Health inspection·September 21, 2023

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 09/18/23 at 10:22 A.M., revealed Resident #19 was sitting in his wheelchair in a common area with his blanket over his head. He was not able to be interviewed due to low cognitive function. His fingernails were noted to be long and unkept. Two nails were seen to be jagged. Observation on 09/21/23 at 8:23 A.M., revealed the resident was in the dining room eating breakfast. The resident's fingernails continued to be long and unkept. 3. Review of Resident #26's medical record revealed an admission date of 02/16/23, with diagnosis including dementia, Alzheimer's, ischemic cardiomyopathy, diabetes mellitus, acute renal failure, and congestive heart failure. Review of Resident #26's quarterly MDS assessment dated [DATE] revealed the resident had a low cognitive function. He required personal assistance from two staff for dressing and personal hygiene. Review of Resident #26's shower and bath schedule revealed he was to receive a shower every Monday and Thursday. Review of Resident #26's most recent care plan revealed he had an ADL self-care performance deficit related to hemiplegia following an old cerebral vascular accident., neuropathy, dementia, weakness, arthritis, anxiety, tremor, health/functional decline. Resident #26 was noted to have bilateral lower extremity contracture's and required an extensive need of one to two staff for personal hygiene. Review of Resident #26's medical record revealed he was to have a bath/shower every Monday and Thursday. Observations on 09/18/23 at 1:08 P.M. revealed Resident #26 was lying in bed. His fingernails were noted to be long and unkept. Further observation of Resident #26 on 09/20/23 at 11:01 A.M., revealed the resident's fingernails continued to be long and jagged. Interview with Resident #26 on 09/18/23 at 9:52 A.M., revealed he would like to have his nails trimmed. Interview with Licensed Practical Nurse (LPN) #305, on 09/20/23 at 1:12 P.M., revealed nails were to be trimmed and filed/checked at each shower twice weekly. If a resident refused nail care, it should be reported to the nurse and the nurse would then attempt. If the resident refused care, it would be documented in the medical record. The nurses were also responsible for diabetic resident's nail care. Interview with State Tested Nursing Aide (STNA) #306, on 09/20/23 at 1:12 P.M., revealed all residents nails were to be trimmed/checked after every shower which would be twice weekly. Interview with LPN #305, on 09/21/23 at 7:59 A.M., verified Residents #4, #19, and #26's nails were long and in need of trimming and nail care should have been completed on their shower day. Review of the policy titled Activities of Daily Living dated September 2018 revealed the facility will provide care and services for the following activities of daily living: hygiene which included bathing, dressing, grooming, oral care, and nail care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility's Hospice Agreement, the facility failed to ensure coordination of care between the facility and Hospice provider. This affected one (#43) of one resident reviewed for Hospice care. The facility identified one resident in the facility was under Hospice care. The facility census was 44. Residents Affected - Few Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/04/23, with diagnoses of dementia, hemiplegia, and hemiparesis. Review of the modified quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and required extensive assistance of two people for bed mobility, dressing, was totally dependent on two people for transfers, and required extensive assistance of one person for eating. Review of a physician order dated 05/26/23 revealed Resident #43 was admitted to hospice. Review of the facility's current care plan for Resident #43 revealed she received Hospice services. Interventions included Hospice aide to provide care and Hospice Registered Nurse to provide care. The care plan provided no guidance regarding the tasks to be completed by Hospice and the tasks to be completed by the facility when providing care to Resident #43. Interview on 09/19/23 at 4:47 P.M., with Unit Manger (UM) #309 revealed a Hospice care plan was not in Resident #43's medical record. Further interview confirmed a Hospice care plan should be in the paper chart for each resident under Hospice care. Interview on 09/21/23 at 12:21 P.M., with UM #309 revealed she called Hospice and a care plan for Resident #43 was faxed to the facility on [DATE]. UM #309 confirmed the care plan began 05/26/23. UM #309 further confirmed the facility's Hospice care plan for Resident #43 provided no guidance regarding the coordination of care between the facility and the Hospice staff. Review of the facility's Hospice agreement, initiated 10/20/14, revealed responsibilities of the facility included coordinating with Hospice in developing a plan of care for each Hospice patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, Certified Nurse Practitioner interview, and review of the policy, the facility failed to ensure behavior interventions of non pharmacological interventions were implemented prior to increasing antipsychotic medication doses. This affected one (#18) of five residents reviewed for psychotropic medications. The facility census was 44. Findings include: Review of the medical record for Resident #18 revealed an admission date of 05/03/19, with diagnoses of schizoaffective disorder and traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition and required supervision with one person assistance for transfers and locomotion. Further review revealed no physical or verbal behaviors towards others or not toward others, no rejection of care. Review of the behavior care plan initiated 05/19/18 revealed Resident #18 had a traumatic brain injury, schizoaffective disorder, impaired decision making, and short term memory loss, and may exhibit episodes of being short tempered, cursing, or giving gestures. Resident #18 had a tendency to overreact to situations and could become agitated and aggressive and not easily redirected by staff. Resident #18 needed supervision with group activity and meals when other residents were around. Interventions included an update 09/12/23 for Resident #18 to avoid group settings. Meals to be provided in room instead of dining room. Resident to not attend group activities with other residents in the facility. Review of a discontinued physician order for Resident #18 revealed an order dated 02/24/22 through 07/25/23 for Risperdal (an antipsychotic medication) 0.5 milligrams (mg) by mouth twice daily. Review of a nursing progress note dated 06/25/23 revealed Resident #18 was in the dining room for the evening meal at a table with another resident (Resident #38) who accidentally spilled his water on the table. The water spilled onto Resident #18 who became upset and threw his own water cup, with water in it, at Resident #38. Resident #18 was sent to the emergency room on [DATE] and returned to the facility the same day with no new orders. The facility initiated a self-reported incident with the State of Ohio on 06/25/23. Review of a nursing progress note dated 07/24/23 revealed Resident #18 was agitated when another resident called him junior. Review of a nursing progress note dated 07/25/23 revealed the behavioral and mental health Nurse Practitioner (NP) (Certified Nurse Practitioner #308) was aware of Resident #18's increased agitation and outbursts. The NP ordered an increase in the Risperdal to 1.0 mg twice daily. Review of the current physician order dated 07/25/23 revealed Resident #18 received Risperdal 1.0 mg by mouth twice daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 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 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/18/23 at 4:36 P.M., with Resident #18 revealed he was not allowed to participate in activities such as bingo and wished he could eat in the dining room. Resident #18 stated he had not recently asked to eat in the dining room or participate in activities. Interview on 09/18/23 at approximately 5:10 P.M., with the Administrator and Director of Nursing (DON) revealed Resident #18 demonstrated behaviors that were disruptive to other residents and therefore was permitted to attend only supervised activities such as bingo. Resident #18 would not be permitted to attend unsupervised activities such as watching a movie. Further interview revealed Resident #18 was offered a choice between eating in his room or eating in the dining room at his own table, and Resident #18 chose to eat in his room. Interview on 09/19/23 at approximately 10:00 A.M., with Unit Manager #309 confirmed behavioral health had not seen Resident #18 since 06/28/23 because the Nurse Practitioner rounded on Monday when Resident #18 was at day-work. Interview on 09/20/23 at 10:09 A.M., with the DON revealed Resident #18 had an outburst in June 2023 and remained angry after that, so the facility began at that time to separate Resident #18 from other residents to keep from triggering his behaviors. The DON stated Resident #18 was disruptive to other residents and used foul language in the facility. The DON stated Resident #18's guardian regularly visited and provided diet Pepsi, but when Resident #18 used foul language and was disruptive, Resident #18's guardian withheld the visits and diet Pepsi. The DON stated Resident #18 would fixate on his desire for diet Pepsi, and when the facility offered an off-brand of soda to Resident #18, he refused because he preferred only diet Pepsi. Further interview revealed staff would occasionally purchase a diet Pepsi with their own money to calm Resident #18 down. However, the DON stated Resident #18 would continue to request more diet Pepsi and was not calmed with only one. The facility did not purchase diet Pepsi for Resident #18. The DON, verified there was no other interventions attempted. Continued interview at that time, with the DON revealed the facility did not speak with Resident #18's guardian to advise her of Resident #18's increased behaviors due to the lack of visits and diet Pepsi. Interview on 09/20/23 at 4:09 P.M., with the Administrator revealed Resident #18 was unable to de-escalate himself once he became upset. The Administrator stated Resident #18 was upset since the interaction in June when Resident #38 accidentally spilled water on Resident #18. Further interview revealed Resident #18's guardian, shortly after that time, began withholding visits, snacks and drinks from Resident #18 which increased his behaviors. The Administrator stated the facility did not consider purchasing Resident #18 diet Pepsi. Telephone interview on 09/21/23 at 12:25 P.M., with Certified Nurse Practitioner (CNP) #308 for the behavioral and mental health company, who provided services to Resident #18 revealed she recalled the conversation from July 2023 regarding the increase in Risperdal for Resident #18. CNP #308 stated she only met Resident #18 once, but as yet had not conducted a face-to-face session with him since she began with the facility in July 2023. CNP #308 stated when she visited in the facility in July and August 2023, Resident #18 was out of the facility at a day-work. CNP #308 recalled the conversation from July 2023 wherein the facility advised her Resident #18 was having behaviors and threw a cup at another resident. Further interview revealed she was aware Resident #18's guardian was not visiting or providing snacks, and was also aware Resident #18 was restricted from activities and the dining room. CNP #308 stated diet Pepsi was not mentioned specifically. CNP #308 restated she was new to the facility in July 2023 and had not had a session with Resident #18 at that time and relied on the facility's perspective at that point. Further interview revealed CNP #308 and the facility staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 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 0758 did not discuss alternative behavioral interventions before doubling the Risperdal dose on 07/25/23. Level of Harm - Minimal harm or potential for actual harm Telephone interview on 09/21/23 at 1:58 P.M., with Resident #18's Case Manager #312 revealed Resident #18 had no negative behaviors or outbursts at workshop. Resident #18 attended workshop three days per week. The facility had given the Resident #18 a 30 day notice to discharge and his guardian was upset as to where Resident #18 would go because she was unable to care for him at home. Case Manager #312 stated Resident #18's guardian, as a result of the 30-day notice, told Resident #18 he had to behave and stopped buying his diet Pepsi. Case Manager #312 stated she arranged for Resident #18 to attend many shows and outings paid for by his guardian. Resident #18 never had any issues with behaviors at these outings. Residents Affected - Few Review of the policy Psychotropic Medications, revised 09/14/23, revealed it is the intent of the policy that a resident's mood, mental status, or behavior may be appropriately managed without antipsychotic drugs through the use of non-drug interventions to manage resident behavior. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the menu spreadsheet, review of recipe, review of resident diet list, the facility failed to ensure pureed protein was prepared following the recipe to ensure adequate protein was provided. This affected one (#19) of one resident identified on a pureed diet. Additionally, the facility failed to ensure appropriate scoop sizes were used to serve protein portions to Resident #19 on a pureed diet, and to 11 (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) residents identified on a mechanical soft diet. The facility census was 44. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 09/02/19. Diagnoses included dementia with psychotic disturbance and hemiplegia and hemiparesis following a cerebral vascular accident. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a low cognitive function. Review of a physician order dated 12/20/21 revealed Resident #19 received a no-added-salt diet with pureed texture and thin liquids. Observation on 09/20/23 at 10:52 A.M., revealed [NAME] #301 preparing the pureed protein using a food processor. Observed inside the food processor was noodles, two veal parmesan patties and marinara sauce. Continued observation revealed [NAME] #301 added an unmeasured amount of hot water at two intervals during the preparation of the puree. Interview on 09/20/23 at approximately 10:54 A.M., with Dietary Manager #307 revealed the food processor contained two veal parmesan patties, one cup of noodles, and eight ounces of marinara sauce. Further interview revealed a double portion was made because the size of the machine made it difficult to make a single portion of puree. Interview on 09/20/23 at approximately 12:40 P.M., with Dietary Manager #307 while reviewing the recipe for pureed veal parmesan, revealed only the veal patty should be pureed and served with a three-ounce scoop. No additional menu items, such as noodles or sauce, should have been included in the protein serving. Further review revealed a nutritive liquid, such as broth or milk, should be used to thin the protein, as needed. Continued interview with Dietary Manager #307 confirmed [NAME] #301 used only water to thin the pureed protein. Review of the recipe for Veal Parmesan, dated 09/25/17, revealed puree instructions: remove desired number of servings and add nutritive liquid, milk, broth, etc. Blend until desired consistency. 2. Review of the menu spreadsheet for the noon meal on 09/20/23 revealed residents on a pureed diet should receive three ounces of pureed veal parmesan. Further review revealed residents on a mechanical soft diet should receive three ounces of ground veal parmesan. Observations beginning on 09/20/23 at 12:00 P.M., revealed [NAME] #301 serving lunch using a green handled scoop to serve the pureed protein and to serve the mechanical soft protein. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 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 0800 Level of Harm - Minimal harm or potential for actual harm Interview on 09/20/23 at approximately 12:15 P.M., with Dietary Manager #307 stated the green handled scoop portions provided three-ounce servings. Review of a facility provided diet list revealed one resident (#19) was on a pureed diet, and 11 (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) residents identified on a mechanical soft diet. Residents Affected - Some Follow up interview on 09/21/23 at 9:32 A.M., with Dietary Manager #307 confirmed the green handle scoops provided only two and two-third (2 2/3) ounce portions and further confirmed residents who received the puree portion of protein and mechanical soft portion of protein did not receive the required amount of protein for the meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 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 366255 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/21/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, staff interview, review of resident diet list, and review of policy, the facility failed to ensure hand hygiene was practiced during the preparation of mechanical soft food. This had the potential to affect 11 residents (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) identified on a mechanical soft diet. The facility census was 44. Findings include: Observations on 09/20/23 beginning at 11:03 A.M., revealed [NAME] #301 wearing gloves and handling tongs to pick up patties of veal parmesan to prepare mechanical soft textured food. Interview at that time with [NAME] #301 stated there were 11 residents on a mechanical soft diet, and she prepared the patties of veal parmesan in batches to not overload the food processor. Continued observation revealed [NAME] #301 placing four patties in the food processor, closing the lid, pressing the start button, pressing the stop button, opening the lid, using a spatula lying on the countertop to push the food lower into the food processor, picking up a carafe of hot water and pouring the water into the food processor, replacing the lid of the food processor, and continuing to process the patties. Continued observation revealed [NAME] #301 retrieved a pan for the final product, stopped the food processor, opened the lid, tapped the stirring arm of the food processor with her right index finger to allow the food to drop back into the machine, then picked up the food processor and spatula and scooped the processed patties into the pan. [NAME] #301 repeated this process two more times, each time tapping the stirring arm of the food processor with her right finger, and also wiping food from the blade with her finger, into the processor before removing the blade. Interview on 09/20/23 at 11:11 A.M., with [NAME] #301 confirmed she touched multiple non-food items and also touched ready-to-eat mechanical soft veal parmesan patties. Review of a facility provided diet list revealed 11 (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) residents identified on a mechanical soft diet. Review of the undated policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices revealed employees must wash their hands during food preparation to prevent cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366255 If continuation sheet Page 9 of 9