Health inspection·December 22, 2025

F 0641 had been inaccurately coded. Level of Harm - Minimal harm or potential for actual harm Review of the antipsychotic, antianxiety, antidepressant, hypnotic, anticoagulant (warfarin, heparin, or low-molecular weight heparin), antibiotic, diuretic, antiplatelet, hypoglycemic, and anticonvulsant medications. Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.20.1 dated October 2025, stated the intent for Section N- Medications, was to record the number of days, during the last seven days, that any type of injection, insulin, and/or select medications were received by the resident. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 2 of 16 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 12/22/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observations, staff and resident interviews, medical record review and review of facility policy, the facility failed to develop a person centered comprehensive assessment for one (#36) out of 18 residents reviewed. The census was 77. Review of the medical record for Resident #36 revealed an admission date of 09/09/25 with medical diagnoses of paraplegia, chronic obstructive pulmonary disease, atherosclerotic heart disease, and anxiety. Review of the medical record for Resident #36 revealed an admission Minimum Data Set (MDS) assessment, dated 09/15/25, which indicated Resident #36 had moderate cognitive impairment and required substantial/maximum staff assistance for bathing, bed mobility, and was dependent upon staff for transfers and toilet hygiene. The MDS indicated Resident #36 did not have any skin breakdown. Review of the medical record for Resident #36 revealed a wound physician note dated, 09/17/25, which indicated Resident #36 had an unstageable pressure ulcer (due to necrosis) to coccyx. Review of the medical record revealed a wound physician note stated 09/24/25 which stated Resident #36 was seen for unstageable pressure ulcer to coccyx and Stage III pressure ulcer to the left heel. Further review of a wound physician note dated 12/17/25 stated Resident #36 continued with Stage IV to coccyx. Review of the medical record for Resident #36 revealed no documentation to support the facility developed a person-centered comprehensive care plan for Resident #36's pressure ulcers to coccyx or left heel. Interview on 12/18/25 at 9:40 A.M. with Director of Nursing (DON) confirmed the facility had not developed person-centered comprehensive care plans for Resident #36's pressure ulcers to coccyx or left heel. Review of the facility policy titled, Care plan, comprehensive person-centered policy, revised March 2022 stated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs were developed and implemented for each resident. The policy stated the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The policy stated participation of the resident and his/her resident representative in development of the resident's care plan was determined to be practicable and explanation was to be documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative process. The policy stated the comprehensive, person-centered care plan would include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 3 of 16 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 12/22/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and facility policy the facility failed to conduct quarterly care conferences to include residents and/or resident representatives as required. This affected two (#2, #3) of two reviewed for care conferences. The facility also failed to timely update a resident care plan after there was a change in the residents comprehensive assessment and status. This affected one (#9), of 18 reviewed for care planning. The facility census was 77.Findings include:Review of medical record for Resident #2 revealed admission date of 04/10/25. The resident was admitted with diagnoses including non-pressure chronic ulcer of left heel, Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease and atherosclerosis. The resident remained at the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. She required set up for eating, maximum assistance bed mobility, transfers and was dependent toileting. Interview on 12/18/25 at 11:12 A.M. with Resident #2 revealed she could not recall having a care conference since her admission to the facility. Interview on 12/18/25 at 11:19 A.M. with Social Services Designee (SSD) #185 verified she had not held a care conference with Resident #2 since her admission to the facility 2. Review of the medical record for Resident #03 revealed an admission date of 06/16/25 with medical diagnoses of anemia, right femur fracture, cerebral infarctions, dementia, and hypertension. Review of the medical record for Resident #03 revealed a quarterly MDS assessment, dated 09/18/25, which indicated Resident #10 had moderate cognitive impairment and required partial/moderate staff assistance for toilet hygiene, transfers, and bathing, and supervision for bed mobility. Review of the medical record for Resident #03 revealed a care conference note, dated 10/01/25, which stated Social Services, Unit Manager, Activity Director and Dietary staff were present. Review of the care conference note did not have any documentation to support Resident #03 or her representative were present at the care conference. Interview with Resident #03 on 12/15/2025 at 1:52 P.M. revealed the resident was not aware of any care conferences. Interview on 12/17/25 at 2:19 P.M. with Social Service #185 confirmed Resident #03's care conference was held on 10/01/25 and that Resident #03 or her representatives were not present for the conference. Social Service #185 stated she called Resident #03 representative on the phone to review what was discussed at the care conference. Social Service #185 confirmed Resident #03's medical record did not have documentation to support Resident #03's representative was called and notified of care conference. 3.Review of the medical record for the Resident # 09 revealed an admission date of 08/31/24. Diagnoses included chronic respiratory failure with hypoxia, pan lobular emphysema, chronic obstructive pulmonary disease , asthma and bi-polar disorder. Resident #09 elected the hospice benefit on 11/05/25 with a diagnosis of end stage chronic obstructive pulmonary disease. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 4 of 16 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 12/22/2025 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #09 was cognitively intact with a Brief Interview of Mental Status Score (BIMS) of 14, indicating the resident was cognitively intact. The resident required cueing and one person for set up for activities of daily living and required a Hoyer lift to get out of bed. Review of the care plan on 12/22/25 dated 07/22/25 revealed no indication the care plan was revised and her updated. It did not include Resident #09 receiving hospice services. Interview with the Minimum Data Systems (MDS) Coordinator on 11/18/25 at 2:34 P.M. confirmed the Hospice service was not part of Resident #09 care plan. Interview with the Director of Nursing (DON) on 12/22/25 at 11:10 A.M. after surveyor intervention Resident #09 Care Plan was updated to include Hospice Services. Review of the facility policy titled, Care plan, comprehensive person-centered policy, revised March 2022 stated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs were developed and implemented for each resident. The policy stated the interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, developed and implemented a comprehensive, person-centered care plan for each resident. The policy stated participation of the resident and his/her resident representative in development of the resident's care plan was determined to be practicable and explanation was to be documented in the resident's medical record. The explanation should include what steps were taken to include the resident or representative process. The policy stated the comprehensive, person-centered care plan would include measurable objectives and timeframes, describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 5 of 16 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 12/22/2025 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 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** Based on review of medical records, staff interviews, and review of facility policies, the facility failed to complete comprehensive wound assessments upon identification of skin breakdown which resulted in actual harm when Resident #36 developed an unstageable pressure ulcer [a pressure ulcer where the ulcer is not stageable due to coverage of the wound bed by slough and or eschar] to the coccyx and a Stage III pressure ulcer (a pressure ulcer where there is full thickness tissue loss, subcutaneous fat may be visible, but bone tendon or muscle is not exposed) to the left heel. Additionally, the facility failed to ensure physician wound treatment orders were followed which resulted in actual harm when the facility did not use the ordered treatment for Resident #02 to dress an existing wound to the foot causing a new Deep Tissue Injury (DTI) [purple or maroon area of discolored intact skin due to damage of underlying soft tissue] to the left dorsal foot. The facility census was 77. Findings include: 1. Review of the medical record for Resident #36 revealed an admission date of 09/09/25 with medical diagnoses of paraplegia, chronic obstructive pulmonary disease, atherosclerotic heart disease, and anxiety. Review of the admission nursing evaluation completed 09/09/25 revealed Resident #36's skin was intact. Residents Affected - Few Review of Resident #36's admission Minimum Data Set (MDS) assessment, dated 09/15/25, indicated Resident #36 had moderate cognitive impairment and required substantial/maximum staff assistance for bathing, bed mobility, and was dependent upon staff for transfers and toilet hygiene. The MDS indicated Resident #36 did not have any skin breakdown. Review of the Braden skin assessment [a clinical tool that assesses a patient's risk of developing pressure injuries], dated 09/12/25, indicated Resident #36 was at high risk for skin breakdown. Review of the shower/skin observation report sheet, dated 09/12/25, revealed Resident #36 had a sore to bottom and a report sheet dated 09/14/25 indicated Resident #36 had skin issues to midline spine, left heel, and buttocks/coccyx area. Further review revealed a shower/skin observation report sheet dated 09/19/25 indicated Resident #36 had skin issues to midline spine and buttocks/coccyx area and a report sheet dated 09/23/25 indicated Resident #36 had skin issues to midline spine, left heel and buttocks/coccyx area. Review of the medical record for Resident #36 revealed no documentation to support the facility completed wound/skin assessments for skin issues noted on the shower/skin observation report sheets dated 09/12/25, 09/14/25, 09/19/25, or 09/23/25. Additionally, review of the medical record for Resident #36 revealed no documentation to support the facility completed weekly skin assessments until 10/21/25. Review of the wound physician note, dated 09/17/25, documented Resident #36 was observed to have an unstageable pressure ulcer (due to necrosis) to coccyx which measured 10 centimeters (cm) by 4 cm by 0.1cm, 100% slough noted, no signs/symptoms of infection and a treatment was ordered. Review of the wound physician note, dated 09/24/25, documented Resident #36 had an unstageable pressure ulcer to coccyx with poor healing potential, 100% slough, moderate serous exudate which measured 7 cm by 2 cm by 0.1cm and the wound was debrided. The note also indicated Resident #36 had a Stage III pressure ulcer to left heel which measured 3 cm by 2 cm by 0.1 cm. Review of the wound physician notes for Resident #36 revealed a note, dated 10/17/25, which indicated the ulcer to the left heel had healed and Resident #36 continued with a Stage IV pressure ulcer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 6 of 16 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 12/22/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few [Full thickness tissue loss with exposed bone tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.] to coccyx which measured 5.5 cm by 1.8 cm by 0.4 cm. Review of the wound physician note, dated 12/17/25, documented Resident #36 continued with a Stage IV pressure ulcer to coccyx which measured 2 cm by 1 cm by 0.7 cm. Review of the medical record for Resident #36 revealed a physician order dated 09/13/25 to cleanse lower lumbar with normal saline or soap and water, pat dry, apply medi-honey, and cover with bordered gauze daily and as needed. Review of a physician order dated 09/16/25 indicated weekly skin assessment to be completed, if a new area was noted, complete the skin risk, notify the physician to obtain treatment orders and notify the resident representative, and document findings in the nursing progress note. Further review revealed physician orders dated 09/18/25 to paint left heel with betadine every shift and to cleanse lower lumbar with normal saline or soap and water, pat dry, apply calcium alginate and cover with bordered gauze daily and as needed. Review of the physician orders dated 09/25/25 revealed an order to cleanse left heel with wound cleanser or normal saline, pat dry, apply calcium alginate as primary dressing, cover with bordered gauze as secondary dressing daily and as needed and an order to cleanse lower lumbar (coccyx region) with normal saline or soap and water, pat dry, apply calcium alginate as primary dressing and cover with bordered gauze as secondary dressing daily and as needed. Review of a physician order dated 09/30/25 documented to cleanse midline spine with normal saline, pat dry, apply medi-honey, and cover with bordered gauze every shift and as needed. Review of the Treatment Administration Records (TAR) for September 2025 indicated weekly skin assessments were signed off as completed on 09/16/25, 09/23/25, and 09/30/25; however, the medical record did not contain documentation to support the weekly skin assessments were completed. Review of the TARs for September, October, November, and December 2025 revealed documentation to support treatments were completed as ordered for lower lumbar, left heel, and midline spine. Interview on 12/18/25 at 9:40 A.M. with Director of Nursing (DON) confirmed Resident #36 did not have any skin breakdown noted upon admission. The DON confirmed the shower/skin observation report sheet dated 09/12/25, indicated Resident #36 had a sore to bottom but the facility had no documentation to support a comprehensive wound evaluation was completed upon identification of skin issue. The DON confirmed Resident #36's wound to lower lumbar/coccyx was initially assessed by the wound physician on 09/17/25 and was determined to be an unstageable pressure ulcer. The DON also confirmed the shower/skin observation report sheet dated 09/14/25 indicated Resident #36 had skin issues to midline spine, left heel, and coccyx. The DON confirmed Resident #36's medical record did not have documentation to support the facility completed comprehensive wound assessments to coccyx, left heel or midline spine. The DON also confirmed the wound to Resident #36's left heel was initially assessed by the wound physician on 09/24/25 and determined to be a Stage III pressure ulcer. The DON stated the medical record for Resident #36 had no documentation to support a comprehensive wound evaluation was ever completed for the skin issue to the midline spine or that the facility completed weekly wound user defined assessments (UDA) in the electronic health record to monitor the progress of Resident #36's wounds. The DON also confirmed Resident #36's medical record had no documentation to support weekly skin assessments were completed until 10/21/25. 2. Review of the medical record for Resident #02 revealed an admission date of 04/10/25. The resident was admitted with diagnoses including non-pressure chronic ulcer of left heel, Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease (PVD) and atherosclerosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 7 of 16 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 12/22/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. She required set up assistance for eating, maximum assistance for bed mobility, transfers and was dependent for toileting. Review of the physician orders for the left heel were to cleanse wound with saline, apply Santyl Collagenase (for debridement) ointment, cover with saline soaked gauze, cover with an abdominal pad, kerlix and secure with light ace wrap compression with a start date of 07/30/25. Record review of the 08/04/25 pressure wound report documented a suspected deep tissue injury to the right dorsal foot, not the left dorsal foot where the wound was located. The wound measured 0.5 centimeters (cm) by (x) 1.0 cm. Printed under the other section documented the pressure wound was related to tight bandage. The initial treatment was to monitor. Record review of the 08/12/25 right dorsal foot pressure wound, not the left dorsal foot pressure wound where the wound was located, documented the deep tissue injury measurement was 1.5 cm x 1.0 cm. Printed in the other section documented exacerbated related to stretch gauze. Review of the physician orders for the left dorsal foot wound was to cleanse wound with sterile saline, to wet puracol (collagen) with sterile saline and apply to wound. Apply Murpirocin (antibiotic) ointment and cover wound. Wrap with Kling as needed with a start date of 08/12/25. A second order was for no stretch gauze, bulky kerlix only with treatments. Do not use small stretch gauze with a start date of 08/12/25. Record review of the 08/19/25 Podiatry appointment assessment documented to continue daily dressing to the top of the left foot. Do not have any sort of wrap directly touching the wound as this is what caused the wound in the first place. Interview on 12/22/25 at 11:20 A.M. with the DON verified the documentation of the Deep Tissue Injury was inaccurate. The wound was on the left foot and not the right foot. She also shared the wound was caused by staff using conforming gauze instead of the ordered ACE wrap (elastic bandage). The DON acknowledged the treatment for the 08/04/25 discovery of the deep tissue injury was to monitor the wound. She explained this would have been done during the daily dressing changes. The DON verified there was no documentation of the wound during dressing changes or otherwise until the next pressure wound assessment on 08/12/25 when it had increased in size. Review of the facility policy, Nursing Care Policy and procedures Pressure Ulcer Risk Assessment and Management revised 01/20/25 revealed it is the policy to assess all residents on admission and regularly thereafter to determine the presence of skin conditions and or areas of skin compromise and to identify potential risk factors for their development. All skin conditions and pressure sores will be treated according to physician orders. Review of the facility policy, Managing Skin Integrity undated revealed nursing in collaboration with the interdisciplinary team, will assess and manage skin integrity for all residents throughout the stay. Risk for pressure ulcer development will be evaluated upon admission and on a routine basis for all residents using the Braden Scale. Risk assessments will be done more often when the resident condition warrants more frequent assessment. Skin inspections will be completed on admission and regularly for all residents. The purpose was documented to maintain the integrity of residents' skin, a significant factor in health. To minimize the risks and prevent the occurrence of skin breakdown. To provide for early detection and intervention of all breakdown evident upon admission to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 8 of 16 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 12/22/2025 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 0686 Level of Harm - Actual harm facility and to promote prompt evaluation and intervention of any changes in skin integrity during the stay. Upon identification of a wound a full wound assessment, including its location, and description of the tissue involved will be completed. Interventions and progress towards outcome focused goals need regular documentation according to established procedures. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 9 of 16 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 12/22/2025 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, staff interview, narcotic count record review, and facility policy review, the facility failed to ensure an accurate narcotic count. This affected one (#17) of five reviewed for medications. The census was 77.Findings include:Review of medical record for Resident #17 revealed admission date of 02/13/24. The resident was admitted with diagnoses including depression, artherosclerosis of the renal artery and fibromyalgia. The resident remained at the facility.Observation and record review on 12/22/25 at 9:51 A.M. with Licensed Practical Nurse (LPN) #145 of the controlled medication narcotic count for Resident #17 revealed the narcotic sheet for Lyrica (pain) 150 milligrams (mg) capsule indicated there were five capsules remaining. Observation of the medication card revealed there were six capsules remaining. Interview with LPN #145 at the time of the observation verified the discrepancy with the medication count. LPN #145 verified she had counted with the unnamed night nurse and both signed the count as correct at the start of her shift.Interview and observation with the DON on 12/22/25 at 9:57 A.M. with the Director of Nursing (DON) confirmed Resident #17's narcotic sheet for Lyrica 150 mg indicated there were five capsules remaining and the medication card for Resident #17's Lyrica 150 mg capsule contained six capsules.Review of the progress note dated 12/22/25 at 10:18 A.M. by the DON documented concerns with the Lyrica count. The unnamed Certified Nurse Practitioner (CNP) was notified of the discrepancy. Resident #17 was interviewed and denied increased pain or discomfort and the unit nurse would monitor for increased pain throughout the shift. The pharmacy was contacted and the count was corrected per their recommendations.Review of the facility policy. Controlled Substances revised 11/22 revealed the nursing staff count controlled medication inventory at the end of each shift using the records of personnel access and usage, medication administration records, declining inventory record and destruction or waste of the medication. Report any discrepancies to the DON. Event ID: Facility ID: 366108 If continuation sheet Page 10 of 16 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 12/22/2025 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 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 pharmacy reconciliation review the facility failed to ensure a medication reduction order was followed in a timely manner. This affected one Resident (#33) of five reviewed for medication reconciliation. The census was 77.Findings include: Review of medical record for Resident #33 revealed admission date of 08/09/22. The resident was admitted with diagnoses including Type Two Diabetes Mellitus, atherosclerotic heart disease, delusional disorders, anxiety and depression. The resident remained at the facility.Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 13 indicating intact cognition. She required set up for eating, moderate assistance with bed mobility and transfers.Record review of the July Monthly Medication review revealed documentation Resident #33 was due for a trial dose reduction of medication per the Centers for Medicaid and Medicare Services (CMS) regulation which included Sertraline (depression) 175 milligrams (mg) daily. The physician agreed and an order was written to decrease the Sertraline to 150 mg daily and it was signed on 07/29/25.Review of the physician orders revealed an order for Sertraline 150 mg daily was started on 08/15/25.Interview on 12/18/25 at 2:33 P.M. with the Director of Nursing verified the 07/29/25 physician order to decrease Sertraline to 150 mg was not started until 08/15/25. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 11 of 16 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 12/22/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observations, staff interviews and manufacturer's instructions, the facility failed to ensure Lantus (long lasting insulin) was dated upon opening to ensure it was used in a timely manner. This affected one Resident (#50) of five reviewed for medication. The facility census was 77. Findings include: Review of medical record for Resident #50 revealed admission date of 06/22/23. The resident was admitted with diagnoses including Diabetes Mellitus, stroke and vascular dementia. The resident remained at the facility.Observation and interview on 12/22/25 at 9:51 A.M. with Licensed Practical Nurse (LPN) #145 revealed the Lantus (long lasting insulin) pen for Resident #50 was undated. LPN #145 verified the line for the date was blank and acknowledged the pen should have been dated upon opening to ensure the medication was used in a timely manner.Review of the Lantus manufacture's instruction on page eight documented the Lantus could be used for four weeks after first dose and after that time the pen should be discarded even if there was insulin left in it. Event ID: Facility ID: 366108 If continuation sheet Page 12 of 16 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 12/22/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews and staff interviews, the facility failed to ensure the medical record contained accurate documentation. This affected three (#36, #08, and #02) residents out of 18 records reviewed. The facility census was 77.Findings include: 1.Review of the medical record for Resident #36 revealed an admission date of 09/09/25 with medical diagnoses of paraplegia, chronic obstructive pulmonary disease, atherosclerotic heart disease, and anxiety. Review of the medical record for Resident #36 revealed an admission Minimum Data Set (MDS) assessment, dated 09/15/25, which indicated Resident #36 had moderate cognitive impairment and required substantial/maximum staff assistance for bathing, bed mobility, and was dependent upon staff for transfers and toilet hygiene. The MDS indicated Resident #36 did not have any skin breakdown. Review of the medical record for Resident #36 revealed skill nursing notes, dated 09/12/25, 09/13/25, 09/14/25, 09/19/25 which stated Resident #36 did not have any skin issues. Review of the medical record revealed the facility did not have documentation to support weekly skin assessments were completed from 09/09/25 until 10/21/25. Review of the medical record for Resident #36 revealed a physician order dated 09/13/25 to cleanse lower lumbar with normal saline or soap and water, pat dry, apply medi-honey, and cover with bordered gauze daily and as needed. Review of the medical record for Resident #36 revealed a shower/skin observation report sheet, dated 09/12/25, which indicated Resident #36 had a sore on bottom and a sheet dated 09/14/25 which Resident #36 had skin issues to midline spine, buttocks, and left heel. Review of a shower sheet dated 09/19/25 indicated Resident #36 had skin issues to midline spine and buttocks. Interview on 12/17/25 at 1:44 P.M. with Director of Nursing (DON) stated that when a resident admitted to the facility under skilled services the nurses would complete a daily skilled note which included observation of skin. DON stated weekly skin observation assessments were not required for skilled residents as the nurses document any skin issues and treatments on the daily skilled note. DON confirmed Resident #36's shower sheets dated 09/12/25, 09/14/25, and 09/19/25 all indicated Resident #36 had skin issues and the skilled nursing documentation on those days did not have documentation to support Resident #36 had any skin breakdown or that skin issues were assessed. DON confirmed Resident #36's medical record did not have any documentation to support an evaluation of wound to coccyx was completed until 09/17/25 or a wound evaluation of Resident #36's left heel was done until 09/24/25. DON confirmed that the medical record for Resident #36 had no documentation to support the facility evaluated skin issue to midline spine. DON confirmed the medical record for Resident #36 did not have any documentation to support the facility completed weekly skin assessments until 10/21/25. Interview on 12/17/25 at 1:53 P.M. with Licensed Practical Nurse (LPN) #170 stated he worked on the skilled halls and confirmed the nursing staff were to complete a daily skilled note for each resident who admit under skilled services. LPN #170 confirmed the skilled note included an area for observation of skin for each resident. LPN #170 stated the staff did not always complete a full body assessment for the residents under the skin observation area of the skilled note. LPN #170 stated he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 13 of 16 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 12/22/2025 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 0842 tried to look at each resident's feet, bottom, under breasts and armpits. Level of Harm - Minimal harm or potential for actual harm 2. Review of the medical record for Resident #08 revealed an admission date of 11/03/22 with medical diagnoses of metabolic encephalopathy, moderate protein-calorie malnutrition, quadriplegia, neuromuscular dysfunction of bladder, and dysuria. Residents Affected - Few Review of the medical record for Resident #08 revealed an annual Minimum Data Set (MDS) assessment, dated 10/08/25, revealed Resident #08 was cognitively intact and was dependent upon staff for all activities of daily living. Review of the MDS revealed Resident #08 had impaired range of motion to bilateral upper extremities. Review of the medical record for Resident #08 revealed a physician note dated 07/23/25. Review of the medical record revealed no documentation to support Resident #08 had been seen by the nurse practitioner or physician after 07/23/25. Interview on 12/28/25 at 12:20 PM with Director of Nursing (DON) stated Resident #08 was seen by either the nurse practitioner or physician on 08/01/25, 08/08/25, 08/13/25, 08/29/25, 09/08/25, 09/10/25, 09/15/25, 09/17/25, 10/20/25, 10/27/25, 11/12/25, and 11/14/25. DON confirmed Resident #08's medical record did not contain the nurse practitioner or physician progress notes for the visits on the above dates. #3 Review of medical record for Resident #02 revealed admission date of 04/10/25. The resident was admitted with diagnoses including non-pressure chronic ulcer of left heel and mid foot, Chronic Obstructive Pulmonary Disease (COPD), Peripheral Vascular Disease PVD) and atherosclerosis. The resident remained at the facility. The quarterly Minimum Data Set (MDS) dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 14 indicating intact cognition. She required set up for eating, maximum assistance bed mobility, transfers and was dependent toileting. Review of the 04/15/25 wound physician evaluation documented an unstageable pressure ulcer of the left heel. Review of the non-pressure wound skin assessment dated [DATE] revealed a diabetic ulcer with surgical debridement of the right heel. Further review of the weekly non pressure wound assessments revealed the left heel was documented as a non-pressure surgical wound until 09/04/25 when a note was added the paperwork noted the wound indicated it was a stage four pressure ulcer. Record review of the 08/04/25 weekly pressure wound assessment documented a deep tissue injury to the right dorsal foot. Continued review revealed documentation had been made through 09/04/25 of a right dorsal foot deep tissue injury. Observation and interview on 12/18/25 of the dressing change by Licensed Practical Nurse (LPN ) #155 and assisted by LPN #160 revealed on open pressure area to the left heel and left dorsal foot. Observation of the right foot revealed no current wound, redness or area of concern. Interview with LPN #155, LPN #160 and Resident #2 confirmed there had been no wounds to the right foot since admission to the facility. Interview on 12/22/25 at 11:20 A.M. with the Director of nursing verified the wound was not on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 14 of 16 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 12/22/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm right heel, but on the left heel. She stated it was also a documentation error the wound was labeled on 06/30/25 as a diabetic ulcer. She also explained after the Deep Tissue Injury was surgically debrided, the wound was inaccurately coded as a surgical wound. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 15 of 16 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 12/22/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on medical record review, observations, staff interview, and review of facility policies, the facility failed to follow infection control procedures during indwelling catheter care. This affected one (#08) resident out of two residents reviewed for infection control procedures. The facility census was 77.Findings include: Review of the medical record for Resident #08 revealed an admission date of 11/03/22 with medical diagnoses of metabolic encephalopathy, quadriplegia, lumbar spinal stenosis, and neuromuscular dysfunction of bladder. Review of the medical record for Resident #08 revealed an annual Minimum Data Set (MDS) assessment, dated 10/08/25, which indicated Resident #08 was cognitively intact and was dependent upon staff for all activities of daily living. The MDS indicated Resident #08 had an indwelling catheter. Review of the medical record for Resident #08 revealed a physician order dated 08/28/25 for Enhanced Barrier Precautions (EBP) for foley catheter every shift and an order dated 10/13/25 for foley catheter care every shift. Observation on 12/18/25 at 1:54 P.M. revealed Certified Nursing Assistant (CNA) #197 prepared a basin of soap and water, a basin of warm water, and gathered wash clothes and towels for catheter care for Resident #08. CNA #197 was observed to explain the procedure to Resident #08. The observation revealed an EBP sign posted on Resident #08's door but no personal protective equipment (PPE) cart located inside or outside of Resident #08's room. CNA #197 was observed to use hand sanitizer to bilateral hands and donned gloves. CNA #197 proceeded to position Resident #08 on his right side while in bed to remove soiled brief. Resident #08 was observed to have had a bowel movement and CNA #197 proceeded to complete incontinence cares. After incontinence cares were completed, CNA #197 was observed to remove her gloves and apply new gloves. CNA #197 applied a new brief and positioned Resident #08 on his back to complete indwelling catheter care. CNA #197 was observed to complete indwelling catheter care without any concerns. CNA #197 was observed to apply skin barrier cream to Resident #08's groin after indwelling catheter care was completed due to slight redness to groin. CNA #197 completed applying the barrier cream and then was observed to pull Resident #08's blankets up to cover his body and assisted Resident #08 to reposition in bed while wearing gloves with barrier cream on the gloves. Interview on 12/18/25 at 2:13 P.M. with CNA #197 confirmed Resident #08 had an EBP sign posted on his door, and she had not donned a gown while providing incontinence or indwelling catheter care. CNA #197 confirmed Resident #08 did not have a PPE cart located inside or outside of his room. CNA #197 confirmed she had not performed hand hygiene after removing gloves after incontinence cares and prior to applying new gloves for indwelling catheter care. CNA #197 also confirmed she assisted Resident #08 with repositioning in bed and pulled up his covers while wearing her gloves that she wore during indwelling catheter care and for application of skin barrier cream. Review of the facility policy titled, Enhanced Barrier Precautions, stated EBP are utilized to prevent the spread of multi-drug resistant organisms (MDRO). The policy stated EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. The policy stated examples of high-contact resident care activities requiring the use of gown and gloves for EBP included providing hygiene, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) and wound care. The policy also stated PPE was to available outside of the resident rooms. Review of the facility policy titled, Handwashing, stated proper handwashing technique was used for prevention of transmission of infectious diseases. The policy stated all personnel working in the facility are required to wash their hands before and after each resident contact, before and after performing any procedure, after sneezing, coughing or blowing nose, after using the toilet, before handling food, and when hands become obviously soiled. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366108 If continuation sheet Page 16 of 16