital signs and recent laboratory results. Review of the nurse progress note dated 07/10/19 at 9:59 A.M. revealed new orders for antihypertensive medication adjustments were received from the cardiologist. Review of the nurse progress notes dated 07/11/19 at 5:10 P.M. revealed the resident was noted to have multiple low BP readings and medication changes had little effects. The resident complained of feeling lethargic, decreased appetite, and the inability to participate with therapy services due to symptoms. The physician was notified and a new order was obtained to send the resident to the hospital for evaluation and treatment. Review of hospital documentation dated 07/11/19 at 5:39 P.M. revealed the resident was sent to the local emergency department. Resident #66's vital signs were BP 91/57 mmHg, temperature 98.5 degrees Fahrenheit, respirations 15, and oxygen saturation 97 percent. Clinical impression included generalized weakness, hypotension,acute kidney injury, and transaminitis. Documentation revealed the resident was to be transferred to another hospital were the resident's specialist was located. Telephone interview on 10/03/19 at 8:42 A.M. with the primary care physician for Resident #66 revealed the physician could not recall if the facility called to notify of the low BP assessments. Interview on 10/03/19 at 8:57 A.M. with physical therapy assistant (PTA) #302 revealed the PTA worked with Resident #66 frequently. PTA #302 revealed Resident #66's therapy sessions were often shortened because the resident was lethargic and did not feel well. PTA #302 revealed the resident's BP would often drop during treatment sessions. The PTA reported nursing was made aware when the resident had low BP readings. The PTA had no knowledge if the doctor was made aware of the resident having BP reading concerns during therapy sessions. Interview on 10/03/19 at 9:13 A.M. with licensed practical nurse (LPN) #304 revealed residents who were skilled had their BP assessed every eight hours for the first three days, then every 72 hours while the resident was skilled, and then weekly. BP would be monitored more often if a resident had physician ordered BP medications such as an antihypertensive medication that had parameters with medication administration. LPN #304 revealed a BP reading should be reported to the physician any time the BP dropped below the residents baseline. The LPN revealed per nursing judgment, antihypertensive medication should be held and the doctor notified for further instruction anytime a residents systolic BP falls below 100, unless the resident had physician ordered BP parameters. LPN #304 revealed Resident #66 did not have orders for monitoring the resident's BP prior to the administration of antihypertensive medications. LPN #304 verified antihypertensive medication was administered to Resident #66 on 07/05/19, 07/06/19, 07/07/19, and 07/08/19. The LPN further verified Resident #66's BP was below his baseline on 07/05/19, 07/06/19, 07/07/19, and 07/08/19. LPN #304 verified the residents physician should have been notified of the low BP assessment on 07/05/19 when the residents BP was 92/60. The LPN further verified the physician should have also been notified immediately of the low BP readings on 07/06/19, 07/07/19, and 07/08/19. The LPN confirmed the medical record for Resident #66 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366084 If continuation sheet Page 2 of 5 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 366084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Center of Eaton 1600 Park Avenue Eaton, OH 45320 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 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few contained no evidence of the primary care physician or the cardiologist being notified of the residents low BP readings until 07/09/19, four days after the residents initial low BP reading was obtained. Interview on 10/03/19 at 10:09 A.M. with the cardiologist revealed the facility called the cardiology office on 07/09/19 to inform them Resident #66 was experiencing low BP readings. The cardiologist's nurse returned a call to the facility on [DATE] to have Resident #66 sent to the hospital for evaluation and treatment. The cardiologist revealed after speaking with the facility on 07/10/19 it was decided not to send the resident to the hospital but rather make medication adjustments at the facility. The cardiologist revealed it would be expected that the facility would have notified the cardiologist or the primary care physician immediately of the initial low BP of 82/52 that was assessed on 07/07/19. The cardiologist verified the facility did not notify the cardiologist of Resident #66's low BP readings until 07/09/19. Review of a policy titled, Notification of Change undated, revealed the facility will consult with the resident's physician when there is a significant change in the residents physical, mental, or psychosocial status (that is deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366084 If continuation sheet Page 3 of 5 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 366084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Center of Eaton 1600 Park Avenue Eaton, OH 45320 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, policy review, staff interview, review of center for disease control (CDC) guidance the facility failed to provide pneumonia vaccinations according to current CDC guidelines. This directly affected five Residents (#17, #19, #23, #26 and #117) of five reviewed for immunizations. This had the potential to affect any resident eligible to receive the pneumococcal vaccination series by the physician. The total facility census was 65. Residents Affected - Some Findings include: 1. Review of the medical record revealed Resident #17 was admitted on [DATE] and received the PPSV23 on 10/22/15, prior to admission. 2. Review of the medical record revealed Resident #19 was admitted on [DATE] and had received a Pneumococcal Polysaccharide Vaccine (PPSV)23 vaccination on 08/09/17, prior to admission. 3. Review of the medical record revealed Resident #23 was admitted on [DATE] and had a historical Pneumococcal Conjugate Vaccine (PCV)13 vaccination on 02/20/18, prior to admission. 4. Review of the medical record revealed Resident #26 was admitted on [DATE] and received PPSV23 on 12/01/12, prior to admission. 5. Review of the medical record revealed Resident #117 was admitted on [DATE] and received PPSV23 on 02/22/17, prior to admission. During an interview with Registered Nurse (RN) #300 on 10/03/19 at 11:15 A.M. it was revealed the facility offered PPSV23 only and they have not offered PCV13. RN #300 indicated the facility could not get PCV13 from their pharmacy supplier. During a follow up interview with RN #300 on 10/03/19 at 11:24 A.M. it was confirmed the facility was able to obtain PCV13 from the pharmacy and could administer the vaccination to the facility residents. The RN stated she had spoken to the Director of Nursing (DON) and received clarification. The RN stated the five residents reviewed had either refused the vaccinations or came from the community already vaccinated. The five residents reviewed did not have have refusals documented and because they had one of the vaccinations. The surveyor explained to the nurse there was a sequencing of vaccinations and guidelines included administration of both vaccines to the residents. The nurse verified she had been in her position for two years and in that time the facility had not offered PCV13 to any of the residents. Review of the facility policy titled Pneumococcal Vaccine dated August 2016 revealed all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current CDC recommendations at the time of the vaccination. Review of the CDC guidelines revealed Pneumococcal vaccination schedule revealed: Routine vaccination: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366084 If continuation sheet Page 4 of 5 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 366084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/03/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Center of Eaton 1600 Park Avenue Eaton, OH 45320 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 Age 65 years or older (immunocompetent): Level of Harm - Minimal harm or potential for actual harm One dose PCV13 if previously did not receive PCV13, followed by one dose PPSV23 at least one year after PCV13 and at least five years after last dose PPSV23. Residents Affected - Some When a person previously received PPSV23 but not PCV13 at age [AGE] years or older: give one dose PCV13 at least one year after PPSV23. When both PCV13 and PPSV23 are indicated, administer PCV13 first (PCV13 and PPSV23 should not be administered during same visit) Special situations Age 19 through 64 years with chronic medical conditions (chronic heart [excluding hypertension], lung, or liver disease; diabetes), alcoholism, or cigarette smoking: one dose PPSV23 Age 19 years or older with immunocompromising conditions (congenital or acquired immunodeficiency [including B- and T-lymphocyte deficiency, complement deficiencies, phagocytic disorders, HIV infection], chronic renal failure, nephrotic syndrome, leukemia, lymphoma, Hodgkin disease, generalized malignancy, iatrogenic immunosuppression [e.g., drug or radiation therapy], solid organ transplant, multiple myeloma) or anatomical or functional asplenia (including sickle cell disease and other hemoglobinopathies): one dose PCV13 followed by one dose PPSV23 at least eight weeks later, then another dose PPSV23 at least five years after previous PPSV23; at age [AGE] years or older, administer one dose PPSV23 at least five years after most recent PPSV23 (note: only one dose PPSV23 recommended at age [AGE] years or older) Age 19 years or older with cerebrospinal fluid leak or cochlear implant: one dose PCV13 followed by one dose PPSV23 at least eight weeks later; at age [AGE] years or older, administer another dose PPSV23 at least five years after PPSV23 (note: only one dose PPSV23 recommended at age [AGE] years or older). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366084 If continuation sheet Page 5 of 5