Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0635
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
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, hospital paperwork review, staff interview, and resident interview, the facility failed to
obtain admission physician orders for the treatment of a surgical wound present on admission. This affected
one (#97) of one residents reviewed for admission. The facility census was 47.
Residents Affected - Few
Findings include:
Review of the medical record of Resident #97 revealed an admission date of 11/17/23. Diagnoses include
non-ST elevation myocardial infarction, atherosclerosis of autologous artery coronary artery bypass graft
with angina pectoris with documented spasm and combined systolic (congestive) and diastolic (congestive)
heart failure.
Review of the hospital discharge paperwork dated 11/15/23 revealed Resident #97 was status post left
heart catheterization. A second document titled Cardiac Cath Discharge Instructions undated revealed you
can shower after 24 hours, remove the dressing in the shower.
Review of the Nursing admission assessment dated [DATE] revealed Resident #97 was cognitively intact.
Review of the progress note dated 11/17/23 at 6:32 P.M., revealed the presence of a pressure dressing to
the left groin. A note, written by Registered Nurse (RN) #211, revealed a note stating, Will follow-up on
orders when to be removed.
Interview on 11/20/23 at 9:02 A.M., with Resident #97 revealed the resident was curious as to why the
dressing was still on his groin after his heart catheterization. Resident #97 stated he was reluctant to allow
the surveyor to view the dressing.
Interview on 11/20/23 at 2:19 P.M., with Director of Nursing (DON) provided verification related to the
progress note dated 11/17/23 at 6:32 P.M., which revealed Resident #97 had a pressure dressing to the left
groin upon admission. The note indicated a follow-up of when to remove the dressing will occur. She further
verified no additional notes or physician orders were documented related to the pressure dressing at the
left groin.
Review of the progress note dated 11/20/23 at 3:03 P.M., revealed the DON received clarification orders for
the left groin pressure dressing. Resident #97 had a cardiac catheterization completed on 11/15/23 and
according to the Cardiac Cath Discharge instructions from the Catheterization Laboratory the dressing
could have been removed 24 hours post procedure.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
365232
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
365232
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of St Mary's
1035 Hager Street
St Marys, OH 45885
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 0635
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Review of a progress note dated 11/20/23 at 8:26 P.M., revealed the pressure dressing was removed from
the left groin and no signs or symptoms of infection was noted. No drainage was noted at the time and
Resident #97 tolerated the procedure well.
Interview on 11/21/23 at 11:00 A.M., with the DON verified the dressing was not removed at the hospital
and the facility had no orders to address the wound. The DON also verified once clarification orders were
obtained the facility did not remove the dressing until five hours later.
Event ID:
Facility ID:
365232
If continuation sheet
Page 2 of 7
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
365232
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of St Mary's
1035 Hager Street
St Marys, OH 45885
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 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review and staff interview, the facility failed to accurately assess residents' medications for quarterly
Minimum Data Set (MDS) assessments. This affected two (#23 and #36) of 16 residents reviewed for
accurate assessments. The current census is 47.
Residents Affected - Few
Findings include:
1. Record review for Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses
for Resident #23 included: fracture of femur, aftercare post-surgery, muscle weakness, chronic obstructive
pulmonary disease, and anxiety.
Review of the quarterly MDS assessment dated [DATE] revealed the resident had intact cognition. Per the
assessment the resident was assessed as having received an antipsychotic medication on a routine basis
with no gradual dose reduction attempted.
Review of Resident #23's care plans dated 08/08/23 revealed no focus for antipsychotic medication noted
in the care plans.
Review of Resident #23's prescribed medications dating from August 2023 to September 2023 revealed the
resident had not received any anti-psychotic medications.
Interview on 11/21/23 at 2:45 P.M., with MDS Licensed Practical Nurse (LPN) #310 verified when she
completed the assessment, she coded the resident for antipsychotic use on routine basis even though the
resident had not received an antipsychotic during the review period.
2. Record review of Resident #36 revealed the resident was admitted to the facility on [DATE]. Diagnoses
for Resident #26 included: depression, subarachnoid hemorrhage, hypertension, aphasia, lupus, and
anxiety.
Review of the quarterly MDS assessment dated [DATE] revealed the resident had been coded for receiving
an antipsychotic medication on a routine bases and a gradual dose reduction was attempted.
Review of Resident #23's care plans dated 06/12/23 revealed no focus for antipsychotic medication noted
in the care plans.
Review of Resident #23's prescribed medications dating from September 2023 to October 2023 revealed
the resident had not received any anti-psychotic medications.
Review of Resident #23's Medication Administration Record (MAR) dated October 2023 revealed the
resident had not been prescribed or received any antipsychotic medications.
Interview on 11/21/23 at 2:45 P.M., with the MDS LPN #310 verified when she completed the assessment,
she coded the resident for antipsychotic use on routine basis even though the resident had not received an
antipsychotic during the review period.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365232
If continuation sheet
Page 3 of 7
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
365232
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of St Mary's
1035 Hager Street
St Marys, OH 45885
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
medical record review, hospital paperwork review, staff interview, resident interview, and policy review, the
facility failed to assess a surgical wound and obtain physician orders for the treatment of a surgical wound.
This affected one (#97) of one residents reviewed for admission. The facility census was 47.
Residents Affected - Few
Findings include:
Review of the medical record of Resident #97 revealed an admission date of 11/17/23. Diagnoses include
non-ST elevation myocardial infarction, atherosclerosis of autologous artery coronary artery bypass graft
with angina pectoris with documented spasm and combined systolic (congestive) and diastolic (congestive)
heart failure.
Review of the hospital discharge paperwork dated 11/15/23 revealed Resident #97 was status post left
heart catheterization. A second document titled Cardiac Cath Discharge Instructions undated revealed you
can shower after 24 hours, remove the dressing in the shower.
Review of the Nursing admission assessment dated [DATE] revealed Resident #97 was cognitively intact.
Review of the progress note dated 11/17/23 at 6:32 P.M., revealed the presence of a pressure dressing to
the left groin. A note, written by Registered Nurse (RN) #211, revealed a note stating, Will follow-up on
orders when to be removed.
Interview on 11/20/23 at 9:02 A.M., with Resident #97 revealed the resident was curious as to why the
dressing was still on his groin after his heart catheterization. Resident #97 stated he was reluctant to allow
the surveyor to view the dressing.
Interview on 11/20/23 at 2:19 P.M., with Director of Nursing (DON) provided verification related to the
progress note dated 11/17/23 at 6:32 P.M., which revealed Resident #97 had a pressure dressing to the left
groin upon admission. The note indicated a follow-up of when to remove the dressing will occur. She further
verified no additional notes or physician orders were documented related to the pressure dressing at the
left groin.
Review of the progress note dated 11/20/23 at 3:03 P.M., revealed the DON received clarification orders for
the left groin pressure dressing. Resident #97 had a cardiac catheterization completed on 11/15/23 and
according to the Cardiac Cath Discharge instructions from the Catheterization Laboratory the dressing
could have been removed 24 hours post procedure.
Review of a progress note dated 11/20/23 at 8:26 P.M., revealed the pressure dressing was removed from
the left groin and no signs or symptoms of infection was noted. No drainage was noted at the time and
Resident #97 tolerated the procedure well.
Interview on 11/21/23 at 11:00 A.M., with the DON verified the dressing was not removed at the hospital
and the facility had no orders to address the wound. The DON also verified once clarification orders were
obtained the facility did not remove the dressing until five hours later.
Interview on 11/21/23 at 11:15 A.M. with Administrator, with review of the facility policy titled
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365232
If continuation sheet
Page 4 of 7
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
365232
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of St Mary's
1035 Hager Street
St Marys, OH 45885
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
admission Assessment and Follow-Up: Role of the Nurse revealed the skin should be assessed and the
expectation would be to remove any dressings, unless a specific order not to, to completely assess the
skin.
Review of the policy titled admission Assessment and Follow Up: Role of the Nurse dated September 2012
revealed the purpose of the procedure was to gather information about the resident's physical condition
upon admission for the purpose of managing the resident. One step included to conduct a physical
assessment to include the skin.
Event ID:
Facility ID:
365232
If continuation sheet
Page 5 of 7
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
365232
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of St Mary's
1035 Hager Street
St Marys, OH 45885
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 0760
Ensure that residents are free from significant medication errors.
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 review of the policy, the facility failed to ensure a
resident was free from significant medication error. This affected one (#97) of two residents reviewed for
insulin administration. The facility census was 47.
Residents Affected - Few
Findings include:
Review of the medical record of Resident #97 revealed an admission date of 11/17/23. Diagnosis includes
diabetes mellitus type one without complications.
Review of the Nursing admission assessment dated [DATE] revealed Resident #97 was cognitively intact.
Review of the physician order dated 11/21/23 revealed an order for Lispro insulin to be administered seven
units and per sliding scale with meals. An added instruction read Resident may self-regulate insulin sliding
scale.
Review of the medication administration record (MAR) and insulin administration records for November
2023 revealed the Lispro insulin ordered for 11/21/23 at 5:00 P.M., was not documented as having been
administered.
Interview on 11/22/23 at 8:03 A.M., with Director of Nursing (DON) while reviewing the MAR for Resident
#97 provided verification the 5:00 P.M. dose of Lispro insulin was not documented as having been
administered on 11/21/23 at 5:00 P.M.
Telephone interview on 11/22/23 at 8:10 A.M., along with DON, with Licensed Practical Nurse (LPN) #218
provided verification the Lispro insulin was not administered on 11/21/23 at 5:00 P.M.
Observation on 11/22/23 at 8:15 A.M., with LPN #219 revealed LPN #219 was observed to place a needle
onto the Lispro inulin pen and dialed the knob to 3 (three) and did not prime the needle. LPN #219
administered the insulin to Resident #97. LPN #219 had failed to prime the inulin pen.
Interview on 11/22/23 at 8:20 A.M., with LPN #219 provided verification she had not primed the insulin pen
prior to administering the 3 (three) units of Lispro insulin to Resident #97.
Review of the undated policy titled Insulin Administration Level III revealed a new pen needle will be
attached and primed to remove air bubbles. It must be primed before each injection. Turn the dosage knob
to the 2 (two) unit indicator with the pen pointing upward, push the knob all the way to release the air. One
drop of insulin should appear, repeat the step as needed until you see a drop of insulin to ensure all of the
air is out.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365232
If continuation sheet
Page 6 of 7
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
365232
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/22/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of St Mary's
1035 Hager Street
St Marys, OH 45885
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 observation, staff interview, and review of policy, the facility failed to maintain hand hygiene while
delivering meal trays on the 200 hall. This had the potential to affect 12 (#24, #35, #37, #95, #96, #97, #98,
#99, #100, #101, #102, and #103) of 12 residents residing in the 200 hall. The facility census was 47.
Residents Affected - Some
Findings include:
Observation, on 11/20/23 beginning at 11:20 A.M., during the lunchroom tray delivery on the 200 hall,
revealed the Director of Nursing (DON) was observed to enter the room of Resident #98 and touch the
resident's glasses and cell phone. DON placed the tray onto the over bed table and proceeded out of the
room and began reaching for another resident tray. Interview at this time with the DON, verified she had
reached for another resident's tray and stated, I should have washed my hands after touching the personal
items.
Observation 11/20/23 at 11:40 A.M., revealed a State Tested Nursing Assistant (STNA) #257 was observed
to assist a therapist with repositioning Resident #100. STNA #257 exited the room and began reaching for
a resident tray from the insulated cart. Interview at the time of the observation, with STNA #257 verified she
was proceeding to grab a resident food tray and stated I did not wash my hands after repositioning him.
Review of the policy titled Handwashing/Hand Hygiene dated August 2015, revealed an alcohol-based
hand rub containing at least 62% alcohol, or alternatively soap and water should be used before and after
direct contact with residents and assisting residents with meals.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365232
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F635 - Admission orders
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the November 22, 2023 survey of VANCREST OF ST MARY'S?
This was a inspection survey of VANCREST OF ST MARY'S on November 22, 2023. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VANCREST OF ST MARY'S on November 22, 2023?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide doctor's orders for the resident's immediate care at the time the resident was admitted."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.