Health inspection·February 16, 2023

F 0558 Level of Harm - Minimal harm or potential for actual harm Observations on 02/15/23 from 7:45 A.M. through 5:15 P.M. of Resident #28 revealed he was lying in bed and was never gotten up out of bed throughout the day. Observations on 02/16/23 from 8:20 A.M. through 4:10 P.M. of Resident #28 revealed he was transferred in and out of bed for an appointment outside the facility via a stretcher. Residents Affected - Few Review of the facility policy titled Scheduling Therapy Services, dated July 2013, revealed the therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 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 366108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of New Carlisle 1885 N Dayton Lakeview Rd New Carlisle, OH 45344 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 0564 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on video observation, review of QSO memos, medical record review, resident family interview, staff interview, and facility policy review, the facility failed to accurately and appropriate express/inform resident representatives of visitation guidelines. This affected one (Resident #209) of three residents reviewed for observations. The census was 65. Findings Include: Observation of video provided by Resident #209 family, recorded date unknown, revealed a three minute and two second video, a nurse supervisor, later identified as Licensed Practical Nurse (LPN) #128, told the family of Resident #209 that they had to follow Center for Medicare and Medicaid (CMS) guidelines when it came to visiting in the facility. The guidelines that she gave were the family had to keep a mask on at all times and not to go in other resident rooms. She did not specify any other visitation guidelines. She told the family that if they did not want to follow these rules, they had to leave. Review of the medical record revealed Resident #209 was admitted to the facility on [DATE]. Diagnoses were periprosthetic fracture around internal prosthetic right knee joint, atherosclerotic heart disease, hypertensive heart disease, anxiety disorder, major depressive disorder, osteoporosis, dementia, hyperlipidemia, Alzheimer's disease, anemia, unspecified hearing loss, muscle weakness, difficulty walking, and osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 12/05/22, revealed Resident #209 had a significant cognitive impairment. Review of Resident #209 physician orders, dated 12/15/22, revealed she was on hospice care. Review of Resident #209 progress notes, dated 12/17/22, revealed Registered Nurse (RN) #132 made Resident #209's family aware that per Centers for Medicare & Medicaid Services (CMS) guidelines, a hospice patient may only have four members in the room and that the family can rotate in and out of that room. Later in the shift, LPN #128 came to the facility, which was recorded by Resident #209 family. The progress note confirmed that LPN #128 explained the CMS guidelines again that only four family members could be in the resident's room. Interview with Administrator on 02/15/23 at 2:46 P.M. confirmed they did not have anu policies or guidelines to limit the number of family members in a resident's room while visiting, especially a resident on hospice care. The only time they would limit is if the resident had a roommate and the roommate stated they had a problem with the number of visitors. But even then, they would work with both residents and the family to find a suitable solution. Interview with LPN #128 on 02/16/23 at 1:57 P.M. confirmed that she tried to tell the family they had to follow CMS guidelines when entering the facility for visitation. She would not confirm whether a specific number of staff were permitted in the room with the resident, only that they were to follow CMS guidelines. Review of facility policy titled Visitation, dated September 2022, revealed the facility permits (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 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 366108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of New Carlisle 1885 N Dayton Lakeview Rd New Carlisle, OH 45344 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 0564 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents to receive visitors subject to the resident's wishes and the protection of the rights of other residents in the facility. Residents are permitted to have visitors of their choosing at the time of their choosing. Family members are designated as such by the resident or representative. Immediate family is not limited to individuals related by blood, adoption, marriage, or common law. Some visitation may be subject to reasonable clinical and safety restrictions that protect the health, safety, security, and/or rights of the facility's. The facility reserves the right to limit the number of visitors in the room at one time to protect the rights of the person sharing the room. A critically ill resident may have visitors of his/her choice at any time, as long as visitation is not medically contraindicated. The rationale for medically-restricted visitation is documented in the resident's medical record. Review of CMS QSO-20-39-NH Revised memo, dated 09/23/22, revealed no specific guidelines or limitations on the number of visitors a resident can have while in the facility. This represents non-compliance related to Complaint Number OH00138660. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 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 366108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of New Carlisle 1885 N Dayton Lakeview Rd New Carlisle, OH 45344 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on record review, interviews, and policy review, the facility failed to ensure the Ombudsmen was notified for hospital discharges. This affected two (#28 and #50) out of three residents reviewed for discharges. The facility census was 65. Findings include: 1. Review of the medical record for Resident #28 revealed an admission date of 03/21/18 with hospitalizations on 08/16/22, 09/17/22, and 12/11/22. Diagnoses included cerebrovascular disease, legal blindness, benign prostatic hyperplasia, hypertensive heart disease without heart failure, polyneuropathy, and history of transient ischemic attack. Review of the Ombudsmen transfer and discharge notification for August, September, and December 2022 revealed Resident #28 was not listed on the discharge list. Interview on 02/16/23 10:53 A.M. with Social Worker #139 confirmed she did not send notices to the Ombudsmen for those residents who planned to return to the facility after hospitalization. 2. Review of the medical record for Resident #50 revealed an admission date of 11/03/22 with a hospitalization on 12/25/22. Diagnoses included sepsis, quadriplegia, major depressive disorder, acute and chronic respiratory failure with hypoxia, and anxiety disorder. Review of the Ombudsmen notification for December 2022 revealed Resident #50 was not listed on the discharge list. Interview on 02/16/23 10:53 A.M. with Social Worker #139 confirmed she did not send notices to the Ombudsmen for those residents who planned to return to the facility after hospitalization. Review of the facility policy titled Transfer or Discharge Documentation, dated December 2016, revealed when a resident was transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information would be communicated to the receiving health care facility or provider. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 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 366108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of New Carlisle 1885 N Dayton Lakeview Rd New Carlisle, OH 45344 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a thorough baseline care plan two (#116 and #121) of 16 resident care plans reviewed. The census was 65. Findings Include: 1. Review of the medical record revealed Resident #116 was admitted to the facility on [DATE]. Diagnoses included low back pain, congestive heart failure, type II diabetes, hypertensive heart disease, dementia without behavioral disturbances, mood disturbances, and anxiety, wheezing, peripheral vascular disease, cerebrovascular disease, muscle weakness, difficulty in walking, acute kidney failure, atherosclerotic heart disease, major depressive disorder, anxiety disorder,a nd hyperlipidemia. Review of admitting medical records, it was identified that her family stated she had suicidal ideations prior to being admitted to the facility. Review of Resident #116's physician orders revealed she was prescribed Seroquel for a mood stabilizer. Review of the baseline care plan revealed no documentation to support care areas related to mental health, the use of a psychotropic, or potential for suicidal ideation. Interview with Registered Nurse (RN) #134 on 02/16/23 at 10:07 A.M. and 11:45 A.M. revealed Resident #116 was ordered Seroquel initially for depression, which contributed to her suicidal ideation. She confirmed this was reported by her family, which occurred prior to being admitted to this facility. She confirmed there was no baseline care plan for suicidal ideations or her use of Seroquel because the facility was under the understanding that Resident #116 mental health was under control. 2. Review of the medical record revealed Resident #121 an admission to the facility on [DATE]. Diagnoses included complete intestinal obstruction, pleural effusion, cirrhosis of liver, type II diabetes, multiple myeloma, shortness of breath, idiopathic hypotension, primary insomnia, hypertensive heart disease, and muscle weakness. Review of Resident #121's orders revealed she was placed on neutropenic precautions on 02/02/23, to reduce the likelihood of a visitor to her room giving her an infection as she was on treatment for cancer. Review of Resident #121 baseline care plan revealed they did not have any care areas related to her being on isolation precautions. Interview with RN #134 on 02/16/23 at 10:07 A.M. and 11:45 A.M. confirmed they did not have a baseline care plan, and did not add to her existing care plan for infections and isolation precautions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 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 366108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of New Carlisle 1885 N Dayton Lakeview Rd New Carlisle, OH 45344 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed follow physician orders regarding the use of oxygen and monitoring oxygen saturation levels. This affected one (Resident #57) of four residents reviewed for respiratory care. The census was 65. Residents Affected - Few Findings Include: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE]. Diagnoses included pneumonia, chronic obstructive pulmonary disease, acute respiratory failure, bacteremia, panobular emphysema, dementia, peripheral vascular disease, anxiety disorder, other chronic pain, and personal history of pulmonary embolism. Review of the Minimum Data Set (MDS) assessment, dated 12/09/22, revealed he was cognitively intact. Review of Resident #57 medical records revealed an order for oxygen four liters via nasal cannula to keep his oxygen saturation (O2) levels above 92% every shift, which was started on 12/11/22. Review of the Medication Administration Record (MAR) dated December 2022, revealed there were no entries into this record to support his O2 saturation levels were completed. Review of Resident #57 vital signs, which included O2 saturation levels, were not recorded on 12/12/22, but it was documented on the MAR that his saturation levels were checked and oxygen was not administered due to O2 saturation levels being appropriate. Review of Resident #57 progress notes, dated 12/13/22, revealed Resident #57 contacted emergency management services (EMS) due to him expressing concerns over being short of breath. EMS arrived and took him to the hospital, where he was admitted for pneumonia. Interview with Registered Nurse (RN) #134 and Licensed Practical Nurse (LPN) #120 on 02/16/23 at 10:37 A.M. confirmed the O2 saturation levels were not documented as being obtained on 12/12/22. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 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 366108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of New Carlisle 1885 N Dayton Lakeview Rd New Carlisle, OH 45344 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on medical record review, staff interview, and facility policy review, the facility failed to to provide non-pharmaceutical interventions prior to administering an as needed medication for one (#212) of five residents reviewed for unnecessary medications. The census was 65. Findings Include: Review of the medical record for Resident #212 revealed an admission date of 01/27/23. Diagnoses included cerebrovascular accident, dementia without behavioral disturbance, cerebral infarction, transient ischemic attack, type two diabetes mellitus, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 02/03/23, revealed Resident #212 had severe cognitive impairment. Review of the care plan dated 02/14/23 revealed Resident #212 had potential risk for altered behavior patterns, disruptive interactions, disruptive verbally, resistive to care, dementia, and anxiety. Interventions included administer prescribed medications, observe for side effects, and monitor for effectiveness. Staff to allow resident to pace where she can be observed. Staff to assess for internal/external contributors. Staff to be careful not to invade resident's personal space. Staff to consult with psych if needed. Staff to document summary of each episode. Staff to keep environment calm/relaxed. Review of the physician order dated 01/26/23 revealed Resident #212 was ordered Haldol tablet 1 mg, give 0.5 tablet by mouth every four hours as needed for agitation, nausea, and vomiting. Review of the physician order dated 01/27/23 revealed Resident #212 was ordered Haldol oral concentrate 2 mg/milliliter (ml), give 0.5 ml by mouth every six hours as needed for agitation, nausea, and vomiting. Review of the physician order dated 01/27/23 revealed Resident #212 was ordered Melatonin three mg, give one tablet by mouth as needed for sleep at bedtime. Review of the physician order dated 01/27/23 revealed Resident #212 was ordered trazadone 50 mg, give a half tablet by mouth every 24 hours as needed for sleep at bedtime, Review of the medication administration record (MAR) dated January 2023 revealed Resident #212 received Haldol 0.5 ml by mouth on 01/30/23. There was no evidence any non-pharmaceutical interventions were tried before administering the as needed medication. Review of the MAR dated February 2023 revealed Resident #212 received Haldol 0.5 ml by mouth on 02/02/23 and 02/13/23. Resident #212 received Haldol 0.5 mg tablet by mouth on 02/06/23. There was no evidence any non-pharmaceutical interventions were tried before administering the as needed medication. Review of the MAR dated 02/06/23 for Resident #212 revealed on 02/06/23 she was given trazadone 50 mg, Melatonin 3 mg, and Haldol 0.5 mg tablet as needed. There was no evidence any non-pharmaceutical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 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 366108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of New Carlisle 1885 N Dayton Lakeview Rd New Carlisle, OH 45344 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 0758 interventions were tried before administering the as needed medication. Level of Harm - Minimal harm or potential for actual harm Interview on 02/06/23 at 3:31 P.M. with Assistant Director of Nursing (ADON) confirmed there was no documentation of previous interventions being tried before the medication was administered. Residents Affected - Some Review of the facility policy titled Antipsychotic Medication Use, dated December 2016, revealed residents would only receive antipsychotic medications when necessary to treat specific conditions which they are indicated and effective. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 9 of 9