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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
the medical record revealed Resident #15 was admitted to the facility on [DATE]. Diagnoses included, but
were not limited to, dementia with severe anxiety, chronic respiratory failure with hypoxia, psychosis, major
depressive disorder, generalized anxiety disorder, and insomnia.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #15 was severely cognitively
impaired and required extensive assistance or was totally dependent upon staff for ADLs. Resident #15
received an antipsychotic, antianxiety, antidepressant, a diuretic, and an opioid medication seven times in
the seven day look back period.
Review of the care plan revealed Resident #15 had the potential for or actual decline in condition related to
receiving hospice services, adjustment disorder, depression, grief, and anxiety.
Review of a pharmacy recommendation dated 02/23/22 regarding Resident #15's order for Lorazepam
(medication used to treat anxiety) 1 mg via peg tube every four hours as needed (PRN) for agitation/anxiety
revealed a recommendation that if the physician felt it was appropriate for the PRN order to be extended
beyond 14 days, the physician should document rationale and indicate the duration of the PRN order.
Further review of the medical record revealed the physician did not address the pharmacy recommendation
until 05/02/22.
Interview on 01/12/23 at approximately 1:30 P.M. with the Director of Nursing (DON) verified the physician
did not address the pharmacy recommendation dated 02/23/22 until 05/02/22. The DON indicated the
expectation was for the physician to address the pharmacy recommendation sooner.
Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure as
needed (PRN) antipsychotic medications prescribed were limited to 14 days. Additionally, the facility failed
to re-evaluate a resident for continued use of PRN antipsychotic medication. This affected one (Resident
#14) of five residents reviewed for psychotropic medications. Additionally, the facility failed to ensure
pharmacy recommendations were addressed by the physician in a timely manner. This affected one
(Resident #15) of five residents reviewed for pharmacy recommendation response. The facility's census
was 49.
Findings include:
1. Medical record review for Resident #14 revealed an admission date of 07/15/22. Resident #14 was
discharged on 08/04/22 and returned on 09/06/22 with diagnoses including but not limited to
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
366084
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
366084
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest Health Care Center of Eaton
1600 Park Avenue
Eaton, OH 45320
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
respiratory failure, interstitial pulmonary disease, pulmonary fibrosis, peripheral vascular disease,
paroxysmal fibrillation, chronic diastolic congestive heart failure, hypotension, polyneuropathy, anxiety,
shortness of breath, right bundle block, and diaphragmatic hernia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was
cognitively intact and required extensive assistance with Activities of Daily Living (ADLs). Resident #14
received antianxiety and antidepressant medications during the assessment period.
Review of the plan of care dated 09/12/22 and revised on 10/03/22 revealed Resident #14 was at risk for
altered mood pattern related to generalized anxiety disorder. Interventions included administer medications
as ordered, explain the importance of taking medication, monitor for signs and symptoms of anxiety, one on
one visits as needed, and review medications as needed for recommendations for gradual trial reduction.
Review of the hospital discharge orders dated 09/06/22 revealed an order for Ativan (medication used to
treat anxiety) 1 milligram (mg) every 12 hours as needed for four days.
Review of the physician progress note dated 09/09/22 revealed no documentation the physician
re-assessed the resident for the appropriateness Ativan administration.
Review of the physician order dated 09/16/22 revealed an order for Ativan 1 mg tablet, give one tablet every
twelve hours as needed (PRN) for anxiety, dispense 60 tablets. Further review of the handwritten
prescription revealed no stop date was identified.
Review of the physician progress note dated 09/30/22 revealed no documentation related to continued use
of Ativan.
Review of Resident #14's Medication Administration Record (MAR) for September 2022 revealed an order
for Ativan 1 mg tablet, give one tablet by mouth as needed for congestive heart failure dated 09/06/22 and
discontinued on 10/12/22. Further review of the MAR revealed Ativan was administered on 09/07/22,
09/16/22, 09/17/22, 09/18/22, 09/19/22, 09/20/22, 09/21/22, 09/22/22, 09/23/22, 09/25/22, 09/26/22,
09/27/22, 09/29/22, and 09/30/22.
Review of Resident #14's MAR for October 2022 revealed an order for Ativan 1 mg, give one tablet by
mouth every 12 hours as needed for congestive heart failure dated 09/06/22 and discontinued on 10/12/22.
Ativan was administered on 10/01/22, 10/02/22, 10/03/22, 10/04/22, 10/09/22, and 10/10/22. Additional
review revealed an order for Ativan 1 mg one tablet by mouth as needed for congestive heart failure dated
10/12/22 and discontinued 10/20/22. Ativan 1 mg by mouth was administered on 10/13/22, 10/14/22,
10/17/22. Further review revealed an order for Ativan 1 mg tablet, give one tablet by mouth every 12 hours
as needed for anxiety dated 10/20/22. Ativan 1 mg by mouth was administer on 10/20/22 and 10/21/22.
Review of the physician progress note dated 10/29/22 revealed no documentation the physician
re-assessed the resident for the appropriateness Ativan administration or justified reasoning for continued
Ativan use.
Review of physician orders revealed an order for Ativan 1 mg, give one tablet by mouth two times a day for
anxiety dated 12/06/22 and discontinued on 12/28/22. An order for Ativan 1 mg tablet, give one by mouth
every 12 hours as needed for anxiety dated 12/28/22.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366084
If continuation sheet
Page 2 of 4
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
366084
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest Health Care Center of Eaton
1600 Park Avenue
Eaton, OH 45320
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
Review of Resident #14's MAR for December 2022 revealed an order for Ativan 1 mg, one tablet by mouth
two times a day for anxiety dated 12/06/22 and discontinued on 12/28/22. Resident #14 received Ativan two
times a day from 12/06/22 through 12/28/22.
Further review of the medical record revealed no documentation PRN Ativan was limited to 14 days.
Additional review revealed no documentation the physician re-assessed the resident for the
appropriateness of Ativan administration nor was there any documentation alleging the resident required
long term use of Ativan.
Interview on 01/11/23 at 10:39 A.M. with Licensed Practical Nurse (LPN) #119 verified the order for Ativan
dated 09/16/22 was a PRN order and did not have a stop date limiting use to 14 days.
Interview on 01/11/23 at 2:10 P.M. with Consulting Pharmacist #69 verified there were no recommendations
made for the PRN Ativan in September 2022.
Interview on 01/11/23 at 2:19 P.M. with the Director of Nursing (DON) verified the physician progress notes
did not contain documentation related to Resident #14 being reassessed for the appropriateness of PRN or
continued use for Ativan.
Review of the facility policy titled, Antipsychotic Medication Use, dated 12/2016 revealed residents who are
admitted from the community or transferred from a hospital and who are already receiving antipsychotic
medication, will be evaluated for the appropriateness and indications for use. The facility will re-evaluate the
use of antipsychotic medication at the time of the admission or within two weeks to consider whether of not
the medication can be reduced, tapered or discontinued.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366084
If continuation sheet
Page 3 of 4
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
366084
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/12/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vancrest Health Care Center of Eaton
1600 Park Avenue
Eaton, OH 45320
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 observations, staff interview, and review of facility policy, the facility failed to ensure medication
carts were secured when unattended. This had the potential to affect four (Residents #4, #12, #26, and
#42) identified by the facility as confused and independently mobile residing on the South unit. The facility
census was 49.
Findings included:
Observation on 01/09/23 at 12:20 P.M. revealed the medication cart located on the South unit was unlocked
and unattended. Licensed Practical Nurse (LPN) #119 was in a resident's room.
Interview on 01/09/23 at 12:30 P.M. with LPN #119 verified the medication cart was unlocked and
unattended while she was in a resident's room.
Observation on 01/11/23 at 11:21 A.M. revealed the medication cart located on the South unit was
unlocked and unattended.
Interview on 01/11/23 at 11:29 A.M. with Licensed Practical Nurse (LPN) #119 verified the medication cart
was unlocked and unattended in the unit hallway LPN #119 verified the medication cart should be locked
when unattended.
Review of the facility policy titled Storage of Medication dated 04/2007 revealed compartments containing
drugs and biologicals shall be locked when not in use and shall not be left unattended and otherwise
potentially available to others.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366084
If continuation sheet
Page 4 of 4
