Health inspection·April 19, 2021

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to ensure residents and resident representatives were provided a copy of the bed hold notice upon discharge when the resident was transferred to the hospital. This affected one resident (#40) of one resident reviewed for hospitalization. The facility identified five residents were transferred/discharged to the hospital since 01/02/21. The census was 45. Findings include: Review of the medical record for Resident #40 revealed the resident was admitted to the facility on [DATE]. Diagnoses included heart disease, diabetes mellitus type II, gastro-esophageal reflux disease, hypertension, chronic kidney disease stage IV, wedge compression fracture of the thoracic vertebrae, intellectual disabilities and history of pulmonary embolus. Review of progress notes for Resident #40 dated 03/14/21 at 5:31 A.M. revealed the resident had an emergent transfer to the hospital for evaluation. An attempt was made to notify family and a message was left for the family to return their call. Review of progress notes dated 03/15/21 at 10:57 A.M. revealed the family was notified of the transfer. There was no documentation of any bed hold policy being provided to the family. Interview with Resident #40 on 04/12/21 at 3:00 P.M. revealed the resident did not receive a copy of the bed hold notice at the time of her transfer to the hospital or at anytime after her transfer to the hospital. Interview with Social Worker #130 on 04/14/21 at 3:30 P.M. verified no bed hold notice was provided to the resident or resident representative upon the resident's transfer to the hospital. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 If continuation sheet Page 2 of 8 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Ctr of Ho 600 Joe E Brown Road Holgate, OH 43527 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 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of a facility policy, the facility failed to ensure side rails were applied to a resident bed to assist with bed mobility. This affected one (#12) of one residents reviewed for activities of daily living (ADLs). The facility identified 15 residents with orders for side rails used to assist with bed mobility. The census was 45. Residents Affected - Few Findings include: Review of Resident #12's medical record revealed an admission date of 02/02/21. Diagnoses included diabetes mellitus type II, encounter for palliative care, personal history of transient ischemic attack, malignant neoplasm of female breast, and cardiomegaly. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 was cognitively intact and was assessed to require extensive two-plus person physical assistance with bed mobility. Review of the Care Area Assessment (CAA) for ADL Functional/Rehabilitation Potential revealed Resident #12 required extensive staff assistance for bed mobility and her goal was to maintain her current level of function with ADLs or have a slow decline. Review of an ADL self care performance deficit care plan, dated 02/15/21, revealed Resident #12 required extensive assistance of one to two staff members for bed mobility and had an intervention for bilateral half side enablers to her bed to improve bed mobility. Review of a physician order dated 02/02/21 revealed Resident #12 was ordered bilateral half side enablers to improve bed mobility. Review of the February, March, and April 2021 treatment administration record (TAR) revealed Resident #12's bilateral half side enablers were documented as in place to her bed every shift during these months. Observation on 04/12/21 at 2:19 P.M., 3:04 P.M., and 3:56 P.M. revealed Resident #12 was laying in bed in her room. Further observation of Resident #12's bed frame revealed no side rails were installed to her bed. Review of Resident #12's census information revealed she was moved to her current room on 04/01/21. Observation on 04/13/21 at 7:27 A.M. revealed Resident #12 laying in bed with no side rails installed on her bed. A subsequent observation was made on 04/13/21 at 10:28 A.M. and revealed Resident #12 was sitting in a chair in her room and her bed continued to have no side rails installed. Interview on 04/13/21 at 10:40 A.M. with Resident #12 stated she was not able to fully turn and reposition herself in bed and required staff assistance with this task. Resident #12 stated she was not aware if she was supposed to have bilateral half side rails on her bed. Interview on 04/13/21 at 2:29 P.M. with Stated Tested Nurse Aide (STNA) #258 stated Resident #12 did assist with some ADLs and stated it was often difficult to turn and reposition Resident #12 in bed due to her inability to fully assist. STNA #258 verified Resident #12 did not have side rails on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 If continuation sheet Page 3 of 8 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Ctr of Ho 600 Joe E Brown Road Holgate, OH 43527 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 0676 her bed to assist with bed mobility. Level of Harm - Minimal harm or potential for actual harm Interview on 04/13/21 at 2:50 P.M. with Maintenance Assistant (MA) #460 stated Resident #12 was getting a different bed because the one she was currently in did not have side rails and Resident #12 needed them. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 If continuation sheet Page 4 of 8 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Ctr of Ho 600 Joe E Brown Road Holgate, OH 43527 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 - 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 facility policy review, the facility failed to complete pressure wound assessments at least once every seven days. This failed practice affected one (#20) of three residents reviewed for pressure wounds. The facility identified four residents with pressure ulcers. The census was 45. Residents Affected - Few Findings include: Review of the medical record for Resident #20 revealed an admission dated of 02/23/21, discharged [DATE] and re-admission date of 03/19/21. Diagnoses include history of hip fracture, chronic kidney disease, diabetes mellitus, hypertension, congestive heart failure and presence of a Stage 2 pressure ulcer at the sacral region which was present upon admission on [DATE]. ,, Review of the pressure wound assessments revealed assessments were completed on 02/23/21, 03/05/21, 03/12/21, 03/19/21, 03/22/21, 04/02/21, and 04/09/21. The weekly assessment was not completed for 11 days from 02/23/21 to 03/05/21 and not completed for eight days from 03/22/21 to 04/02/21. Interview on 04/13/21 at 3:28 P.M. with the wound nurse, Licensed Practical Nurse (LPN) #109, verified a minimum of every seven wound assessments was not completed for Resident #20. Review of the facility policy titled Pressure Ulcer Risk Assessment and Management, revised 10/25/16, revealed all skin conditions and pressure areas will be treated according to physician's orders, monitored on a regular basis and documented according to facility procedures. A facility nurse will be responsible for measurement and treatment evaluation of pressure areas during weekly rounds. The wound care nurse or designee will measure each pressure area weekly. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 If continuation sheet Page 5 of 8 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Ctr of Ho 600 Joe E Brown Road Holgate, OH 43527 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. Based on observation, staff interview, and medical record review, the facility failed to ensure hand positioning devices for contractures were applied as ordered by a physician. This affected one (#19) of two reviewed for positioning and mobility. The facility identified four residents with orders for positioning devices. The census was 45. Findings include: Review of Resident #19's medical record revealed an admission date of 01/01/18. Diagnoses included dementia with Lewy bodies, hypertension, contracture of the left and right hand, and muscle weakness. Review of the Minimum Data Set (MDS) assessment, dated 02/17/21, revealed Resident #19 had severely impaired cognitive skills for daily decision making. Review of a physician order dated 02/02/21 revealed Resident #19 was ordered bilateral hand rolls on when up for the day and off at night with instructions for the wide end of the roll to go toward the thumb. Review of an activities of daily living (ADL) self care performance deficit care plan, dated 01/04/21, revealed Resident #19 required extensive assistance from staff for dressing, using between one and two staff members. An intervention was added on 02/03/21 which revealed Resident #19 had bilateral hand rolls to be applied in the morning and taken off at night. Review of a splint and brace program care plan, dated 02/24/21, revealed Resident #19 was dependent with splint and brace application and removal and had contractures to bilateral hands. An intervention as part of the care plan revealed Resident #19's bilateral hand rolls should be on when he was up for the day and off at night with the wide end of the roll applied toward the thumb. Observation on 04/12/21 at 2:23 P.M. and 3:16 P.M. revealed Resident #19 laying in bed with no hand rolls in place. The resident's fingers on bilateral hands were observed to be flexed over his palms in a fixed position, with the pads of his fingers lying against the palm of his hands. One blue padded hand roll was observed on top of the dresser in Resident #19's bedroom. Observation on 04/13/21 at 7:31 A.M., 8:07 A.M., 9:07 A.M., and 10:25 A.M. revealed Resident #19 was laying in bed with no hand roll placed in either hand. A blue padded hand roll was observed on the over-bed table in Resident #19's bedroom. Observation on 04/13/21 at 11:23 A.M. revealed Resident #19 was sitting in his reclining chair with no hand rolls in place. At 2:32 P.M. Resident #19 was laying back in bed with no hands rolls placed in his hands. The blue padded hand roll remained on the over-bed table. Review of Resident #19's April 2021 treatment administration record (TAR) on 04/13/21 at 2:35 P.M. revealed documentation to indicate Resident #19's hand roll was applied on the day shift on 04/13/21. Interview on 04/13/21 at 2:48 P.M., Registered Nurse (RN) #124 stated Resident #19 was dependent on staff for dressing and verified Resident #19's hand rolls were to be placed on during the day and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 If continuation sheet Page 6 of 8 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Ctr of Ho 600 Joe E Brown Road Holgate, OH 43527 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 taken of at night. RN #124 stated none of the nurse aides informed her Resident #19 refused to wear his hand rolls on 04/13/21. Observation on 04/13/21 at 2:54 P.M. of Resident #19 in his bedroom, with RN #124, revealed Resident #19 was laying in bed with no hand rolls in place, which RN #124 verified. RN #124 located the blue hand roll laying on his over-bed table, but after searching in Resident #19's dresser, closet, bathroom, chair, and bed, a second hand roll was not located. Interview on 04/13/21 at 3:07 P.M. with State Tested Nurse Aide (STNA) #136 and at 3:15 P.M. with STNA #137 both stated they were not told by the off-going nurse aides that Resident #19 refused any of his care on their shift. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 If continuation sheet Page 7 of 8 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest Health Care Ctr of Ho 600 Joe E Brown Road Holgate, OH 43527 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and facility policy review, the facility staff failed to follow their policy to complete hand sanitizing to prevent the spread of infection. This failed practice had the potential to affect 45 of 45 residents residing in the facility. The census was 45. Residents Affected - Many Findings include: Review of the medical record for Resident #147 revealed she was admitted to the facility on [DATE] with diagnoses of dementia, anemia, depression and urinary tract infection. Review of the physician orders dated 03/29/21 revealed Resident #147 was under contact precautions for Proteus Mirabilis/Morganella Morganii (an infection causing bacteria) in the urine. Observation on 04/12/21 at 12:02 P.M. revealed State Tested Nurse Aid (STNA) #112 was passing lunch trays on the 200-Hall. STNA #112 left one resident room and without sanitizer her hands. She went to the tray cart, obtained a meal tray and entered the isolation room of Resident #147. STNA #112 could be heard asking Resident #147 if she wanted tarter sauce. STNA #112 then exited the isolation room without hand sanitizing, walked down the hall toward the kitchen and returned to the isolation room with tarter sauce. STNA #112 did not sanitizer her hands prior to reentering the room. Interview with STNA #112 on 04/12/21 at 12:06 P.M. she stated she was not aware Resident #147 was in isolation. STNA #112 verified there was a Contact Precautions isolation sign on the wall beside the door and there was a supply of personal protective equipment on the door. STNA #112 verified she did not apply hand sanitizer prior to entering the room, after exiting the room, or upon re-entering the room. Observation of the signage beside the room door revealed Contact Precautions with instructions to clean hands when entering and exiting the room. Interview on 04/12/21 at 12:11 P.M. with Registered Nurse (RN) #124 verified Resident #147 was on contact precautions for bacteria in her urine. Review of the undated facility policy titled Procedure for Handwashing revealed when to wash hands included before and after resident contact. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 If continuation sheet Page 8 of 8