Inspection visit
Health inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, staff and resident interviews, and policy review, the facility failed to
ensure a resident had a call light within reach at all times. This affected one (#10) of 32 residents observed
for call light use. The facility census was 109.
Residents Affected - Few
Findings include:
Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included multiple sclerosis, quadriplegia, obesity, and diabetes mellitus.
Review of the Minimum Data Set (MDS) assessment, dated 11/11/21, revealed Resident #10 was
cognitively intact and he was totally dependent on one to two staff members for all activities of daily living.
Review of the plan of care, dated 07/07/21, revealed Resident #10 had a muscular skeletal disorder and
limited range of motion. The interventions included to be sure his call light was within reach and respond
promptly to all requests for assistance.
Observation on 11/21/21 at 10:20 A.M. revealed Resident #10's soft touch call light cord was draped over
the top left side of the mattress with the call light on the floor. Resident #10 was asleep in the bed.
Subsequent observations on 11/21/21 at 12:30 P.M. revealed Resident #10's call light was in the same
place as the observation on 11/21/21 at 10:20 A.M.
Observation and interview with Resident #10 on 11/21/21 at 1:15 PM revealed the call light was hanging
from the top left corner of the mattress with the call light touching the floor out of the resident's reach.
Resident #10 stated the call light has to be in his hand so he can use it. Resident #10 stated he was
unaware of where his call light was now. Resident #10 verified he has some movement of his fingers and
can use a soft touch call light and he verified he could not turn himself in bed or raise his arms to feed
himself. Resident #10 verified his call light was not in his hand.
Interview with Licensed Practical Nurse (LPN) #300 on 11/21/21 at 1:20 P.M. stated Resident #10 can use
a soft touch call light if it was in his hand as he has some movement of his hands. LPN #300 verified
Resident #10's call light was hanging from the top left corner of his mattress and was out of the resident's
reach.
Review of the facility's policy titled Call Lights, last revised 04/2019, revealed before leaving the resident's
room, check to see that the resident's call light is within reach.
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 14
Event ID:
365735
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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 0569
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Level of Harm - Minimal harm
or potential for actual harm
Based on record review, review of the facility's policy, and staff interview, the facility failed to notify the
resident and resident's representative when the resident's amount exceeded the resource limit. This
affected one (Resident #84) of five residents reviewed for personal trust fund accounts. The facility
identified 70 residents who have personal trust fund accounts. The facility census was 109.
Residents Affected - Few
Findings include:
Review of Resident #84's medical record revealed an admission date of 01/29/16 with diagnoses which
included spastic hemiplegia, cerebral vascular accident, diabetes, and depression. Review of the Minimum
Data Set (MDS) assessment, dated 10/02/21, revealed Resident #84 had impaired cognitive skills.
Review of Resident #84's profile revealed the resident's brother was the resident's responsible party and
emergency contact.
Interview on 11/22/21 at 7:45 A.M. with the Business Office Manager (BOM) #140 revealed Resident #84's
current balance was $4,593.21. The BOM #140 identified the resident's amount included a stimulus check
of $600 received in January 2021 and a $1,400 stimulus check received in April 2021. BOM #140
confirmed Resident #84's trust account, excluding the stimulus amounts, exceeded the maximum allowed
by Medicaid. BOM #140 confirmed knowledge that exceeding the allowed amount puts the resident at risk
for loss of their Social Security Income (SSI) benefits. BOM #140 confirmed the resident's representative
had not been notified.
Review of the facility's policy titled Resident Trust Policy, dated 07/2019, revealed a resident on medical
assistance must be notified whenever their accounts are within $200 of their asset limit. The policy revealed
the resident's balances should be monitored monthly to ensure the state maximum balances are not
exceeded.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 2 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
Based on medical record review, review of the facility's policy, and staff interviews, the facility failed to
ensure the resident's Ohio Comfort Care Do Not Resuscitate (DNR) form was accurately completed. This
affected one (Resident #38) of three residents reviewed for advanced directives. The facility census was
109.
Findings include:
Review of Resident #38's medical record revealed an admission date of 12/16/20. Diagnoses included
pneumonia, morbid obesity, and cerebrovascular disease.
Review of the Minimum Data Set (MDS) assessment, dated 11/05/21, revealed Resident #38 had impaired
cognition and the resident required extensive one-person assistance for bed mobility, dressing, toileting,
and personal hygiene.
Review of Resident #38's Ohio Comfort Care Do Not Resuscitate (DNR) order form, dated 12/23/20,
revealed the form was completed by the Certified Nurse Practitioner (CNP) #450. The form included a
statement which read; REQUIRED for APRN (advanced practice nurse) or PA (physician assistants): Name
of supervising physician (PA) or collaborating physician (APRN) for this patient and the physician's National
Provider Identifier (NPI), Drug Enforcement Administration (DEA), or the Ohio medical license number. The
form did not have the physician's name and/or NPI, DEA, or medical license number.
Interview on 11/22/21 at 1:35 P.M. with the Administrator confirmed Resident #38's Ohio Comfort DNR form
was incomplete.
Interview on 11/22/21 at 1:55 P.M. with the facility's Medical Director (MD) #500 confirmed the form was
incomplete.
Review of the facility's policy titled Promoting the Right of Self-Determination for Healthcare Decisions and
Advanced Healthcare Directives, dated 03/2021, revealed the physician is responsible for determining the
resident's diagnosis, prognosis, and capacity for making healthcare decisions and to educate the resident
and legal healthcare-decision-maker.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 3 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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
medical record review, resident and staff interviews, and policy review, the facility failed to notify the
physician of significant weight gain for one resident (#60) of five residents reviewed for alteration in weight.
The facility identified nine residents with unplanned significant weight gain or loss. The facility census was
109.
Findings include:
Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including non alcoholic liver cirrhosis, diabetes mellitus, and psoriasis. Review of the annual
Minimum Data Set (MDS) assessment, dated 10/12/21, revealed Resident #60 had no cognitive deficits.
Review of the History and Physical, dated 11/17/20 (prior to admission on [DATE]) revealed on 05/04/20,
the resident experienced elevated liver enzymes . On 10/12/20, the resident was diagnosed with lactic
acidemia and liver cirrhosis due to non alcoholic fatty liver disease.
Review of the plan of care, dated 07/12/21, revealed the goals were for Resident #60 to be adequately
hydrated and consume at least 50% of most meals through next review. The interventions included to
assess the resident for signs and symptoms of dehydration (increased confusion, agitation, decreased
urine output, dry mucous membranes) and notify the physician of abnormalities. Monitor the resident's oral
intake and weight routinely.
Review of the nutrition progress note, dated 07/12/21, revealed Resident #60's weight was 109 pounds with
no significant change. The resident's oral intakes were between 25 to 75% and she was receiving Ensure
(a nutritional supplement ) twice a day.
Review of the physician visit, dated 08/19/21, seen by Certified Nurse Practitioner (CNP) #400, stated
Resident #60's weight was 109 pounds.
Review of the nutrition progress note, dated 09/15/21, revealed Resident #60 triggered a significant weight
gain of 23.4 % in two months. Her weight was 133 pounds. A request was made for the resident to be
re-weighed with no re-weigh available. The resident's appetite has increased since July 2021. She was
receiving Ensure twice a day. Will monitor her weight and discontinue the Ensure if weight increases
continue.
There was no documentation in Resident #60's medical record the physician and/or CNP was notified of
Resident #60's significant weight gain from 09/15/21 to 10/18/21.
Review of the physician visit, dated 10/19/21, revealed Resident #60 was seen by CNP #400 and her
weight was noted to be 133 pounds. There was no mention of the cirrhosis of the liver.
Review of the nutrition progress note, dated 10/21/21, revealed Resident #60 triggered an additional
significant weight gain of 7.2% in one month. Her weight was 140 pounds and it was up by seven
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 4 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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
pounds in one month. The resident's oral intakes remained at 50 to 100% of meals. The recommendation
was to discontinue the Ensure supplements.
Review of the nursing progress notes, dated 10/24/21, revealed Resident's #60 family member called and
stated an appointment with Gastroenterologist #410 was missed on Friday, 10/22/21. The family member
stated the appointment needs to be rescheduled.
Review of the nutrition progress note, dated 11/16/21, revealed Resident #60 continues to have a
significant weight gain with current weight of 145 pounds. Her meal intakes continue to be 50-100% of a
carbohydrate controlled no added diet . The Ensure supplements were discontinued on 10/28/21.
There was no documentation in Resident #60's medical record the physician and/or CNP was notified of
Resident #60's significant weight gain from 10/20/21 to 11/21/21.
Observation on 11/22/21 at 8:51 A.M. revealed Resident #60 was lying in bed on her right side. Her
abdomen was exposed revealing her abdomen to be very large.
Interview with Resident #60 on 11/22/21 at 8:51 A.M. stated she has not been able to get out of bed for two
days due to back pain. She stated she was able to get up in a wheelchair but the past two days she can't
even sit up. She verified she has experienced an increase in the size of her abdomen over the past few
months.
Interview with Director of Nursing (DON) on 11/23/21 at 2:30 P.M. verified Gastroenterologist #410 was
managing the resident's care for cirrhosis of the liver. She verified the resident had missed an appointment
on 10/22/21 due to the transportation was not arranged by the facility. She verified the appointment has
been rescheduled for 11/30/21. She verified CNP #400 and Gastroenterologist #410 were not updated on
the continued significant weight gain. She verified the resident had gained 36 pounds in four months.
Subsequent interview with Resident #60 on 11/23/21 at 2:45 P.M. verified she had missed an appointment
with the gastroenterologist on 10/22/21 because the facility did not take her. Resident #60 stated she was
aware her abdomen has increased in size. Resident #60 stated she doesn't feel she was eating that much
and feels it could be fluid due to her liver disease. She verified this has happened in the past.
Review of the facility's policy titled Notification of Change, revised 06/2019, stated under Examples of
Notification of Physician and Family, physicians should be notified for significant changes in weight.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 5 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses
including non alcoholic liver cirrhosis, diabetes mellitus, and psoriasis. Review of the annual Minimum Data
Set (MDS) assessment, dated 10/12/21, revealed Resident #60 had no cognitive deficits.
Review of the plan of care, dated 07/12/21, revealed the goals were for Resident #60 to be adequately
hydrated and consume at least 50% of most meals through next review. The interventions included to
assess the resident for signs and symptoms of dehydration (increased confusion, agitation, decreased
urine output, dry mucous membranes) and notify the physician of abnormalities. Monitor the resident's oral
intake and weight routinely.
Review of the nutrition progress note, dated 07/12/21, revealed Resident #60's weight was 109 pounds with
no significant change.
Review of the nutrition progress note, dated 09/15/21, revealed Resident #60 triggered a significant weight
gain of 23.4% in two months. Her weight was 133 pounds.
Review of the nutrition progress note, dated 10/21/21, revealed Resident #60 triggered an additional
significant weight gain of 7.2% in one month. Her weight was 140 pounds and it was up by seven pounds in
one month.
Review of the nutrition progress note, dated 11/16/21, revealed Resident #60 continues to have a
significant weight gain with current weight of 145 pounds.
Further review of the plan of care in the electronic record revealed the revealed the plan of care was last
updated on 07/12/21. There was an alert in the medical record stating the plan of care update was over
due. There was no mention in the plan of care concerning the weight gain of 37 pound weight gain in the
past four months or new interventions in place.
Interview with the Director of Nursing (DON) on 11/23/21 at 2:30 P.M. verified the resident had gained 36
pounds in four months.
Interview with Registered Nurse (RN) MDS Coordinator #500 on 11/22/21 at 2:30 P.M. verified the plan of
care for Resident #60 was not updated since 07/12/21. The plan of care should have been updated
following the quarterly MDS review that was completed 10/12/21. RN MDS Coordinator #500 verified there
was not mention in the plan of care regarding a significant weight gain of 36 pounds.
Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure
care conferences were completed quarterly for Resident #50. The facility also failed to ensure the care
plans were revised quarterly for Resident #60. This affected two (#50 and #60) out of 22 residents reviewed
for care plans during the annual survey.
Findings include:
1. Medical record review for Resident #50 revealed an admission date of 09/21/17. Diagnoses included
bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/19/21,
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 6 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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 0657
revealed Resident #50 was cognitively intact.
Level of Harm - Minimal harm
or potential for actual harm
Review of the care conferences, dated 01/13/21, revealed this was the last care conference provided to
Resident #50.
Residents Affected - Few
Interview with Resident #50 on 11/21/21 at 10:30 A.M. revealed she had not received a care conference in
a long time.
Interview with Licensed Social Worker (LSW) #204 on 11/23/21 at 9:31 A.M. confirmed she was only doing
quarterly care conference if the residents and the families requested one to be completed.
Review of the facility's policy titled Care Plan Policy, dated 08/01/18, revealed each resident will have an
initialized care plan based on comprehensive assessment and developed by the interdisciplinary team.
Care conferences will be held quarterly and as needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 7 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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
Based on medical record review, staff interview, and policy review, the facility failed to ensure weights were
obtained and documented as ordered for Resident #85. This affected one (#85) of two residents reviewed
for edema. The facility census was 109.
Residents Affected - Few
Findings include:
Review of Resident #85's medical record revealed an admission date of 11/20/19. Diagnosis included
cerebrovascular disease, hypertension, atherosclerotic heart disease of native coronary artery without
angina pectoris, paroxysmal atrial fibrillation, and chronic kidney disease.
Review of the plan of care, dated 06/24/21, revealed Resident #85 was at risk for alteration in cardiac
function related to coronary artery disease, cardiac arrhythmia, hypertension, and history of myocardial
infarction. Interventions included to assess for edema and report any problems to the physician.
Review of the annual Minimum Data Set (MDS) assessment, dated 10/21/21, revealed Resident #85
received diuretics.
Review of the physician orders, dated 10/20/21, revealed an order for weekly weights every Wednesday for
edema.
Review of the weight documentation in the electronic medical record, revealed there were weights obtained
on 10/05/21 and 11/03/21. There was no documentation that weights were obtained on five Wednesdays:
10/20/21, 10/27/21, 11/03/21, 11/10/21, and 11/17/21. Review of the Treatment Administration Record
(TAR) for November 2021 revealed weekly weight day shift every Wednesday was signed off by nursing
staff on 11/03/21, 11/10/21, and 11/17/21 with no weights documented in the medical record.
Interview on 11/22/21 at 2:07 P.M. with the Director of Nursing (DON) stated she was not able to produce
the actual weights obtained on 11/10/21 and 11/17/21 that were signed off by nursing staff.
Review of the facility's policy titled Weight Policy, revised date 02/2019, revealed to determine weight gain
or loss, weights will be monitored on admission/readmission, weekly times four weeks, and monthly
thereafter, unless otherwise ordered.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 8 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM
and/or mobility, unless a decline is for a medical reason.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observations, resident and staff interviews, the facility failed to implement a palm
protector to prevent further decline in range of motion for one resident (#49). This affected one (#49) of
three residents reviewed for limited range of motion. The facility identified 27 residents with contractures.
The facility census was 109.
Findings include:
Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE].
Diagnoses included dementia, contracture of multiple sites and Parkinson's disease.
Review of the annual Minimum Data Set (MDS) assessment, dated 07/06/21, revealed Resident #49 had
moderate cognitive deficits. Resident #49 required extensive assistance one person for personal hygiene
and dressing. He had no rejection of care.
Review of the plan of care, dated 07/09/21, revealed Resident #49 had Parkinson's disease. The goal was
for Resident #49 to remain free of further signs and symptoms of discomfort or complications related to
Parkinson's disease. The interventions included adaptive devices as recommended by therapy or physician
and monitored for safe use.
Review of the physician order, dated 09/15/21, stated Resident #49 was to wear a palm protector splint in
his left hand at all times except for care as tolerated. Remove for care and monitor for skin integrity.
Review of the Occupational Therapy Discharge Summary, dated 11/19/21, revealed the discharge
recommendations and status stated a splint and brace program and staff was trained on the use of a left
hand palm protector to be worn at all times except during care to prevent further decline in range of motion
of his left hand.
Interview with Occupational Therapist (OT) #425 on 11/22/21 at 3:00 P.M. verified Resident #49 had a palm
protector order to be in his left hand at all times except during for care. OT #425 verified Resident #49 had
received occupational therapy and was discharged on 11/19/21. OT #425 verified the discharge
recommendation for Resident #49 was to wear a palm protector in his left hand to prevent further decline in
the range of motion in his left hand. OT #425 stated Resident #49 was very cooperative and had no
complaints regarding wearing the palm protector.
Observation on 11/22/21 at 9:00 A.M. revealed Resident #49 was in bed with soft touch call light in place.
Both hands appeared contracted. There were no splint or palm protector in place.
Interview with Licensed Practical Nurse (LPN) #100 on 11/22/21 at 9:20 A.M. stated Resident #49 had
bilateral contracture of his hands. LPN #100 verified Resident #49 did not have his splints in place. She
stated sometimes they place rolled wash clothes in his hands.
Observation on 11/22/21 at 11:00 A.M. revealed Resident #49 was in bed. Resident #49's left hand was
contracted. There was no splint or palm protector in place.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 9 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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 0688
Level of Harm - Minimal harm
or potential for actual harm
Interview on 11/22/21 11:00 A.M. with LPN #151 verified Resident #49 did not have a splint. LPN #151
stated sometimes the staff used wash clothes in his hands.
Interview on 11/22/21 at 2:30 P.M. with State Tested Nursing Assistant (STNA) #160 verified she works with
Resident #49 and Resident #49 does not have any splints for his hands.
Residents Affected - Few
Observation on 11/23/21 at 2:00 P.M. revealed Resident #49 was in a wheelchair in his room and not
wearing a palm protector or a splint. A palm protector was noted to be on the over bed table.
Interview with Resident #49 on 11/23/21 at 2:00 P.M. verified the palm protector was on the over bed table.
Resident #49 stated the staff was supposed to put it in his left hand but they do not do this. Resident #49
verified he does not refuse to let staff put it on as he thinks it was comfortable.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 10 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated,
prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic
medications are only used when the medication is necessary and PRN use is limited.
Based on medical record review, staff interview, and policy review, the facility failed to ensure an
anti-anxiety medication was addressed every 14 days. This affected one (#88) of five residents reviewed
during the annual survey for unnecessary medications. The facility census was 109.
Findings include:
Medical record review for Resident #88 revealed an admission date of 02/22/21. Diagnoses included
anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/05/21, revealed
Resident #88 was severely cognitively impaired.
Review of the physician orders, dated 10/17/21, revealed Lorazepam 0.5 milligram (mg) to give one tablet
every six hours as needed (PRN) for anxiety. There was no physician order to extend Lorazepam past the
14 days from 10/17/21 and there was not a specified duration of the medication noted by the prescriber.
Lorazepam was discontinued on 11/20/21.
Review of the Note to Attending Physician recommendation from the pharmacy, dated 10/28/21, revealed
Resident #88 was receiving a PRN psychotic therapy Lorazepam and per the Center of Medicare and
Medicaid Services (CMS) guidance, this medication order cannot be extended beyond 14 days without a
specified duration of therapy by the prescriber indicating the appropriateness of continuing the medication.
This was not signed by the physician.
Review of the Medication Administration Record (MAR) from 10/17/21 through 10/31/21 revealed
Lorazepam was administered six times during this time period. From 11/01/21 through 11/19/21,
Lorazepam was administered six times.
Interview with the Director of Nursing (DON) on 11/23/21 at 12:00 P.M. verified the Lorazepam for Resident
#88 did not have a specified duration of therapy by the prescriber and it was administered beyond the 14
days for a PRN antipsychotic medication. The DON stated the physician was given 45 days to address the
pharmacy recommendation even if it was for something that would be considered a significant medication
change.
Review of the facility's policy titled Medication Regimen Review Policy, dated 06/01/18, revealed the
pharmacist must report irregularities to the Attending Physician and the DON, and the irregularities must be
acted upon. Any irregularities noted by the pharmacist must be documented on a separate report and sent
to the facility for review by the Attending Physician and the DON. For non-urgent recommendations, the
Attending Physician must address in a timely manner to best needs of the resident, which should be on the
next scheduled visit but no later then 45 days.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 11 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
Based on record review, observation, review of the facility policy, and staff interview, the facility failed to
ensure stored medications were within expiration dates. This affected one of four medication carts reviewed
for medication storage. The facility had a total of six medication carts. This affected two residents (#24 and
#41) who had insulin stored in the medication cart. The facility census was 109.
Findings include:
Observation of the facility's South medication cart on 11/22/21 at 3:48 P.M. with Licensed Practical Nurse
(LPN) #243 revealed a vial of Lantus Insulin Glargine Injection 100 units/milliliter (units/ml) for Resident #41
with an open date 09/25/21. Review of the pharmacy label on the vial revealed instructions to discard 28
days after opening. Observation of Lantus Insulin Glargine Injection Flexpen 100 units/ml for Resident #41
revealed an open date of 09/19/21. Observation of Novolin 70/30 Human Insulin Isophane Suspension
Flexpen for Resident #24 revealed an open date 10/09/21. Review of the pharmacy label to discard 28 days
after opening. These findings were verified by LPN #243.
Review of the facility's undated policy titled Medication Storage, dated 06/21/17, revealed contaminated, or
deteriorated medications and those in containers that are cracked, soiled, or without secure closures are
immediately removed from stock, disposed of according to procedures for medication destruction, and
reordered from the pharmacy, if replacements are needed.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 12 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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 0770
Provide timely, quality laboratory services/tests to meet the needs of residents.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
medical record review, observation, and staff interview, the facility failed to obtain laboratory tests as
ordered by the physician for one resident (#60) of six residents reviewed for laboratory results. The facility
census was 109.
Residents Affected - Few
Findings include:
Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with
diagnoses including non alcoholic liver cirrhosis and psoriasis. Review of the annual Minimum Data Set
(MDS) assessment, dated 10/12/21, revealed Resident #60 had no cognitive deficits.
Review of the physician progress note from Gastroenterologist #410, dated 07/22/21, revealed Resident
#60 was seen in the office for alternating constipation and diarrhea and cirrhosis of the liver. The plan
stated to obtain an ultrasound of the liver, laboratory studies including complete blood count (CBC),
comprehensive metabolic panel (CMP), ammonia level and pro-time (PT) in three months and follow up
with the Gastroenterologist for a 30-minute follow up visit. The gastroenterologist appointment was
scheduled for 10/22/21.
Review of the laboratory results revealed on 10/21/21, the CBC and CMP were drawn and results were
obtained. There was no results for ammonia or protime levels. There was no indication in Resident #60's
medical record ammonia level or protime was obtained. The medical record was silent as to an ultrasound
of the liver being obtained.
Observation on 11/22/21 at 8:51 A.M. revealed Resident #60 was lying in bed on her right side. Resident
#60's abdomen was exposed revealing her abdomen to be very large.
Interview with Director of Nursing (DON) on 11/23/21 at 2:30 P.M. verified Gastroenterologist #410 was
managing Resident #60's care for cirrhosis of the liver. The DON verified the ammonia level, protime, and
ultrasound of the liver as ordered by Gastroenterologist #410 had not been obtained. The DON verified the
laboratory studies and ultrasound of the liver was to be completed prior to the 10/22/21 appointment with
the Gastroenterologist and had not been obtained. The DON stated she called the Gastroenterologist office
that day (11/23/21) and verified the tests were to be completed prior to Resident #60's follow up
appointment on 10/22/21. The DON verified Resident #60 missed her gastroenterologist appointment on
10/22/21 because the facility did not schedule transportation. The DON stated the appointment has been
rescheduled for 11/30/21.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 13 of 14
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
365735
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/23/2021
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest-Upper Valley
3232 North County Road 25a
Troy, OH 45373
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 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
Based on record review, observation, review of the facility's policy, and staff interviews, the facility failed to
ensure resident care equipment was maintained in a clean condition. This affected one (Resident #26) of
32 residents observed for clean environment. The facility census was 109.
Findings include:
Medical review for Resident #26 revealed admission date 03/08/13 and readmission date 05/16/21.
Diagnoses included anoxic brain damage, dysphagia, aphasia, gastrostomy, and tracheostomy.
Review of the annual Minimum Data Set (MDS) assessment, dated 09/10/21, revealed Resident #26
required tube feed nutrition and tracheostomy care.
Observation on 11/21/21 at 2:18 P.M. revealed there was tube feed dried on Resident #26's platform for the
tracheostomy mist machine. A thick layer of dried tube feed covered the entire back ledge of the platform. A
housekeeper was cleaning the room and had sprayed a cleaner on the dried tube feed spots on the floor.
The housekeeper stated she did not clean the tube feed pump, stand, platform, or the tracheostomy mist
machine.
Interview on on 11/21/21 at 2:25 P.M. with Registered Nurse (RN) #20 verified the dried tube feeding on the
tracheostomy mist machine platform.
Interview on 11/22/21 at 2:08 P.M. with the Director of Nursing (DON) stated it was housekeeping
responsibility to clean the floors. She stated nursing should clean the equipment poles, pumps, and the
tracheostomy mist machine.
Review of the facility's policy titled Cleaning Resident Rooms Policy, revision date of 04/2019, revealed
cleaning should be top to bottom, and dirtiest surfaces should be cleaned last.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365735
If continuation sheet
Page 14 of 14
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Back to topCitations
11 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.
F569 - Notice of certain balances
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F688 - Mobility
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F770 - Laboratory Services
Provide timely, quality laboratory services/tests to meet the needs of residents.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the November 23, 2021 survey of Vancrest-Upper Valley?
This was a inspection survey of Vancrest-Upper Valley on November 23, 2021. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Vancrest-Upper Valley on November 23, 2021?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death."
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.