Health inspection·May 18, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medical record review, staff interview and review of the Resident Assessment Instrument (RAI) 3.0, the facility failed to complete admission Minimum Data Set (MDS) assessments within the required timeframe. This affected four (#208, #209, #212 and #55) out of the four residents reviewed for timely completion of admission MDS assessments. The facility census was 53. Findings include: 1. Review of the medical record for Resident #212 revealed an admission date of 04/13/23 with medical diagnoses of hypotension, atrial fibrillation, status post left hip fracture, and chronic obstructive pulmonary disease. Review of the medical record for Resident #212 revealed an admission nursing assessment dated [DATE] which indicated Resident #212 was cognitively intact and required extensive assist with bed mobility, transfers, toileting, and dressing. Review of the medical record revealed an admission MDS had not been completed. 2. Review of the medical record for Resident #209 revealed an admission date of 04/14/23 with medical diagnoses of altered mental status, acute respiratory failure with hypoxia, dementia, and peripheral vascular disease. Review of the medical record for Resident #209 revealed an admission nursing assessment, dated 04/14/23, which indicated Resident #209 was alert to person only and required extensive assistance with bed mobility, transfers, dressing, and toileting. Review of the medical record for Resident #209 revealed an admission MDS had not been completed. 3. Review of the medical record for Resident #208 revealed an admission date of 05/02/23 with medical diagnoses of arthritis, hyperlipidemia, anxiety, depression, and anemia. Review of the medical record for Resident #208 revealed an admission nursing assessment, dated 05/02/23, which indicated Resident #208 was cognitively intact and required extensive assist for bed mobility, transfers, dressing and toileting. Review of the medical record for Resident #208 revealed an admission MDS had not been completed. (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 3 Event ID: 366444 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 366444 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Ada 600 West North Avenue Ada, OH 45810 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)