F 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds
bed-hold policy.
Based on staff interview, record review, and review of facility policy, the facility failed to permit a resident to
return to the facility following a hospitalization. This affected one (Resident #160) of three residents
reviewed for discharge. The facility census was 57.
Findings include:
Review of the medical record for Resident #160 revealed an admission date of 05/19/23 and a discharge
date of 06/02/23. Diagnoses included fracture of the left humerus (bone in the arm), a fracture of the left
fibula (bone in the lower leg), fracture of the lumbar (back), history of falls, and bradycardia.
Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 05/26/23, revealed Resident
#160 was cognitively intact. Resident #160 required the extensive assistance of two person for bed mobility,
transfers, dressing, toilet use, and personal hygiene.
Review of the nursing note dated 06/02/23 revealed Resident #160 was being transferred to the hospital
due to status post fall.
Review of the nursing note dated 06/06/23 at 3:14 P.M. revealed the resident representative was verbally
notified of Resident #160's denial of return to the facility due to his care needs.
Interview on 07/03/23 at 11:31 A.M. with Regional Administrator (RA) #312 stated a collaborative decision
was made with herself and the Administrator that the facility would not take Resident #160 back based on
the family being upset. They felt this would have a negative impact on the resident. The trust between the
facility and the family had been broken and this would impact the recovery of the resident and felt another
facility would be best for the best outcome of the resident and family.
Interview on 07/03/23 at 3:30 P.M. with Social Services (SS) #313 stated she communicated with Resident
#160's representative notifying of denial of readmission due to unable to meet the resident's care needs.
SS #313 also stated she communicated with the local hospital of denial and documented this denial on a
log of all referrals she keeps.
Telephone interview on 07/03/23 at 4:53 P.M. with the Administrator stated a collaborative decision was
made with the RA #312 that Resident #160 was refused re-admission back to facility based on not being
able meet the families' expectations, danger to himself in the facility by not using the call light, unsure of
behavior, and family dissatisfaction with blaming facility for fall and fracture. The Administrator stated she
did not have knowledge if this was documented other than unable to meet
(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 2
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
07/03/2023
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)
F 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
the resident's needs on the denial log. The Administrator refused to answer a specific question of if the
family was not upset, would Resident #160 be allowed to be re-admitted . The Administrator was also asked
a specific question of what were the care needs the facility was unable to meet with Resident #160
re-admission considering Resident #160's initial admission was for a fall with fractures and the need for
therapy for goals to return to the community. The re-admission for Resident #160 would be for fall with
fractures (fall in facility with femur fracture and surgical repair) and need for therapy. The Administrator did
not answer the question.
Review of the facility policy titled Transfer or Discharge, Facility-Initiated, dated 10/2022, revealed residents
who are sent emergently to an acute setting such as a hospital are permitted to return to the facility. If the
facility does not permit a resident's return to the facility (i.e., initiated a discharge) based on inability to meet
the resident's needs, the facility will notify the resident, and/or his or her representative in writing of the
discharge, including the notification of appeal rights.
This deficiency represents non-compliance investigated under Complaint Number OH 00143555.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366444
If continuation sheet
Page 2 of 2
