Health inspection·September 28, 2023

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, observation, staff interviews, and facility policy review, the facility failed to ensure a resident had access to hearing devices and failed to investigate missing hearing aids. This affected one (Resident #23) of one resident reviewed for hearing aids. The facility census was 75. Residents Affected - Few Findings include: Review of the medical record revealed Resident #23 admitted to the facility on [DATE] with diagnoses including hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus, acute kidney failure, essential hypertension, chronic kidney stage 4, major depressive disorder, atrial fibrillation, presence of cardiac pacemaker, and anemia. Review of the most recent Minimum Data Set (MDS) revealed Resident #23 utilized hearing aids. Review of physician's orders revealed an order dated 08/22/23 to put left hearing aid in and collect hearing aid every shift. Review of the care plan initiated on 08/19/23 revealed Resident #23 had altered communication or impaired verbal communication related to hearing deficit, with intervention of ensure hearing aids are put in every morning and collected at bedtime. Review of the progress note dated 09/03/23 at 8:36 A.M. revealed Resident #23 was noted to be without her hearing aid. Staff looked through the room and was unable to find it. Laundry was notified of missing hearing aid and will be looking for it. Review of the progress note dated 09/03/23 at 11:40 A.M. revealed administration was notified of missing hearing aid. Review of the progress noted dated 09/03/23 1:40 P.M. revealed Resident #23's power of attorney was notified of the missing hearing aid. Staff would continue to search for the hearing aid and the resident continued to state she did not know where it could be. Further review of the medical record revealed no additional documentation pertaining to the missing hearing aid. Observation on 09/26/23 at 2:24 P.M. revealed Resident #23 seated in a recliner chair with hearing aids not in place. Staff interview on 09/26/23 at 2:26 P.M. with Registered Nurse (RN) #316 revealed Resident #23's hearing aids are missing. The treatment cart was checked and hearing aids were not in the cart. Staff interview on 09/26/23 at 3:44 P.M. with the Director of Nursing (DON) revealed when an item is missing, it is reported to the social worker and she passes it along to the Administrator. Lost or broken items are investigated and if it is staff's fault, the item is fixed or replaced, if it resident breaks the item or loses it, the family is notified, and it is the family's discretion on whether they want to replace or fix it. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366189 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 366189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Delphos 1425 East Fifth Street Delphos, OH 45833 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 0685 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Staff interview on 09/27/23 at 2:19 P.M. with the Administrator and Social Services #342 revealed they were not aware of the missing hearing aid until 09/26/23, when Resident #23's son called the Administrator to say the hearing aids were missing. The Administrator acknowledged they did not follow up on the missing hearing aids when reported. Review of the undated Personal Property Policy revealed the facility promptly investigates any complaints of misappropriation or mistreatment of resident property. If it is found that the facility has lost or damaged a resident's personal property, the item will be replaced by the facility. Event ID: Facility ID: 366189 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 366189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Delphos 1425 East Fifth Street Delphos, OH 45833 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews, and policy review, the facility failed to provide restorative programs per therapy recommendations. This affected one (Resident #66) of two residents reviewed for positioning and range of motion. The facility census was 75. Findings include: Review of the medical record for Resident #66 revealed an admission date of 07/11/23 with medical diagnoses of acute cystitis, atherosclerosis heart disease (ASHD), chronic kidney disease stage III, and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #66 was cognitively intact and required extensive staff assistance with bed mobility, transfers, toileting, and bathing. Resident #66 received physical therapy (PT) and occupational therapy (OT) services. Review of the OT evaluation and treatment plan dated 07/19/23 revealed Resident #66's sitting balance was fair and Resident #66 required maximum assistance for functional mobility during activities of daily living (ADLs) and required 25% verbal cues for safety and proper positioning. Continued review of OT progress notes revealed a note dated 07/21/23 which stated OT was working on techniques to increase safety for ADLs in sitting, wheelchair seating, and positioning during ADLs. Review of an OT discharge summary note dated 08/04/23 stated therapy services were discontinued because Resident #66's insurance provider denied further coverage of therapy services. The OT discharge summary note stated therapy recommended restorative nursing/functional maintenance programs to facilitate Resident #66' ability to maintain current level of performance and prevent decline. The note stated OT recommended range of motion (ROM) and ambulation restorative programs. Review of the form titled, VanCrest Health Care Center Department of Rehabilitation Therapy Referral to Nursing, dated 08/04/23, revealed therapy recommended Resident #66 receive restorative ROM and positioning programs six to seven days per week. The form stated the programs were to include wheelchair, walker, and positioning in sitting. The form stated Resident #66 refused wedge cushion, lateral support, half lap tray, and tilt chair to assist with positioning. The form also stated to monitor seated position and fix as needed and to perform active ROM in sitting. Further review of the medical record for Resident #66 revealed no documentation to support Resident #66 participated in restorative ROM or positioning programs. Observation and interview on 09/26/23 at 8:26 A.M. revealed Resident #66 sitting in his wheelchair leaning to the right side with right side of his abdomen bent over the side of the right handle of the wheelchair and his right arm hanging over the handle with his hand touching the floor. Interview with Resident #66 stated he always leaned to the right side of his wheelchair, but the lean has worsened since he was no longer receiving therapy services. Observation on 09/26/23 at 2:27 P.M. of Resident #66 sitting in his wheelchair with right side of abdomen leaning into right wheelchair handle and right arm handing over the handle with his hand touching the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366189 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 366189 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Delphos 1425 East Fifth Street Delphos, OH 45833 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 0688 Level of Harm - Minimal harm or potential for actual harm Interview on 09/26/23 at 2:27 P.M. with State Tested Nursing Assistant (STNA) #371 confirmed Resident #66 was leaning over the right side of his wheelchair with the right side of his abdomen pressing into the handle and right arm hanging over the handle with his hand touching the floor. STNA #371 stated the facility had tried positioning devices to assist Resident #66 with proper positioning in his wheelchair but Resident #66 refused to use the devices. Residents Affected - Few Interview on 09/27/23 at 8:54 A.M. with Occupation Therapist (OT) #328 stated Resident #66's ability to maintain upright posture had declined since the resident was on therapy services. OT #328 stated Resident #66 was discharged from therapy services on 08/04/23. OT #328 stated when restorative programs are recommended upon discharge from therapy services, the therapist would write the programs and provide them to nursing staff. Interview on 09/27/23 at 3:45 P.M. with Licensed Practical Nurse (LPN) #343 confirmed the therapy department provided recommendations for restorative programs for Resident #66 on 08/04/23. LPN #343 stated staff assisted Resident #66 with positioning in wheelchair daily but confirmed the facility did not have documentation to support staff completed the restorative programs for positioning and ROM as recommended by the therapy department. Review of Restorative Program policy stated rehabilitation goals and objectives are developed for each resident and outlined in his/her plan of care relative to therapy services and staff are to assist the resident in adjusting to his/her abilities and encouraging the resident to maintain his/her independent and self-esteem. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366189 If continuation sheet Page 5 of 5