Inspection·June 3, 2024

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, staffing interview, and policy review, the facility failed to provide residents and/or resident representatives with written notification of a room change. This affected three (Residents #06, #56, and #75) of the three reviewed for room changes. The facility census was 73. Findings include: 1. Review of the medical record for Resident #75 revealed an admission date of 04/03/24 with medical diagnoses of specified disorders of the brain, dementia, aneurysm of the ascending aorta without rupture, hydrocephalus, and diaphragmatic hernia. The medical record indicated Resident #75 discharged on 05/09/24. Review of the medical record for Resident #75 revealed an admission Minimum Data Set (MDS) assessment dated [DATE], which indicated Resident #75 had severe cognitive impairment and required supervision to touching assistance with eating and ambulation up to 50 feet, moderate staff assistance with toilet hygiene, bed mobility, and transfers, and maximum staff assistance with bathing. Review of the medical record for Resident #75 revealed a Social Service progress note dated 04/17/24 at 3:15 P.M. which stated Social Services and Resident #75's daughter discussed a possible room change and that Resident #75 would have a roommate. The note also stated Resident #75's daughter was informed that Medicaid would not pay for a private room and the daughter stated she was not sure that Resident #75 would be okay with that. Further review of the medical record revealed a Social Service progress note dated 04/23/24 at 11:30 A.M. which stated attempted to reach Power of Attorney (POA) to discuss move to long term care and a voicemail message was left. Review of the medical record revealed a Social Service note dated 04/30/24 at 10:59 A.M. which stated daughter accepted the long-term care room change. Review of the medical record for Resident #75 revealed Resident #75 moved rooms on 05/02/24. Review of the medical record did not reveal any documentation to support the facility provided a written notice of room change on 05/02/24. 2. Review of the medical record for Resident #56 revealed an admission date of 02/13/24 with medical diagnoses of fibromyalgia, osteoarthritis, irritable bowel syndrome, and depression. Review of the medical record for Resident #56 revealed a quarterly MDS dated [DATE] which indicated Resident #56 was cognitively intact and required moderate staff assistance with eating, maximum staff assistance with bed mobility, and was dependent upon staff for toileting, bathing and transfers. (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: 366108 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 366108 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/03/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of New Carlisle 1885 N Dayton Lakeview Rd New Carlisle, OH 45344 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)