Inspection·January 18, 2024

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 medical record review and staff interview the facility failed to ensure resident assessments were accurately completed. This affected two (#15 and #31) of two residents reviewed for accurate resident assessments. The facility census was 43. Residents Affected - Few Findings include: 1. Review of the medical record revealed Resident #15 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease, acute and chronic respiratory failure, hemiplegia affecting left nondominant side, essential hypertension, Alzheimer's disease, major depressive disorder, and acute respiratory failure with hypoxia. Review of the Minimum Data Set assessment dated [DATE] revealed Resident #15 was cognitively intact. The assessment documented Resident #15 was taking an anticoagulant. Review of current physician orders revealed an order dated 09/15/22 for aspirin chewable tablet 81 milligram (mg) with directions to give one tablet by mouth one time a day. 2. Review of the medical record revealed Resident #31 was admitted on [DATE]. Diagnoses included poly-osteoarthritis, unspecified dementia, unspecified osteoarthritis, essential hypertension, type two diabetes mellitus without complications, muscle weakness, fibromyalgia, unspecified dementia, hyperlipidemia, anxiety disorder, and depression. Review of the MDS assessment dated [DATE] revealed Resident #31 was severely cognitively impaired. The assessment documented Resident #31 was taking an anticoagulant. Review of physician orders dated 01/26/23 revealed an order for aspirin tablet delayed release 81 milligram (mg) with directions to give one tablet by mouth at bedtime. Review of physician orders from 01/25/23 to 01/18/24 revealed no medications classified as a anticoagulant were prescribed for Resident #31. Interview on 01/18/24 at 8:33 A.M. with MDS Coordinator #150 verified Resident #15 and #31's physician order for aspirin were miscoded as an anticoagulant. 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 2 Event ID: 365680 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 365680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/18/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Hicksville 601 Defiance Avenue Hicksville, OH 43526 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)