Inspection visit
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 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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview and policy review, the facility failed to ensure residents had accurate
comprehensive, person centered and individualized care plans that reflected the residents' current orders,
diagnoses and treatment decisions. This affected two (#5, #23) of two residents reviewed for care planning.
The facility census was 45.Based on medical record review, staff interview and policy review, the facility
failed to ensure residents had accurate comprehensive, person centered and individualized care plans. This
affected two (#5 and #23) of two residents reviewed for care planning. The facility census was 45.
Findings include:
1. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses
included aphasia (inability to talk) following intracranial hemorrhage (brain bleed), cerebral infarction
(stroke), Sjogren syndrome (autoimmune disease where the body attacks moisture producing glands such
as tear glands), depression, dementia, quadriplegia (decreased or lack of ability to move legs and arms),
seizures, bipolar disorder, and anxiety.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had
impaired cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of nine. Further review
of the MDS revealed diagnoses of dementia, anxiety, depression, and bipolar disorder. The resident was
receiving an antipsychotic medication.
Review of the physician orders for Resident #5 revealed an order dated 07/04/25 for Abilify (an
antipsychotic medication) 10 milligrams (mg) by mouth one time daily.
Review of Resident #5's comprehensive care plan dated 09/15/25 revealed there was no care plan
problem, goal, or interventions addressing the diagnosis of bipolar disorder. Further review revealed there
was no care planning related to the use of an antipsychotic medication, including monitoring for
effectiveness or potential adverse side effects.
Interview on 12/17/25 at 1:33 P.M. with the Director of Nursing (DON) and the MDS Nurse #224 verified
Resident #5 was prescribed Abilify, verified Abilify was an antipsychotic medication, and verified the
resident had a diagnosis of bipolar disorder. Further interview verified there was no specific, individualized
care plan addressing the use of an antipsychotic medication or the diagnosis of bipolar disorder. The MDS
Nurse #224 further stated the facility was monitoring for side effects of the antipsychotic medication and the
resident's bipolar disorder; however, this monitoring was documented under other care-planned areas and
was not reflected in a clearly identified, individualized care
(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 6
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
12/18/2025
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 0656
plan addressing bipolar disorder or antipsychotic medication use.
Level of Harm - Minimal harm
or potential for actual harm
Review of the policy titled Behavioral Health Services, dated February 2019, revealed the facility will
provide and residents will receive behavioral health services as needed to meet mental and psychosocial
well-being in accordance with the plan of care and staff training include implementing care plan
interventions that are relevant to the resident's diagnosis.
Residents Affected - Few
2. Review of the medical record review revealed Resident #23 was admitted on [DATE]. Diagnoses included
pneumonia due to methicillin resistant staphylococcus aureus, methicillin resistant staphylococcus aureus
infection as the cause of diseases classified elsewhere, type two diabetes mellitus without complications,
hypotension, chronic kidney disease stage four, and major depressive disorder.
Review of the MDS assessment dated [DATE] revealed the resident was cognitively intact.
Review of the physician orders dated 04/14/25 revealed an order for Resident #23's advance directive as
DNRCC-arrest (Do Not Resuscitate Comfort Care Arrest).
Review of the DNR Comfort Care documentation dated 04/14/25, revealed a signed advanced directive
verifying Resident #23's advance directive was DNRCC-arrest.
Review of the care plan dated 07/31/23 revealed Resident #23's plan of care was the resident was a full
code.
Interview on 12/17/25 at 2:01 P.M. with the DON verified Resident #23's care plan for advanced directives
were not accurate.
Review of the policy titled Interdisciplinary Team Care Planning, dated March 2022, verified comprehensive,
person-centered care plans are based on the resident assessments and developed by an interdisciplinary
team.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365232
If continuation sheet
Page 2 of 6
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
12/18/2025
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, resident interview, staff interview and review of facility policy, the facility failed to
implement appropriate infection control practices during care of residents on isolation. This affected
Resident #2. Additionally, the facility failed to ensure proper signage was posted for type of isolation and
usage of personal protective equipment (PPE) for residents who were on isolation. This affected four
Residents (#59, #4, #1, #44, and #23). Six residents were reviewed for isolation practices. The facility
census was 45.Based on medical record review, resident and staff interview, and policy review, the facility
failed to implement appropriate infection control practices during care of residents on isolation. This affected
one (#02) out of six reviewed for infection control. Additionally, the facility failed to ensure proper signage
was posted for the type of isolation and usage of personal protective equipment (PPE) for residents who
were on isolation. This affected six (#02, #59, #04, #01, #44, and #23) of six residents reviewed for isolation
practices. The facility census was 45.
Residents Affected - Some
Findings Include:
1.Review of the medical record for Resident #02 revealed an admission date of 12/04/25. The resident was
admitted with diagnosis of pneumonia, hypoxia and pressure induced deep tissue damage of back and
sacral area.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status
(BIMS) score of 11, indicating moderately impaired cognition. The Medicare five days were currently in
progress.
Review of the Care Plan revised on 12/15/25 revealed altered respiratory status related to pneumonia in
hospital, acute respiratory failure with hypoxia, and history of emphysema.
Observation on 12/16/25 at 9:50 A.M. revealed Resident #02 did not have a sign for isolation precautions.
Interview and observation on 12/16/25 at 9:58 A.M. with License Practical Nurse (LPN) #234 revealed the
facility practice was to place a See Nurse Sign on the residents' door and a symbol to represent what type
of isolation the resident was in for staff to know. The LPN #234 verified Resident #02 did not have a see
nurse sign or a symbol on doorway. LPN #234 placed a sign and a carrot symbolizing contact isolation on
Resident #02's doorway.
Observation on 12/16/25 at 10:53 A.M. revealed Resident #02 was in the restroom. Certified Nurse
Assistant (CNA) #205 entered Resident #02's room, entered the restroom, assisted Resident #2 off the
toilet and into a wheelchair, wheeled Resident #02 out of the resident's room, down the hallway and into the
dining room without a mask. CNA #205 was not wearing personal protective equipment (PPE) when
providing care in Resident #02's room.
Interview on 12/16/25 at 11:01 A.M. with CNA #205 verified no PPE was worn when assisting Resident #02
with care.
Interview on 12/16/25 at 11:02 A.M. with LPN #234 verified Resident #02 was diagnosed with pneumonia
on 12/15/25 and Resident #02 should have a daisy (symbolizing droplet isolation) instead of a carrot.
Reviewed isolation symbols with LPN #234 and they were the following: a daisy was for droplet
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365232
If continuation sheet
Page 3 of 6
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
12/18/2025
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
isolation, a carrot was for contact isolation and an elephant was for enhanced barrier precautions. LPN
#234 verified Resident #02 should be wearing a mask when ambulated through the halls and in the dining
room.
2. Review of the medical record for Resident #59 revealed an admission date of 12/12/25. The resident was
admitted with cutaneous abscess of right lower limb and type two diabetes.
Review of the MDS assessment dated [DATE] revealed Resident #59 had a Brief Interview Mental Status
(BIMS) score of 14, indicating intact cognition. The Medicare five day were currently in progress.
Review of the Care Plan dated 12/16/25 revealed Resident #59 was at risk for alterations in nutrition and
hydration due to facility placement due to cutaneous abscess right knee, intravenous antibiotic therapy and
diabetes.
Observation on 12/16/25 at 9:51 A.M. revealed Resident #59 had no sign for isolation precautions.
Interview on 12/16/25 at 9:58 A.M. with LPN #234 verified Resident #59 did not have a see nurse sign or a
symbol for isolation on doorway. The LPN #234 placed a sign and a carrot symbol indicating contact
isolation on Resident #59's doorway.
Interview on 12/16/25 at 11:55 A.M. with LPN #234 verified Resident #59 should not be in contact isolation
and should be in enhanced barrier precautions. LPN #234 changed the carrot symbol to an elephant
indicating enhanced barrier precautions for cutaneous abscess right knee, intravenous antibiotic therapy
and diabetes .
3. Review of the medical record for Resident #04 revealed an admission date of 10/06/25. Diagnoses
included intertrochanteric fracture of the left femur, diabetes, transient cerebral ischemic attack, stage three
kidney disease, and a diabetic foot ulcer to the left heel.
Review of the MDS assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15,
indicating intact cognition. The MDS indicated pressure ulcer, falls, pain, and nutritional status.
Review of the Care Plan revised on 12/15/25 revealed acute pain related to recent fracture of left femur, risk
of alteration in nutrition and hydration due to facility placement due to left hip fracture, diabetic foot ulcer to
the left heel, and risk for falls related to a recent fracture of the left femur.
Observation on 12/16/25 at 9:50 A.M. revealed Resident #04 had no sign for isolation precautions.
Interview on 12/16/25 at 11:33 A.M. with LPN #234 verified Resident #04 did not have a see nurse sign or a
symbol for isolation on doorway. LPN #234 placed a sign and an elephant (enhanced barrier precautions)
on Resident #04's doorway for diagnosis of diabetic foot ulcer to left heel.
4. Review of Resident #01's medical record revealed an admission date of 09/27/24. Diagnoses included
type II diabetes, cellulitis, colostomy complications, peripheral venous insufficiency, lymphedema, chronic
gout, and methicillin resistant staphylococcus (MRSA).
Review of Resident #01's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365232
If continuation sheet
Page 4 of 6
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
12/18/2025
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
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
(BIMS) score of 15 indicating Resident #01 was cognitively intact. Resident #01 required touching
assistance or supervision with toilet use, dressing, and personal hygiene. Resident #01 required maximal
assistance with bathing.
Review of Resident #01's care plan revised 10/30/25 revealed supports and intervention for contact
isolation for extended spectrum beta lactamases (ESBL) and MRSA chronic in bilateral lower extremity
wounds, self-care deficit, high risk for falls, pain, risk for fluid volume deficit related to diuretic use, and risk
for impaired skin integrity.
Review of Resident #01's physician orders revealed an order dated 12/04/24 to maintain contact isolation
precautions related to ESBL and MRSA.
Observation on 12/15/25 at 9:08 A.M. of Resident #01's room found Resident #1 was out of the room. A
cart with personal protective equipment (PPE) was observed inside the door along with two lidded
receptacles one labeled soiled linens and one labeled trash. A carrot symbol was observed next to
Resident #01's name on the name plate outside of the room along with a sign saying to see nurse before
entering the room. The carrot symbolized Resident #01 was on contact isolation. There were no postings
found indicating what type of PPE was required to be used when providing care to Resident #01.
Interview on 12/15/25 at 9:47 A.M. with LPN #242 verified Resident #01 was on contact isolation for ESBL
and MRSA in bilateral lower extremity wounds.
Observation on 12/15/25 at 11:33 A.M. of Resident #01's PPE cart and posted signage found no postings
indicating what PPE was required to be worn, donned or doffed. Coinciding interview with LPN #242
verified there were no postings for PPE use.
Interview on 12/15/25 at 11:36 A.M. with Resident #01 revealed he had seeping edema on his legs and the
nurses applied wraps for him when they were due. Resident #01 verified there were a PPE cart and trash
cans in his room for isolation. Resident #1 reported he was not sure he was still on isolation because he
thought the staff were not using the supplies in the cart anymore.
Observation on 12/16/25 at 9:12 A.M. and 12/17/25 at 8:05 A.M. of Resident #01's room found there
continued to be no signage indicating what PPE was to be worn when providing care to Resident #01 who
was on contact isolation.
5. Review of Resident #44's medical record revealed an admission date of 12/03/24. Diagnoses included
cervical fusion of spine, spinal stenosis, type II diabetes, protein calorie malnutrition, conjunctivitis, anxiety
disorder, and pruritus (itchy skin).
Review of Resident #44's MDS assessment dated [DATE] revealed a Brief Interview for Mental Status
(BIMS) score of 15 indicating Resident #44 was cognitively intact. Resident #44 was dependent on staff for
toilet use, personal hygiene, bed mobility, and transfer. Resident #44 required maximal assistance with
bathing, dressing. Resident #44 displayed no behaviors during the review period.
Review of Resident #44's care plan revised 10/30/25 revealed supports and interventions for contact
isolation related to extended spectrum beta lactamases (ESBL) in the urine, self-care deficit, pain, risk for
alteration in skin integrity, and risk for falls.
Review of Resident #44's physician orders revealed an order dated 01/20/25 to maintain contact
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365232
If continuation sheet
Page 5 of 6
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
12/18/2025
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
isolation related to ESBL.
Level of Harm - Minimal harm
or potential for actual harm
Observation on 12/15/25 at 9:43 A.M. Resident #44 was in bed in her room. Resident #44 had a PPE cart
and trash cans inside her room with a sign posted on her door frame to see nurse before entering.
Additionally, Resident #44 had a carrot symbol next to her name on the room name plate. The carrot
symbol indicated Resident #44 was on contact isolation. There was no signage posted indicating what PPE
was to be used when providing care to Resident #44. Coinciding interview with Resident #44 verified staff
wore PPE when providing her care.
Residents Affected - Some
Interview on 12/15/25 at 9:47 A.M. LPN #242 verified Resident #44 was on contact isolation for ESBL in her
urine.
Observation on 12/15/25 at 11:32 A.M. of Resident #44's room and PPE cart found there continued to be
no signage posted for what type of PPE was to be used when providing care to Resident #44 who was on
contact isolation. Coinciding interview with LPN #242 verified there were no postings for PPE use when
providing care to Resident #44 who was on contact isolation.
Further observation on 12/16/25 at 9:10 A.M. and 12/17/25 at 8:28 A.M. of Resident #44 ' s room found
there continued to be no signage indicating what PPE was to be worn when providing care to Resident #44
who was on contact isolation.
6. Review of the medical record review revealed Resident #23 was admitted on [DATE]. Diagnoses included
pneumonia due to methicillin resistant staphylococcus aureus, methicillin resistant staphylococcus aureus
infection as the cause of diseases classified elsewhere, type two diabetes mellitus without complications,
hypotension, chronic kidney disease stage four, and major depressive disorder.
Review of the MDS assessment dated [DATE] revealed Resident #23 was cognitively intact.
Observation on 12/15/25 at 12:50 P.M. revealed the outside of Resident #23 ' s door a magnetic notice to
see nurse prior to entering and a picture of a carrot symbol on the name plate. Inside of the room was a
PPE cart with no signage.
Interview on 12/16/25 at 3:29 P.M. LPN #242 verified Resident #23 ' s room had no PPE instructions.
Review of the facility policy titled Isolation-Categories of Transmission-Based Precautions revised
September 2022, revealed transmission-based precautions are initiated when a resident develops signs
and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a
laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Droplet
precautions requires a mask is placed on the resident during transport from his or her room. The resident is
encouraged to follow respiratory hygiene/cough etiquette to minimize dispersal of droplets.
Review of the facility policy titled Personal Protective Equipment revised October 2018, revealed training on
the proper donning, use and disposal of PPE is provided upon orientation and at regular intervals.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365232
If continuation sheet
Page 6 of 6
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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.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0905GeneralS&S Epotential for harm
Ensure that gas containers are correctly designed and tested, and in locations that are labeled.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 December 18, 2025 survey of VANCREST OF ST MARY'S?
This was a inspection survey of VANCREST OF ST MARY'S on December 18, 2025. 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 December 18, 2025?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have properly installed electrical wiring and gas equipment."
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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.