Inspection visit
Inspection
30 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 30 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0553
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Allow resident to participate in the development and implementation of his or her person-centered plan of
care.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff and resident interview, the facility failed to invite and involve a resident and/or their
representative in their care planning and conduct care plan meetings. This affected one (#26) of 24
residents reviewed for care planning. The facility census was 67.
Findings include:
Review of the medical record for Resident #26 revealed admission date of 04/01/22. The resident was
admitted with diagnoses including stroke and hemiplegia of the left dominant side.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had
intact cognition and required extensive two person assistance for bed mobility, one total dependence for
transfers, toileting, and supervision for eating. Resident #26's MDS documentation revealed a quarterly
MDS assessment was completed on 10/14/22.
Review of the progress notes for Resident #26 revealed no documentation of care conferences being held.
Upon request the facility provided paperwork for a care conference dated 10/26/23. There was no evidence
of an invitation to a care plan meeting.
Interview on 02/27/23 at 2:52 P.M., with Resident #26 revealed she or her representative had not had care
conference or an invitation.
Interview on 03/02/23 at 5:00 P.M., with Social Services Designee #139 verified the last care conference for
Resident #26 was on 10/26/23 and no family or resident attended.
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 30
Event ID:
365437
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interviews, and policy review, the facility failed to notify a physician of a fall with a head
injury. This affected one (#63) of two reviewed for accidents. The facility census was 67.
Findings include:
Review of medical record for Resident #63 revealed admission date of 02/02/23. The resident was admitted
with diagnoses including pneumonia, bacteremia, hypertension, atrial fibrillation, depression, and anxiety.
The resident remains in the facility.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has
intact cognition and required extensive one person assistance for bed mobility, transfers, dressing, toileting,
personal hygiene, and supervision for eating.
Record review revealed Resident #63 had an unwitnessed fall in the bathroom on 02/28/23. The fall
resulted in contusion to the left forehead. Neurological assessments were initiated and were negative.
Notification of the fall was written in the provider communication book.
Interview on 03/02/23 at 8:44 A.M., with Certified Nurse Practitioner (CNP) #153 revealed she was not
informed of Resident #63's fall. She added she created a list which was posted in the provider
communication book of examples of when to call the provider and when it was acceptable to leave the
information in the communication book. CNP #53 verified a fall with head injury requires a call to the
provider.
Interview on 03/02/23 at 9:10 A.M., with the Director of Nursing (DON) verified Resident #63 had a fall
which resulted in a contusion to her left forehead, and it was the expectation the provider would be notified.
The DON also verified there was no documentation CNP #153 had been notified, other than written in the
communication book.
Review of the policy tilted Fall Policy, dated September 2012, revealed preceding an assessment, the staff
and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of
serious consequences of falling.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 2 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0582
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
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 inform a resident/ representative of cost for care and
services that they would be responsible for when a payor source would change. This affected two (#7 and
#36) of three residents reviewed for beneficiary notification the cost of the skilled service after by Medicare
Part A. The total facility census was 67.
Residents Affected - Few
Findings include:
1. Review of Resident #7's medical record revealed the resident was admitted to the facility on [DATE], with
Medicare Part A as her payor source. The resident record revealed the resident payor source changed on
02/16/23 to Medicaid and the resident remained in the facility. Resident #7's diagnoses included diabetes,
chronic kidney disease, hypertensive heart disease, Parkinson's disease, hyperlipidemia, and depression.
Review of Resident #7's quarterly minimum data set (MDS) assessment dated [DATE], revealed the
resident was cognitively intact, had no behaviors, and required extensive assist for bed mobility, and
personal hygiene, limited assist with transfers, toileting, and dressing and required supervision for eating.
The resident received 15 minutes of speech therapy, 245 minutes of occupational therapy and 160 minutes
of physical therapy during the review period.
Review of the Skilled Nursing Facility/Advanced Beneficiary Notice (SNF/ABN) provided to Resident #7's
Power of Attorney (POA) on 02/12/23, revealed the resident was receiving skilled services at the facility
through the Medicare Part A benefit starting on 12/30/23 and the skilled benefit through Medicare Part A
would end on 02/14/23. Review of Resident #7's SNF/ABN revealed the facility informed the POA the
inpatient skilled nursing facility stay would not be paid by Medicare Part A and the resident/POA would be
responsible for the following payment related to the resident's continued stay at the facility. Room and board
payment of $288.00 a day, eight incontinent supplies per day with no monetary value provided, and six
days of oxygen therapy with no monetary value provided. The SNF/ABN did not provide the cost of the
skilled services the resident was being cut from for the POA to review and decide if the POA wanted to the
resident to continue with the skilled services.
Interview on 03/02/23 at 11:18 A.M., with Social Service Designee (SSD) #139 confirmed the cost for the
skilled services which were no longer being provided under Medicare Part A for Resident #7 was not
provided on the SNF/ABN.
2. Review of Resident #36's medical record revealed the resident was initially admitted to the facility on
[DATE], with the most recent re-admission date of 11/02/22, with the payor source of Medicare Part A. The
resident record revealed the payor source changed to Medicaid on 01/11/23 and the resident remained in
the facility. Resident #36's diagnoses included hypertension, chronic kidney disease, peripheral vascular
disease, anemia, and chronic obstructive pulmonary disease.
Review of Resident #36's discharge from Medicare Part A, MDS assessment dated [DATE] revealed the
resident had received 145 minutes of speech therapy, 2198 minutes of occupational therapy and 1432
minutes of physicial therapy while on Medicare part A services.
Review of Resident #36's SNF/ABN revealed the facility informed the resident the inpatient skilled
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 3 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0582
Level of Harm - Minimal harm
or potential for actual harm
nursing facility stay will not be paid by Medicare part A starting on 01/11/23 and the resident would be
responsible for the following payment related to the resident's continued stay at the facility. Room and board
payment of $288.00 a day, and eight incontinent supplies per day with no monetary value provided. The
SNF/ABN did not provide the cost of the skilled services the resident was being cut from for the resident to
review and decide if they wished to continue with the skilled services.
Residents Affected - Few
Review of Resident #36's quarterly minimum data set (MDS) assessment dated [DATE] revealed the
resident was cognitively intact, had no behaviors, and required extensive assist for bed mobility, transfers,
dressing, toileting, and personal hygiene, and required supervision for eating.
Interview on 03/02/23 at 11:18 A.M. with SSD #139 confirmed the cost for the skilled services which were
no longer being provided under Medicare Part A for Resident #36 was not provided on the SNF/ABN.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 4 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon
observation, resident and staff interviews, the facility failed to maintain a environment in good repair. This
affected one (#30) of 67 residents reviewed for homelike environment. The facility census was 67.
Findings include:
Review of medical record for Resident #30 revealed admission date of 04/29/22. The resident was admitted
with diagnoses including stroke, hemiplegia affecting right dominant side. The resident remains in the
facility.
Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had intact cognition
and required supervision for eating and extensive assistance for all other activities of daily living.
Interview and observation on 02/27/23 at 1:02 P.M., with Resident #30 revealed she was bothered by the
chipped paint and dry wall damage beside her bed, which was caused by her recliner hitting the wall.
Resident #30 shared the facility moved her bed against the damaged wall after a fall and she would like the
wall fixed. Observation of the wall, at the time of the interview, revealed beside Resident #30's bed an area
approximately three foot by six inch of scattered gouging of drywall.
Interview on 03/02/23 at 8:29 A.M., with Maintenance Director (MD) #73 verified the damaged area to the
wall of Resident #30's room. MD #73 acknowledged the room was not homelike and shared the facility was
aware of the damage to walls from recliners and would be identifying and fixing those areas.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 5 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0636
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every
12 months.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument
(RAI) 3.0 User's Manual, the facility failed to complete a discharge assessment in a timely manner. This
affected one (#64) of 24 residents reviewed for assessments. The facility census was 67.
Findings include:
Review of the closed medical record for Resident #64 revealed admission date of 08/31/22. The resident
was admitted with diagnoses including stroke, diabetes mellitus type two, hypertension and atrial fibrillation.
The resident was discharged on 10/20/22.
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident had impaired
cognition and required extensive assistance or was totally dependent for her activities of daily living.
Review of the MDS assessments in the medical record revealed a discharge assessment was not
completed as of 02/28/23.
Interview on 03/01/23 at 8:09 A.M., with MDS Nurse #124 verified a discharge MDS was not completed as
required for Resident #64.
Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual v1.17.1R,
effective July 15, 2022, revealed a discharge assessment must be completed no later than 14 days after
the date of discharge.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 6 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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, observation, review of the Long-Term Care Facility Resident Assessment Instrument (RAI)
3.0 User's Manual, and staff interviews, the facility failed to accurately assess a resident and reflect the
accurate assessment on the the Minimum Data Set (MDS) 3.0 assessment. This affected two (#48 and
#57) of 24 resident assessments reviewed for accuracy. The total facility census was 67.
Residents Affected - Few
Findings include:
1. Review of Resident #48's medical record revealed the resident was admitted to the facility on [DATE],
with diagnoses that included Alzheimer's disease, rheumatoid arthritis, idiopathic peripheral neuropathy,
and palliative care.
Review of Resident #48's physician orders revealed the resident started hospice care on 09/27/22 with a
terminal diagnosis of Alzheimer's Disease. Resident #48 additionally had a physician order for bilateral
palm protectors for four hours daily as tolerated dated 06/27/22.
Review Resident #48's care plans revealed the resident had a care plan for activities of daily living with an
intervention of bilateral palm protectors for four hours daily dated 07/05/22, and a hospice care care plan in
place dated 09/27/22.
Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident
#48 had cognitive impairment, and was dependant on staff for all daily cares. Resident #48 was assessed
as not having any functional limitation in range of motion. Section J 1400 was listed as no, indicating the
resident did not have a condition or chronic disease that may result in a life expectancy of less that 6
months. and section O 0100 K hospice was not marked.
Review of the quarterly MDS assessment dated [DATE], revealed Resident #48 had cognitive impairment,
and was dependant on staff for all daily cares. Resident #48 was assessed as not having any functional
limitation in range of motion. Section J 1400 was listed as no, indicating the resident did not have a
condition or chronic disease that may result in a life expectancy of less that 6 months. and section O 0100
K hospice was not marked.
Observation of Resident #48 on 02/27/23 at 2:10 P.M., revealed the resident was sitting in her room in the
wheelchair and her hands were closed and her fingers were touching her palms. There was a note above
the bed which stated to have palm protectors in place. The resident was asked if she could open her hands
and she was unable to straighten her fingers on command.
Observation of Resident #48 on 02/28/23 at 8:08 A.M., revealed bilateral palm protectors were in place.
Interview on 03/01/23 at approximately 10:25 A.M., with the Director of Nursing (DON) confirmed the
resident has bilateral hand contractures and uses palm protectors daily. The DON also confirmed the
resident was on hospice services.
Interview on 03/01/23 at 3:30 P.M.,with MDS Nurse #124 confirmed Resident #48 was on hospice services
but it was not indicated on the quarterly MDS dated [DATE] or on the significant change MDS dated [DATE]
and J 1400 was listed as no on both assessments. MDS Nurse #124 stated she reviews the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 7 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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
information provided by the nursing staff to complete the MDS assessments.
Level of Harm - Minimal harm
or potential for actual harm
2. Review of record for Resident #57 revealed admission date on 10/05/21. Diagnoses included palliative
care, cerebral infarction, and mild cognitive impairment.
Residents Affected - Few
Review of Significant Change MDS assessment dated on 11/07/22 revealed Resident #57 was cognitively
intact and Section J 1400 was listed as no, indicating the resident did not have a condition or chronic
disease that may result in a life expectancy of less than 6 months. and section O 0100 K hospice was not
marked.
Review of MDS dated on 02/07/23 revealed Resident #57 was cognitively intact and Section J 1400 was
listed as no, indicating the resident did not have a condition or chronic disease that may result in a life
expectancy of less than 6 months. and section O 0100 K hospice was not marked.
Review of Plan of Care dated 02/21/23 revealed Resident #57 had diagnosis of cerebral atherosclerosis
and was admitted to hospice. Interventions included one on one visit as needed, allow resident to ventilate
feelings, call hospice with any concerns, observer for pain, observe for signs and symptoms of depression
and grief, offer reassurance, and see hospice plan of care.
Review of physician order dated on 10/28/22 revealed Resident #57 had been admitted to hospice on
10/27/22 with diagnosis of cerebral atherosclerosis.
Interview on 03/01/23 at 3:40 P.M., with MDS Nurse #124 confirmed Resident #57 was on hospice services
but it was not marked on the quarterly MDS dated [DATE] or on the significant change MDS dated and J
1400 was marked as no on both assessments. MDS Nurse #124 stated she reviews the information
provided by the nursing staff to complete the MDS assessments.
Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual v1.17.1R,
effective July 15, 2022, revealed under section G 0400: Functional Limitation in Range of Motion revealed
revealed Upper Extremity - includes shoulder, elbow, wrist, and fingers. For each hand, instruct the resident
to make a fist and then open the hand.
Coding Tips: Do not look at limited ROM in isolation. You must determine if the limited ROM impacts
functional ability or places the resident at risk for injury.
Under Section J 1400: Prognosis (cont.): Coding Instructions-Code 0, no: if the medical record does not
contain
physician documentation that the resident is terminally ill and the resident is not receiving hospice services.
Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or
2) the resident is receiving hospice services
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 8 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0655
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being
admitted
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument
(RAI) 3.0 User's Manual, the facility failed to develop a baseline care plan timely. This affected one (#172) of
24 residents reviewed fro care planning. The facility census was 67.
Findings include:
Review of medical record for Resident #172 revealed an admission date of 02/06/23. The resident was
admitted with diagnoses including stoke, hemiplegia of left non dominant side and dysarthria (slurred or
slow speech that can be difficult to understand). The resident remains in the facility.
Review of the admission Minimum Data Set (MDS) dated [DATE], revealed the resident had intact cognition
and required extensive one person assistance for bed mobility, transfers, dressing, eating and toileting.
Review of a care plan, initiated on 02/13/23, revealed a communication focus related to dysarthria due to a
stroke; activities of daily living self-care performance due to hemiplegia and nutritional/dehydration risk
related to a stroke, dysphagia and vitamin deficiency.
Record review of the electronic charting for Resident #172 revealed no baseline care plan for
communication, nutrition or activities of daily living was completed within 48 hours.
Interview on 03/02/23 at 11:11 A.M., with the Director of Nursing (DON) verified communication, nutrition
and activities of daily living were not addressed in a baseline care plan.
Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual v1.17.1R,
effective July 15, 2022, revealed the baseline care plan must be developed within 48 hours and include
dietary orders and the instructions needed to provide effective person-centered care if the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 9 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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, observations, and staff interviews, the facility failed to ensure a physician ordered
consult with specialized physician appointment was made timely. This affected one (#63) of 24 residents
records reviewed for quality of care. The facility census was 67.
Residents Affected - Few
Findings include:
Review of medical record for Resident #63 revealed admission date of 02/02/28. The resident was admitted
with diagnoses including pneumonia, bacteremia, hypertension, depression and anxiety.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had
intact cognition and required extensive one person assistance for bed mobility, transfers, dressing, toileting,
personal hygiene, and supervision for eating.
Review of the physician orders for Resident #63 revealed a 02/23/23 order for a gastrointestinal (GI)
consult.
Observation on 03/01/23 at 9:47 A.M., revealed Medical Records #134 was on the phone making an
appointment for Resident #63. Interview with Medical Records #134, after she hung up, she stated was not
informed of the consult order until Monday 02/27/23 and the consulted physician required a signed written
order prior to making the appointment. She stated she faxed a signed copy of the order with a note later in
the day with a request to have the office call to set the appointment. She shared the office did not call back
on Monday so she just called them to follow up. A request was made to have a copy of the fax. This was not
provided during the survey.
Interview on 03/01/23 at 10:01 A.M., with Unit Manager #108 revealed new admission and follow up
appointments are given to Medical Records #134 to make. She stated the order is written and signed by the
nurse on an order form and placed in a folder for Medical Records #134 to make the appointment. She
stated the order sometimes needs signed by the practitioner for the consulted office prior to the
appointment being made. A request was made for the signed follow up order. This was not provided by the
end of the survey.
Interview on 03/02/23 at 8:44 A.M., with Certified Nurse Practitioner (CNP) #153 revealed she was not
asked to sign the GI consult order, and she was not made aware the appointment was not made until
03/01/23.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 10 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0685
Assist a resident in gaining access to vision and hearing services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, resident and staff interview, the facility failed to ensure a follow up appointment
with an ophthalmologist was scheduled and a physician ordered medication was started for maintaining
This affected one (#10) of four residents reviewed for vision and hearing services. The facility census was
67.
Residents Affected - Few
Findings include:
Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE], with
the diagnoses included osteomyelitis, peripheral vascular disease, type two diabetes, atrial fibrillation,
dementia, and hypertension.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was
cognitively impaired and had adequate vision without corrective lenses.
Review of Resident #10's care plan indicated he had impaired visual function related to a bind spot of the
unspecified eye. Interventions include to arrange consultation with eye care practitioner as required,
monitor for any changes in ability to complete activities of daily living, a decline in mobility, or sudden vision
loss.
Review of the optometry note dated 07/06/22 revealed Resident #10 was seen at the facility, by the
optometrist and the resident was diagnosed to have age related nuclear cataracts bilaterally, and had mild
macular degenerations. The note plan stated cataracts are visually significant, please schedule for cataract
evaluation with the ophthalmologist of the facilities choice, and the plan was to monitor the macular
degeneration at regular intervals and the supplement AREDS (nutritional supplement for age related
macular degeneration) was discussed with the patient.
Review of Resident #10's record revealed there were no notes from an ophthalmologist and the resident
was not on the AREDS supplement.
Interview on 02/27/23 at 11:30 A.M., with Resident #10 revealed he was seen by the eye doctor at the
facility and told he had cataracts and needed surgery for them, but there had been no follow up and it had
been a long time ago he was told about needing cataract surgery.
Interview on 03/01/23 at 4:09 P.M., with the Director of Nursing (DON) revealed the process for ancillary
practitioners is the Social Service Designee (SSD) #139 will set up the practitioner visits at the facility. After
the visit the SSD #139 will place the practitioner notes on the resident's medical record. The DON stated on
02/28/23, the facility identified the process was not being followed and the SSD #139 was not obtaining the
ancillary practitioner notes and placing them in the resident's medical record. Resident #10's optometry
practitioner note from 07/06/22, was reviewed with the DON and it was verified Resident #10 had not been
seen or had an appointment set up to be seen by an ophthalmologist and the resident was not on the eye
supplement AREDS.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 11 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview, and review of the policy, the facility failed to ensure new fall interventions were
timely implemented after a resident sustained a major injury requiring a hospital visit. This affected one
(#22) of two residents reviewed for accidents. The facility census was 67.
Findings include:
Medical record review for Resident #22 revealed an admission date on 12/22/21. Diagnoses included
chronic kidney disease and chronic obstructive pulmonary disease. Resident #22 was sent to the hospital
on [DATE] and readmitted to the facility on [DATE] with a new diagnosis of non-traumatic subdural
hemorrhage.
Review of the Minimum Data Set (MDS) assessment dated on 01/05/23 revealed Resident #22 was
severely cognitively impaired. Resident #22 utilized a wheelchair to ambulate at the facility.
Review of the progress note dated 02/05/23 revealed an activity staff member observed Resident #22 on
the floor, face first. Resident #22 was bleeding from above the right eyebrow and under right eye. The
progress note dated 02/05/23 at 7:13 P.M. revealed Resident #22 was being transferred to the hospital for
subdural hematoma.
Review of the facility's fall investigation dated 02/05/23 revealed Resident #22 had an unwitnessed fall.
Resident #22 had come into the activities room and wanted a snack. Activities Director (AD) #70 turned
around for two seconds, then heard a thump. AD #70 instantly turned around and saw that Resident #22
had fallen out of her wheelchair. Resident #22 was found lying on her stomach on the right side of face.
There was blood on the floor and Resident #22 had a skin tear to her right forearm, a cut above the right
eyebrow, and under the right eye. Resident #22's eye was swelling and was black and blue and sent to the
emergency room. The new intervention was for occupational therapy (OT) to assess Resident #22 in her
wheelchair upon return from the hospital.
Review of the hospital discharge note dated 02/11/23 revealed Resident #22 was discharged from the
hospital with diagnosis of subdural hematoma.
Review of the plan of care dated 02/12/23 revealed Resident #22 had an alteration in neurological status to
right temporal subdural hematoma related to a fall on 02/05/23. Interventions included to monitor and
document tremors, rigidity, and dizziness, offer pain management as needed, reposition, and ambulate as
tolerated. Physical therapy (PT) and OT to evaluate and treat as ordered.
Review of the OT assessment for Resident #22 revealed Resident #22 was not assessed by OT until ten
days later on 02/21/23 after Resident #22 returned from the hospital (02/11/23). OT recommendations were
to change Resident #22's wheelchair to a lower seat height to increase Resident #22's foot contact on the
floor. Resident #22's prior wheelchair did not allow for full foot contact on the floor. This new seat height will
decrease risk for falls anteriorly but not prevent falls forward.
Interview on 03/01/23 at 10:30 A.M. with Unit Manager #111 verified the new fall interventions to Resident
#22 was therapy to evaluate the wheelchair to see if it was appropriate for Resident #22.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 12 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 03/01/23 at 5:35 P.M. with Therapy Director #15 stated he did not assess Resident #22's
wheelchair, because it was to be done by OT #155. OT #155 was out of the facility with COVID-19. Therapy
Director #154 stated the facility could have called in another OT to assess Resident #22 in her wheelchair
but did not explain why this didn't occur.
Interview on 03/02/23 at 10:30 A.M. with OT #155 stated he was the only person who could assess
Resident #22. OT #155 stated Resident #22 and her wheelchair was assessed on 02/21/22. OT #155
stated he placed Resident #22 in another wheelchair that was lower to the floor so her feet would touch the
floor on 02/21/22. OT #155 stated Resident #22 had not fallen since the new wheelchair was given to her
on 02/21/23. OT #155 verified Resident #22 was not timely assessed for the wheelchair after coming back
from the hospital on [DATE].
Review of the policy titled Fall Policy, dated September 2012, revealed based on assessment, the staff and
physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of
serious consequences of falling. If underlying causes cannot be readily identified or corrected, staff will try
various relevant interventions, based on assessment of the nature of falling.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 13 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, policy review, and staff interviews, the facility failed to obtain weights in a timely manner. This
affected two (#172 and #63) of three residents reviewed for nutrition. The facility census was 67.
Residents Affected - Few
Findings include:
1. Review of medical record for Resident #172 revealed an admission date of 02/06/23. The resident was
admitted with diagnoses including stroke, hemiplegia of left non dominant side and dysarthria (slurred or
slow speech that can be difficult to understand).
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident has
intact cognition and required extensive one person assistance for bed mobility, transfers, dressing, eating
and toileting.
Review of the care plan initiated on 02/16/23, revealed a nutritional/dehydration risk related to a stroke,
dysphagia and vitamin deficiency. Interventions included to obtain a weight at a minimum of monthly and
report any significant change to the physician, provide and serve nutritional supplements as ordered, and
monitor and report any pocketing, choking, coughing, drooling or refusals to eat.
Record review of the electronic charting on 03/01/23 for Resident #172 revealed one weight documented
on 02/08/23 of 146.6 pounds.
Interview on 03/01/23 at 8:51 A.M., with the Director of Nursing (DON) revealed the weight policy was: to
obtain an admission weight, weekly weights times four weeks and then monthly. She verified Resident #172
has had one weight since admission.
Interview on 03/01/23 at 7:51 A.M., with the DON revealed a second weight obtained of Resident #172 on
03/01/23 at 11:11 A.M. ,was 137.6. This represented a 6.7 percent loss. The DON shared Resident #172's
spouse and physician were notified.
2. Review of medical record for Resident #63 revealed admission date of 02/02/23. The resident was
admitted with diagnoses including pneumonia, bacteremia, hypertension, depression, and anxiety. The
resident remains in the facility.
Review of the admission MDS assessment dated [DATE], revealed she had a Brief Interview Mental Status
(BIMS) score of 14 indicating intact cognition. She required extensive one person assistance for bed
mobility, transfers, dressing, toileting, personal hygiene, and supervision for eating. Her weight was listed as
173.
Review of the care plan for nutrition and dehydration risk was initiated on 02/02/23, with interventions which
included to obtain weights at a minimum of monthly, provide and serve supplements as ordered, dietician to
make diet change recommendations as needed.
Review of the admission progress not revealed admit pending hospital weight 160 pounds (#) of February
10, 2023, reflect a 9#/5.3% weight loss compared to last admission hospital weight. Weight change most
likely related differential of scales due to different hospitals. Anticipate weight change. Nutrition
recommendation: Obtain admission weight, continue to follow and make recommends as needed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 14 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0692
This was documented by Dietitian #151.
Level of Harm - Minimal harm
or potential for actual harm
Record review of the electronic charting for Resident #63 revealed one weight was obtained on 02/27/23 of
138.8 pounds.
Residents Affected - Few
Interview on 03/01/23 at 9:33 A.M., with Dietician #151 revealed she assessed Resident #63 on 02/23/23
and requested staff to weigh Resident #63 because there was no admission weight available.
Interview on 03/01/23 at 8:51 A.M., with the Director of Nursing (DON) revealed the weight policy was: to
obtain an admission weight, weekly weights times four weeks and then monthly. She verified Resident #172
has had one weight since admission.
Review of the undated policy titled Weight Assessment and Interventions, revealed residents are weighed
upon admission and at intervals established by the interdisciplinary team.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 15 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, staff interview and policy review, the facility failed to act on pharmacy recommendations
timely and the facility failed to provide a rationale for refusing a pharmacy recommendation. This affected
three (#2, #8 and #3) of five residents reviewed for unnecessary medications. The facility census was 67.
Findings include:
1. Review of the Resident #2's medical record revealed the resident was admitted to the facility on [DATE],
with diagnoses including weakness, hypothyroidism, left knee replacement, depression, anxiety, dementia
and cerebral infarction.
Review of most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident
is cognitively impaired, wanders daily but had no other behaviors. Resident #2 required limited assist with
personal hygiene, supervision for toileting, and dressing and was independent with bed mobility, transfers,
and eating. Resident #2 received seven days of antipsychotic and antidepressant medication and six days
of antianxiety medication.
Review of Resident #2's physician orders revealed the resident had the following medication orders:
Trazadone (sedative) 50 milligram (mg) daily at bedtime as needed for insomnia, ordered on 10/27/22 with
end date of indefinite; Buspirone (antianxiety) 15 mg twice a day for anxiety dated 10/27/22; Desvenlafaxine
ER (antidepressant) 150 daily for depression dated 10/27/22; Seroquel (antipsychotic) 75 mg daily for
Alzheimer's/dementia; and
Divalproex Sodium (anti seizure) oral tablet delayed release 250 mg daily for behaviors dated 10/27/22
Review of consultant pharmacist review dated 01/08/23 revealed Resident #2 is receiving the following
psychoactive medications that are due for review. Per Centers of Medicare Services (CMS) regulations
please evaluate the resident for trial dose reduction: Buspirone 15 mg give 1 by mouth two times a day for
anxiety ordered on 10/27/22; Desvenlafaxine ER oral tablet 150 mg give on tablet for depression ordered
10/27/22; Divalproex sodium oral tablet delayed release 250 mg give one by mouth two times a day for
behaviors 10/27/22; and Seroquel 75 mg give one tablet by mouth one time a day for Alzheimer dementia.
Consider a GDR for at least on of the above along with a stop date to the as needed Trazodone. If dose
reduction is contraindicated or resident failed previous reduction attempt please document below. The
consultant pharmacist review was blank and there was no indication the physician had seen or addressed
the recommendation.
Interview on 03/02/23 at 9:54 A.M., with the Director of Nursing (DON) confirmed the 01/08/22 consultant
pharmacist recommendation had not been addressed by the physician. The DON also verified Alzheimer's
dementia is not an approved diagnosis for the use of Seroquel, however it is the diagnosis Resident #2 has
for the use of the medication.
2. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with
an diagnoses including traumatic brain injury, dementia, depression and unspecified
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 16 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0756
psychosis.
Level of Harm - Minimal harm
or potential for actual harm
Review of the quarterly MDS assessment dated [DATE] revealed Resident #3 had cognitive impairment, no
behaviors, delusions or hallucinations. Resident #3 received seven days of antipsychotic, antidepressant,
and opioid medication.
Residents Affected - Few
Review of Resident #3's physician orders revealed the resident had: Seroquel (antipsychotic) 12.5 mg twice
daily ordered on 05/19/22 and Zoloft (antidepressant) 50 mg at bedtime dated 03/06/18.
Review of the consultant pharmacist recommendation dated 10/04/22 revealed Resident #3 was receiving:
Seroquel (antipsychotic) 12.5 mg twice daily ordered on 05/19/22 and Zoloft (antidepressant) 50 mg at
bedtime dated 03/06/18. The recommendation stated to consider a gradual dose reduction (GDR) on at
least one of the medications above. The form was mark disagree and signed by the provider on 10/31/22
but there was no rationale for why the GDR was refused.
Review of the consultant pharmacist recommendation dated 04/21/22 revealed Resident #3 was receiving:
Zoloft 50 mg daily at bedtime dated 03/06/18. The recommendation stated to consider a gradual dose
reduction (GDR) on the medication. The form was blank and it was not signed by the provider indicating the
provider had not been made aware of the requested GDR.
Interview on 03/02/23 at 12:00 P.M., with the DON verified the practitioner did not explain why they were not
willing to attempt a GDR on Resident #3 on the 10/31/22 and the GDR recommendation from 04/21/22 had
not been addressed by the physician.
3. Review of Resident #8's medical record revealed the resident was admitted to he facility on 03/11/17.
with diagnoses including atrial fibrillation, hypertension, anxiety depression and dementia.
Review to the annual MDS dated [DATE] revealed the resident is cognitively intact and received seven days
of antipsychotic, antidepressant, hypnotic and diuretic medication.
Review of Resident #8's physician orders revealed the resident had the following medication orders:
Ariprazole (antipsychotic) 0.5 mg at bedtime for major depression dated 09/05/21; Bupropion
(antidepressant) 150 mg daily for depression dated 09/07/21; Trazadone (sedative) 50 mg daily for
insomnia dated 05/30/22; Xanax (antianxiety) 0.25 mg three times daily for anxiety dated 09/28/22; Zoloft
(antidepressant) 150 mg daily for depression dated 09/05/21 and Carafate 1 gram (gm) twice daily for
gastro esophageal reflux disease dated 01/17/22.
Review of the consultant pharmacist recommendation dated 08/03/22 revealed Resident #8 was receiving:
Carafate 1 gm twice daily for gastro esophageal reflux disease dated 01/17/22. The recommendation stated
to consider decreasing the Carafate does to once a day to determine if a lower dose will be effective. The
form was blank and it was not signed by the provider indicating the provider had not been made aware of
the requested GDR.
Review of the consultant pharmacist recommendation dated 12/05/22 revealed Resident #8 was receiving:
Ariprazole (antipsychotic) 0.5 mg at bedtime for major depression dated 09/05/21; Bupropion
(antidepressant) 150 mg daily for depression dated 09/07/21; Trazadone (sedative) 50 mg daily for
insomnia dated 05/30/22; Xanax (antianxiety) 0.25 mg three times daily for anxiety dated 09/28/22 and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 17 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Zoloft (antidepressant) 150 mg daily for depression dated 09/05/21. The form was marked disagree and
hand written in have psychiatric services manage the psychotropic medications and signed by the facility
practitioner.
Interview on 03/02/23 at 5:06 P.M., with the DON confirmed the facility was contracting with a new
psychiatric contractor to provided psychiatric services to residents at the facility, however, the services had
not started. The DON verified due to the services not having had started the consultant pharmacist
recommendation dated 12/05/22 had not been acted on and the consultant pharmacist recommendation
dated 08/03/22 was not addressed either.
Review of the undated policy titled Psychotropic Medication revealed the intent of the policy is 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. However, situations do exist in
which behavior management programs must be supplemented with lowest possible antipsychotic drug
dosage. All psychoactive medications will be monitored at the lowest effective dose for the medical
symptom that resident is prescribed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 18 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 - Some
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, staff interviews and policy review, the facility failed to ensure residents who received
psychotropic drugs were provided routine behavior monitoring. This affected four (#2, #3, #8 and # 58) of
five residents reviewed for unnecessary medications. The total facility census was 67.
Findings include:
1. Review of the Resident #2's medical record revealed the resident was admitted to the facility on [DATE],
with diagnoses including weakness, hypothyroidism, left knee replacement, depression, anxiety, dementia
and cerebral infarction.
Review of most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident
is cognitively impaired, wanders daily but had no other behaviors. Resident #2 required limited assist with
personal hygiene, supervision for toileting, and dressing and was independent with bed mobility, transfers,
and eating. Resident #2 received seven days of antipsychotic and antidepressant medication and six days
of antianxiety medication.
Review of Resident #2's physician orders revealed the resident had the following medication orders:
Trazadone (sedative) 50 milligrams (mg) daily at bedtime as needed for insomnia, ordered on 10/27/22 with
end date of indefinite; Buspirone (antianxiety) 15 mg twice a day for anxiety dated 10/27/22; Desvenlafaxine
ER (antidepressant) 150 daily for depression dated 10/27/22; Seroquel (antipsychotic) 75 mg daily for
Alzheimer's/dementia and
Divalproex Sodium (anti seizure) oral tablet delayed release 250 mg daily for behaviors dated 10/27/22.
Review of the last two months of behavior monitoring for Resident #2 revealed the resident had evidence of
behavior monitoring in the medical record.
Interview 03/02/23 at 10:00 A.M., with Licensed Practical Nurse (LPN) #120 revealed the residents on
psychoactive medication have daily behavior monitoring under the assessment tab in the electronic medical
record.
Interview on 03/02/23 at 10:33 A.M., with the Director of Nursing (DON) confirmed the resident had not had
behavior monitoring completed at the facility. The DON stated the resident had a history of inpatient
psychiatric hospitalization, however, there are no diagnosis other than dementia, Alzheimer or depression
in the resident's medical record to support the use of the Seroquel in the care of this resident. The DON
verified the resident should have daily behavior monitoring.
2. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE], with
diagnoses including traumatic brain injury, dementia, depression and unspecified psychosis.
Review of the quarterly MDS assessments dated 01/19/23 revealed Resident #3 had cognitive impairment,
no behaviors, delusions or hallucinations. Resident #3 received seven days of antipsychotic,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 19 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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
antidepressant, and opioid medication.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #3's physician orders revealed Seroquel (antipsychotic) 12.5 mg twice daily ordered on
05/19/22 and Zoloft (antidepressant) 50 mg at bedtime dated 03/06/18.
Residents Affected - Some
Review of Resident #3's medical record revealed the resident had evidence of behavior monitoring on the
following days during the last two months: 01/01/22, 01/04/22, 01/05/22, 01/06/22, 01/09/22, 01/13/22,
01/14/22, 01/25/22, 01/29/22, 02/05/22, 02/09/22, 02/15/22, 02/17/22, 02/18/22, 02/24/22, 02/26/22,
02/27/22 and 02/28/22
Interview on 03/02/23 at 10:33 A.M., with the DON confirmed the resident had not had routine behavior
monitoring completed at the facility. The DON verified the resident should have daily behavior monitoring in
the medical record.
3. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE], with
diagnoses including atrial fibrillation, hypertension, anxiety depression and dementia.
Review to the annual MDS assessment dated [DATE] revealed the resident is cognitively intact and
received seven days of antipsychotic, antidepressant, hypnotic and diuretic medication.
Review of Resident #8's physician orders revealed the resident had the following medication orders:
Ariprazole (antipsychotic) 0.5 mg at bedtime for major depression dated 09/05/21; Bupropion
(antidepressant) 150 mg daily for depression dated 09/07/21; Trazadone (sedative) 50 mg daily for
insomnia dated 05/30/22; Xanax (antianxiety) 0.25 mg three times daily for anxiety dated 09/28/22; and
Zoloft (antidepressant) 150 mg daily for depression dated 09/05/21
Review of Resident #8's medical record revealed there was no behavior monitoring documented on the
following days during the last two months: 01/01,22 01/04/22, 01/06/22, 01/08/22, 01/12/22, 01/13/22,
01/16/22, 01/18/22, 01/22/22, 02/08/22, 02/11/22, 02/15/22, 02/17/22, 02/18/22, 02/20/22, 02/25/22,
02/26/22, and 02/28/22.
01/01,22 01/04/22, 01/06/22, 01/08/22, 01/12/22, 01/13/22, 01/16/22, 01/18/22, and 01/22/22.
Interview on 03/02/23 at 5:06 P.M., with the DON confirmed the resident had not had routine behavior
monitoring completed at the facility. The DON verified the resident should have daily behavior monitoring in
the medical record.
4. Review of record for Resident #58 revealed admission date on 12/13/21, with diagnoses included
dementia without behaviors, bipolar disorder, anxiety, and major depressive disorder.
Review of MDS assessment dated on 12/21/22, revealed Resident #58 was severely cognitively impaired.
Review of Resident #58 physician orders revealed the resident had the following medications orders:
Aripiprazole (antipsychotic) 5 mg by mouth at bedtime every day, ordered 02/25/23; Aripiprazole
(antipsychotic) 2 mg by mouth at bedtime, ordered 09/30/22, end date on 01/25/23; Citalopram
(antidepressant) 5 mg by mouth every day, ordered 12/13/21, end date on 02/09/22; Namenda (dementia)
20 mg by mouth daily, ordered 02/15/23; Donepezil (dementia) 10 mg by mouth at bedtime, ordered
12/13/21; Trazadone (sedative) 50 mg by mouth at bedtime, ordered 12/13/22, end date on 12/01/22 and
Trazadone
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 20 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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
(sedative) 100 mg by mouth at bedtime, ordered 12/01/22.
Level of Harm - Minimal harm
or potential for actual harm
Review of Resident #58 medical record revealed there was no behavior monitoring documented on the
following days during the last two months: 01/01/23, 01/06/23, 01/12/23, 01/13/23, 01/16/23, 01/19/23,
01/22/23, 02/08/23, 02/11/23, 02/15/23, 02/17/23, 02/18/23, 02/19/23, 02/26/23, and 03/01/23.
Residents Affected - Some
Interview on 03/02/23 at 5:06 P.M., with the DON confirmed the resident had not had routine behavior
monitoring and should have been completed daily.
Review of policy titled Behavioral Assessment, Intervention, and Monitoring dated 2001 last revised March
2019 revealed: The facility will provide and residents will receive behavioral health services as needed to
attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with
the comprehensive assessment and plan of care. Behavioral symptoms will be identified using
facility-approved behavioral screening tools and the comprehensive assessment. Residents who do not
display symptoms of, or have not been diagnosed with, mental, psychiatric, psychosocial adjustment,
substance abuse or post-traumatic stress disorder(s) will not develop behavioral disturbances that cannot
be attributed to a specific clinical condition that makes the pattern unavoidable. Behavioral health services
will be provided by qualified staff who have the competencies and skills necessary to provide appropriate
services to the residents. Residents will have minimal complications associated with the management of
altered or impaired behavior. The facility will comply with regulatory requirements related to the use of
medications to manage behavioral changes.
Under the section of Management: When medications are prescribed for behavioral symptoms,
documentation will include: rationale for use; potential underlying causes of the behavior; other approaches
and interventions tried prior to the use of antipsychotic medications;
potential risks and benefits of medications as discussed with the resident and/or family; specific target
behaviors and expected outcomes; dosage; duration; monitoring for efficacy and adverse consequences;
and plans (if applicable) for gradual dose reduction.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 21 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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
record review, policy review and staff interviews, the facility failed to give a physician ordered medication for
a weight gain for congestive heart failure as ordered. This affected one (#44) of five resident records
reviewed for medications. The facility census was 67.
Residents Affected - Few
Findings include:
Review of medical record for Resident #44 revealed admission date of 02/06/23. The resident was admitted
with diagnoses including kidney disease stage three (of four), atrial fibrillation, acute on chronic congestive
heart failure. The resident remains in the facility.
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident has impaired
cognition and required one person assistance for toileting, limited assistance for personal hygiene, bed
mobility, transfers and supervision for eating.
Review of the care plan initiated 02/06/23 revealed an altered cardiovascular status related to acute on
chronic congestive heart failure. Interventions included but were not limited to assess for shortness of
breath, diet as ordered, medications as ordered and monitor/document effectiveness.
Review of the physician orders revealed an order with a start date of 02/08/23 to give Furosemide (diuretic)
80 milligrams (mg) at 2:00 P.M., as needed for congestive heart failure if two-pound increase in daily
weight.
Record review of the daily weights for Resident #44 revealed 02/21/23 weight of 140.1 pounds, there is no
documented weight for 02/22/23, her 02/23/23 weight was 143.0 pounds.
Further record review of the daily weights for Resident #44 revealed a weight of 139.8 pounds on 02/24/23,
144.0 (4.2 pound weight increase) pounds on 02/25/23 and 147.0 (three pound weight increase) pounds on
02/26/23. There is no documentation on the February Medication Administration Record (MAR) of the as
needed Furosemide was given as ordered.
Interview on 02/28/22 at 2:39 P.M., with the Director of Nursing (DON) provided documentation of Resident
#44's refusal for 02/22/23. The DON did verify the physician was not notified of a refusal and subsequent
weight gain of 2.9 pounds in that time period. The DON verified the Furosemide was not given on 02/25/23
or 02/26/23 as ordered for a two pound weight increase.
Review of the policy titled Medication Administration General Guidelines last revised 10/22/07 revealed
medications are to be administered in accordance with the written orders of the physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 22 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0772
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't
provided.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, family and facility staff interview, the facility failed to ensure laboratory test were completed
timely. This affected two (#2 and #3) of five residents reviewed for unnecessary medications. The total
facility census was 67.
Findings include:
1. Review of the Resident #2's medical record revealed the resident was admitted to the facility on [DATE],
with diagnoses including weakness, hypothyroidism, left knee replacement, depression, anxiety, dementia
and cerebral infarction.
Review of most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident
is cognitively impaired, wandered daily but had no other behaviors. Resident #2 received six days of
anticoagulant and antianxiety medication and seven days of antipsychotic and antidepressant medications.
Review of Resident #10's admission orders dated 10/27/22 (Thursday) revealed the following orders:
Coumadin (anticoagulant) 8 milligram (mg) Monday, Wednesday, and Friday; Coumadin 7.5 mg on Tuesday,
Thursday , Saturday and Sunday dated 10/27/22.
Hold Coumadin today and tomorrow (10/27/22 and 10/28/22 and check prothrombin time (PT) and
international normalized ratio (INR) PT/INR prior to Coumadin administration on 10/29/22.
Physician order dated 10/27/22, 11/03/22 and 01/11/23 for Coumadin ordered as 8 mg Monday,
Wednesday, and Friday and 7.5 mg on Tuesday, Thursday Saturday and Sunday.
Coumadin was ordered on a laboratory result slip on 12/26/22 as 7 mg daily on Monday, Tuesday,
Wednesday, Thursday, Friday, and Saturday and 3.5 mg on Sunday.
Review of laboratory results revealed Resident #2's first PT/INR completed a the facility after admission on
[DATE] was on 11/01/22 and not on 10/29/22 as ordered.
Review of Resident #2's Medication Administration Record for October 2022 revealed the resident
Coumadin was not provided on 10/27/22, 10/28/22 as ordered. The Coumadin was held on 10/29/22 and
10/30/22 and the resident received her first dose of Coumadin at the facility on 10/31/22 with an INR
reading of 2.13. There is no laboratory result on the medical record that matches the INR result of 2.13.
Review of Resident #2's PT/INR orders revealed the resident had the following orders in the medical
record:
PT/INR weekly dated 10/31/22; Stat PT/INR on 11/04/22; PT/INR on 11/11/22; PT/INR one time only on
11/21/22; PT/INR every 2 weeks dated 11/23/22 with an end date of 12/02/22; PT/INR every 2 weeks dated
12/06/22; PT/INR on 01/05/22, PT/INR 01/25/23 and PT/INR 02/27/23
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 23 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0772
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident #2's laboratory results revealed the resident had PT/INR laboratory testing completed
on 11/01/22, 11/04/22, 11/07/22, 11/14/22, 11/17/22, 11/22/22, 11/28/22, 12/05/22, 12/07/22, 12/12/22,
12/26/22, 01/05/22, 01/25/22 and 02/27/22.
There were PT/INR laboratory orders on the 11/14/22 laboratory test results paper to draw a PT/INR on
11/17/22.
There is no order in the medical record for the PT/INR laboratory test completed on 11/28/22, 12/07/22,
and 12/12/22.
Interview on 02/27/23 at 9:40 A.M., with Resident #2's daughter stated the facility cannot complete
laboratory testing correctly for the resident's Coumadin administration, which is why she is in the nursing
facility.
Interview on 03/01/23 at 9:15 A.M., with the Director of Nursing (DON) revealed the facility does not have a
flow sheet that they track Coumadin and Pt/INR laboratory test and results on. The DON revealed the unit
manager manages the PT/INR's and Coumadin dosing and should be looking at those daily.
Interview on 03/01/23 at 9:30 A.M., with Unit Manager (UM) #111 stated there is no Coumadin tracking that
is used by the facility. UM #111 stated Resident #2 was initially followed by the house doctor incorrectly and
her Coumadin and PT/INR monitoring is only to go through her physician in the community. UM #111 stated
the laboratory testing and Coumadin monitoring should be clear in the medical record and when asked why
the orders in the medical record do not align with the laboratory testing results in the medical record UM
#111 stated she would have to get with the community physician to see if there were other results and
laboratory orders at their office that were not in the medical record at the facility the UM #111 stated she
would have to get back with the surveyor. No follow up was provided.
Interview on 03/01/23 at 11:01 A.M., with the DON confirmed the PT/INR laboratory test was not completed
on 10/29/22 as ordered at admission and the DON confirmed the PT/INR laboratory results in the medical
record do not follow the physician orders for PT/INR testing.
2. Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE], with
diagnoses including traumatic brain injury, dementia, depression and unspecified psychosis.
Review of the 01/19/23 quarterly MDS assessment revealed Resident #3 had cognitive impairment, no
behaviors, delusions or hallucinations. Resident #3 received seven days of antipsychotic, antidepressant,
and opioid medication.
Review of Resident #3's physician orders revealed an order for Atorvastatin (statin) 10 mg daily for
hyperlipidemia dated 03/24/21.
Resident #3 had a lipid profile ordered every six months dated 03/21/21.
Review of laboratory results revealed the resident had a lipid profile in the last year on 11/07/21 and not
every six months as ordered.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 24 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0772
Interview on 03/02/23 at 2:26 P.M., with Director of Nursing (DON) verified the lipid was not completed
every 6 months as ordered.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 25 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0776
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
review of medical record and staff interviews, the facility failed to ensure physician ordered radiology test
were completed timely. This affected one (#22) of 24 resident reviewed for radiology. The facility census was
67.
Residents Affected - Few
Findings included:
Review of Resident #22's medical record revealed an admission date on od 12/22/21 and re-admission
date of 02/11/23. Diagnoses for Resident #22 included chronic kidney disease, chronic obstructive
pulmonary disease, nontraumatic subdural hemorrhage on 02/05/23, and dysphagia.
Review of the Minimum Data Set (MDS) assessment dated on 01/05/23 revealed Resident #22 was
severely cognitively impaired and required for assistance extensive one-person physical assist for dressing,
bed mobility, transfers, eating, bathing, and toilet use. Resident #22 used a wheelchair to ambulate at the
facility.
Review of hospital discharge document dated on 02/05/23 revealed to complete a CAT (Computed Axial
Tomography) scan of the head without contrast by or approximate on 02/20/23.
Review of progress note dated on 02/16/23 at 9:54 P.M., documented by Licensed Practical Nurse (LPN)
#116, documented the Nurse Practitioner into see resident and a new order for CAT scan without contrast,
to follow up of subdural hematoma.
Review of physician order for Resident #22 dated 02/16/23, revealed an order for CAT Scan without
contrast, to follow up with subdural hematoma on 02/20/23 approximate.
Observation on 02/27/23 at 10:40 A.M., with Resident #22 who had a large black bruise to right cheek that
was swollen the size of golf ball.
Interview on 03/01/23 at 10:30 A.M., with Unit Manager #111, stated she did not remember when the CAT
Scan for Resident #22 was ordered for follow up per hospital discharge.
Interview on 03/01/23 at 10:35 A.M., with Medical Records #134, stated she did not remember when she
set up the CAT Scan of head for Resident #22 for follow up after hospital discharge on [DATE].
Interview on 03/01/23 at 10:45 A.M., with Unit Manager #111, stated the CAT scan was not ordered timely
per physicians order.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 26 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0791
Provide or obtain dental services for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, record review, resident and facility staff interview, the facility failed to timely obtain dental
services. This affected one (#10) of three residents reviewed for dental services. The total facility census
was 67.
Residents Affected - Few
Findings include:
Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE], with
the diagnoses including osteomyelitis, peripheral vascular disease, type two diabetes, atrial fibrillation,
dementia, and hypertension.
Review of the quarterly Minimum Data Set assessment dated [DATE] revealed the resident had cognitive
impairment, and did not have mouth pain, discomfort or difficulty with chewing.
Resident #10's medical record was silent to the resident being provided dental services at the facility.
Review of Resident #10's admission contract signed by the resident revealed the resident had signed to
receive dental practitioner services at the facility.
Review of the last year of dental visits revealed the dentist had been at the facility on the following dates
02/20/23, 12/13/22, 10/17/22, 09/23/22, 07/27/22, 07/13/22, 06/23/22 and 05/06/22 and Resident #10 was
not seen at any of those visits by the dental practitioner.
Observation on 02/27/23 at 11:28 A.M., with Resident #10 revealed he has tooth fragments present in his
mouth but no full teeth are present in his mouth. Interview at the time, Resident #10 stated he would be
interested in having false teeth, but he does no have the money to purchase false teeth. The resident
denied seeing a dental practitioner at the facility and denied pain related to his tooth fragments. Resident
#10 opened his mouth and four teeth fragments were visible on the lower gum line level with the gum
surface. The teeth fragments were white in color with black spots on them and were in the location where
the front four bottom teeth should be present.
Interview and observation on 03/01/23 at approximately 2:15 P.M., with Licensed Practical Nurse #120 of
Resident #10's oral cavity revealed Resident #10 had four partial tooth fragments on the bottom gum line
where the front four teeth would be located, the fragments were level with the gum surfaces and were white
with black spots on the fragments. LPN #120 moved Resident#10's upper lip to reveal the upper gum of
Resident #10 and it was observed the resident had a partial tooth fragment level with the upper gum
surface on the right side of his upper gum. The tooth fragment was white with black spot on the fragment.
LPN #120 verified the tooth fragments were present and during the observation Resident #10 indicated the
areas do no hurt him.
Interview on 03/01/23 at 4:09 P.M., with the Director of Nursing (DON) revealed the process for ancillary
practitioners is the Social Service Designee (SSD) #139 will set up the practitioner visits at the facility and
after the visit the SSD #139 will place the practitioner notes on the resident's medical record. The DON
stated on 02/28/23 the facility identified the process was not being followed and the SSD #139 was not
obtaining the ancillary practitioner notes and placing them in the resident's medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 27 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on record review, observation, staff interview, and policy review, the facility failed to provide a diet
order to meet the needs of the resident. This affected one (#22) of three residents reviewed for dietary
needs. The facility census was 67.
Findings include:
Review of record for Resident #22 revealed an admission date on of 12/22/21 and re-admission date of
02/11/23, with diagnosis including chronic kidney disease, chronic obstructive pulmonary disease,
nontraumatic subdural hemorrhage on 02/05/23, and dysphagia.
Review of Minimum Data Set (MDS) assessment dated on 01/05/23 revealed the resident was severely
cognitively impaired. Resident required for assistance extensive one-person physical assist for dressing,
bed mobility, transfers, eating, bathing, and toilet use.
Review of the plan of care dated on 02/12/23 revealed Resident #22 was at risk for nutritional status due to
fracture to right humerus. Resident was total dependence during meals at all times. Interventions included
monitor for signs and symptoms of chewing or swallowing difficulties, honor food preferences, reinforce to
the resident the importance of maintaining the diet ordered, offer substitutes as needed, and provide serve
diet as ordered.
Observation on 02/27/23 at 12:45 P.M., with Resident #22 who had received a magic cup, thickened juice,
water honey thick, tomato soup, and potatoes. Water and tomato soup was honey thick and running.
Interview on 02/27/23 at 12:50 P.M., with State Tested Nurse Aid (STNA) #304 who stated Resident #22
had honey thick with puree diet.
Review of the medical record on 02/27/23 at 12:52 P.M., of Resident #22 Electronic Chart and hard chart
revealed no diet order was put into the chart.
Interview on 02/27/23 at 1:10 P.M., with Licensed Practical Nurse (LPN) #120 stated there was not a diet
order in Resident #22 electronic chart. LPN #120 stated that the resident had been admitted recently from
the hospital. LPN #120 stated her admission date was on 02/11/23. LPN #120 stated it looks like she does
not have a diet order.
Observation on 02/27/23 at 1:13 P.M., with Resident #22 who was being fed by STNA #304 with thin
tomato soup and thin water in glass.
Interview on 02/27/23 at 1:13 P.M., with LPN #120 who stated the water and tomato soup look like too thin
liquid for the resident. LPN #120 stated she thought Resident #22 should have pudding thick for fluids. LPN
#120 stated she was going to put diet order in right now.
Review of diet order revealed Resident #22 had a diet placed in electronic chart. Diet was regular diet,
pureed texture, and pudding consistency. Dated on 02/27/23 at 1:47 P.M. , the order was placed in chart.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 28 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Review of the policy tilted Therapeutic Diet Policy dated on 10/2017 revealed a therapeutic diet was
considered a diet ordered by a physician, practitioner or dietician as part of treatment for a disease or
clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet for example altered
consistency diet.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 29 of 30
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
365437
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/02/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest of Urbana, Inc
2380 St Rt 68 S
Urbana, OH 43078
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 - Many
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 and policy reviews, the facility failed to store food and maintain food in
a safe fashion and and failed to serve food in a hygienic manner. This had the potential to affect 67 of 67
residents who receive food from the kitchen. The total facility census was 67.
Findings include:
Observation of the reach in refrigerator with Dietary Manager (DM) #113 in the central kitchen on 02/27/23
at 9:40 A.M., revealed turkey lunch meat was in a zipper plastic bag dated 02/20/23 and ham lunch meat
was in a zipper plastic bad was dated 02/20/23. At the time of the observation, DM #113 stated the two
lunch meats should only be stored in the refrigerator for three days and DM #113 removed the lunch meat
zipper bags from the refrigerator so they could not be used. There were two bowls in the reach in
refrigerator that had a red liquid in them and the bowls were not dated or labeled. DM #113 verified the
bowls should be dated and labeled and removed the bowls. DM #113 stated they were tomato soup.
Observation of the lunch meal tray line on 03/01/23 from 12:00 P.M. to 12:35 P.M., observed [NAME] #79
picked up the egg roll, and place it on the plate with his gloved hand. Then [NAME] #79 after all food was
placed on the plate, the cook would pick up the meal ticket for the specific resident and place it next to the
resident plate to be placed in the food cart for distribution to the residents on the floor.
Interview on 03/01/23 at 12:30 P.M., with DM #113 confirmed [NAME] #79 should no touch food items with
his gloved hand and then touch non food items to prevent contamination of the food.
Interview with the Director of Nursing on 03/01/23 at 12:40 P.M. it was confirmed the facility had not had
any outbreak of illness related to food contamination. The DON verified the kitchen staff plating food should
not touch food items with the same gloved hand that touches non food items.
Review of the policy titled Food Storage dated 2021 revealed leftover food should be stored in covered
containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated.
Leftover food must be used within seven days or discarded as per the 2017 Federal Food Code. All foods
should be covered, labeled and dated and routinely monitored to assure that food (including leftovers) will
be consumed by their safe use by dates, or frozen (where applicable), or discarded.
Review of policy titled Food Preparation and Service dated 2001 revealed food and nutrition services
employees prepare, distribute, and serve food in a manner that complies with safe food handling practices.
Cross-contamination can occur when harmful substances, i.e., chemical or disease-causing
microorganisms are transferred to food by hands (including gloved hands), food contact surfaces, sponges,
cloth towels. or utensils that are not adequately cleaned. Cross-contamination can also occur when raw
food touches or drips onto cooked or ready-to-eat foods.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365437
If continuation sheet
Page 30 of 30
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
30 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.
F553 - The right to participate in the development and implementation of his or her
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F584 - Safe Environment
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
F636 - Resident Assessment
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F582 - The facility must—
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F685 - Vision and hearing
Assist a resident in gaining access to vision and hearing services.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F772 - The facility must provide or obtain laboratory services to meet the
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
F776 - Radiology and other diagnostic services
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
- 0271GeneralS&S Fpotential for harm
Have exits that are accessible at all times.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0321GeneralS&S Fpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0511GeneralS&S Fpotential for harm
Have properly installed electrical wiring and gas equipment.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F916 - Have a floor at or above grade level
Have a battery powered remote alarm panel in a location accessible by operating personnel.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F920 - Dining and Resident Activities
Ensure proper usage of power strips and extension cords.
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F758 - Medication Errors
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.
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.
F791 - Dental Services
Provide or obtain dental services for each resident.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the March 2, 2023 survey of VANCREST OF URBANA, INC?
This was a inspection survey of VANCREST OF URBANA, INC on March 2, 2023. The surveyor cited 30 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VANCREST OF URBANA, INC on March 2, 2023?
Yes, 30 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Allow resident to participate in the development and implementation of his or her person-centered plan of care."
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.