Health inspection·November 6, 2025

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 closed medical record review, staff interview, Nurse Practitioner (NP) interview, and review of facility policy, the facility failed to notify the provider and resident representative of a new skin impairment. This affected one (#50) of one resident reviewed for notification of change. The facility census was 48. Findings include:Review of the closed medical record for Resident #50 revealed an admission date of 01/08/25 and a discharge date of 10/31/25. Diagnoses included atrial fibrillation (abnormal heart beat), diabetes mellitus type II, congestive heart failure (CHF), chronic kidney disease (CKD) stage three (CKD is measured in stages one through four, stage four requires renal dialysis), liver cirrhosis, peripheral vascular disease (PVD), bilateral (both sides) below the knee amputation (BKA), and altered mental status.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 was cognitively intact and had no unhealed pressure ulcers.Review of the Weekly Wound and Skin Assessment Documentation dated 10/24/25 Resident #50 revealed a dark blanchable redness to the bilateral buttocks. No measurements or other wound characteristics were documented.Review of the physician orders for October 2025 revealed no new wound orders related to the new skin impairment identified on Resident #50's buttocks on 10/24/25. Review of Resident #50's nursing progress notes revealed no evidence the NP, Wound NP, or responsible party were notified of Resident #50's new skin impairment to her buttocks. Interview on 11/03/25 at 8:18 A.M. with Wound NP #420 confirmed she was not notified of the new skin impairment identified on Resident #50's buttocks on 10/24/25. NP #420 further stated she would typically be notified of new skin impairments for follow-up. Interview on 11/05/25 at 10:52 A.M. with NP #415 confirmed she was not notified of the new skin impairment to the bilateral buttocks of Resident #50. NP #415 further stated she rounded on Resident #50 the morning of 10/24/25 and was still in the facility at the time the facility staff identified the skin impairment. Interview on 11/05/25 at 8:12 A.M. with the Director of Nursing (DON) verified the facility had no evidence the NP or resident representative were notified of the new skin impairment identified on Resident #50's buttocks. Review of the facility policy titled, Change in a Resident's Condition or Status, revised February 2021, revealed the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. Page 1 of 6 366444 366444 11/06/2025 Vancrest of Ada 600 West North Avenue Ada, OH 45810

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of hospital records, review of the facility submitted Self-Reported Incident (SRI), review of staff and resident statements, resident and staff interview, and review of the facility policy, the facility failed to ensure residents did not develop avoidable, facility acquired, pressure ulcers. This resulted in actual harm for Resident #50 on 10/24/25 when facility staff placed the resident on a bedpan and failed to check on her and remove her from the bedpan for an extended period of time. Consequently, Resident #50 developed a deep tissue injury (DTI - a type of pressure injury that begins in the deeper tissues and is caused by prolonged pressure) on her buttocks. Additionally, upon discovery of the DTI, the facility failed to thoroughly assess and document the DTI. This affected one (#50) of three residents reviewed for pressure ulcers. The facility census was 48.Findings include:Review of the closed medical record for Resident #50 revealed an admission date of 01/08/25. Diagnoses included atrial fibrillation (abnormal heartbeat), diabetes mellitus Type II, congestive heart failure (CHF), chronic kidney disease (CKD) stage three (CKD is measured in stages one through four, stage four requires renal dialysis), liver cirrhosis, peripheral vascular disease (PVD), bilateral (both sides) below the knee amputation (BKA), and altered mental status (AMS). Resident #50 transferred to the hospital on [DATE] due to AMS and was subsequently discharged from the facility on 10/31/25, without returning following her hospitalization.Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/06/25, revealed Resident #50 was cognitively intact, required moderate (staff) assistance with toileting, had occasional bladder incontinence, and had no unhealed pressure ulcers. Review of the care plan, revised September 2025, revealed Resident #50 required one (staff) assistance for toileting and bed mobility and preferred the use of a bedpan for toileting. Review of Nurse Practitioner (NP) #415's visit note, dated 10/24/25 at 10:24 A.M., revealed Resident #50 was acutely seen for lethargy and AMS. Resident #50's roommate (Resident #32) was at the nursing station and reported the resident had been more confused and the nursing staff validated the concern, and reported Resident #50 had been slow to respond. Further review revealed Resident #50 complained of lower abdominal pain, loose stools, fever (although no documented fever), strong concentrated urine, and concern for a urinary tract infection (UTI). Continued review revealed the resident was positive for a change in activity, increased weakness, decreased concentration, and abdominal pain with loose stools. Resident #50 was ill-appearing, despite being alert and oriented to person, place and time. Resident #50 had a labile affect, delayed speech, and somnolence (state of drowsiness or strong desire to fall asleep). The resident stated she did not feel well. The plan for treatment was to encourage fluids, obtain a urine sample, and a suspected UTI with a plan to treat with ceftriaxone (antibiotic) one gram (gm) intramuscularly (IM) for three days. A stat (immediate) complete blood count (CBC - measures values for possible infection) and basic metabolic panel (BMP - measures electrolyte values, this will indicate dehydration or electrolyte imbalance) were to be completed. If no improvement, send to the emergency department (ED) for evaluation and treatment. Review of the October 2025 physician orders revealed on 10/24/25, Resident #50 had orders for four ounces of water every two hours related to UTI, obtain urinalysis (UA) with reflex (test to identify an infection in the urinary system), CBC, BMP, and ceftriaxone sodium injection one gm IM daily for three days. Review of the Weekly Wound and Skin Assessment Documentation, dated 10/24/25, revealed Resident #50 had a new, dark blanchable redness area to the bilateral buttocks. No wound measurements or characteristics were documented.Review of a nursing progress note, dated 10/24/25 at 12:38 P.M. and authored by Licensed Practical Nurse (LPN) #341, revealed Resident #50 had increased confusion, unclear speech, and incontinent Residents Affected - Few 366444 Page 2 of 6 366444 11/06/2025 Vancrest of Ada 600 West North Avenue Ada, OH 45810

F 0686 Level of Harm - Actual harm Residents Affected - Few episodes. NP #415 was notified, and orders were obtained for treatment. Review of the ED notes, dated 10/25/25, revealed the attending physician documented that Resident #50 had skin breakdown to the bilateral buttocks. The nurse documented that the nursing facility reported Resident #50 was accidentally left on the bedpan overnight on Thursday (10/23/25 into 10/24/25). Further review of the nursing documentation revealed Resident #50 had a large DTI ring circling the buttocks and the DTI portion on the right buttock was blistered. Further review of the 10/25/25 hospital records revealed a photograph showing the resident's right outer buttock, extending down to the gluteal fold (area where the bottom of the buttock and the top of the posterior thigh begins) was deep red, nearly ruddy, in color. The right outer buttock showed an area that was open, with a deep, dark, nearly purple center of the open area. Review of a second photograph revealed an image of the resident's left buttock that showed a dark red area to the outer buttock. The area on Resident #50's right and left buttocks was in the shape of a bedpan. Review of the hospital wound consultation note revealed Resident #50 had a wound to the bilateral buttocks classified as a DTI. The wound was deep red and purple discoloration that extended to the posterior thigh. Further review revealed the DTI to the bilateral buttocks and posterior thigh was the result of prolonged bedpan use as the wound was the shape/impression of a bedpan. No measurements were documented at that time. Review of a follow-up wound consultation note, dated 11/01/25, revealed the wound on Resident #50's right buttock measured 10 centimeters (cm) by 1.5 cm x less than (<) 0.1cm with slough (dead tissue in a wound), fibrin (protein that aids in blood clotting), and eschar (blackened dead tissue) noted to the areas of the wound bed. The left buttock and posterior thigh measured 24 cm x 1.4 cm x < 0.1 cm with non-blanchable intact skin. Review of a facility submitted SRI, initiated on 10/27/25 and completed on 10/31/25, revealed the Administrator was notified by hospital staff that Resident #50 alleged that a staff member left her on bed on a bedpan for an extended period of time during the night of Thursday, 10/23/25, into the early morning of Friday, 10/24/25. The resident's care plan was reviewed, indicating her preference not to be awakened while sleeping and that she would use the call light when assistance was needed. The resident had a Brief Interview of Mental Status (BIMS) score of 15, indicating she was cognitively intact. Clinical documentation revealed the nursing and NP notes from the morning of 10/24/25 reflected the resident was experiencing increased confusion and diarrhea, but there were no reports or observations of pain, emotional distress, or mental anguish during the timeframe referenced. The resident was alert and oriented. During catheterization that morning, the bedpan was removed, and a reddened area was noted. Certified Nursing Assistant (CNA) documentation confirmed routine checks were performed before and after the alleged timeframe referenced by hospital staff, with no record of the resident requesting assistance or complaining about the bedpan after use. The resident's roommate stated CNA #303 provided care around 2:45 A.M. and placed Resident #50 on the bedpan and left the room. The roommate also stated the resident did not use her call light or otherwise request assistance. CNAs interviewed confirmed that the resident typically signaled staff via call light when she wished to be removed from the bedpan, and no such request was made that night. The facility unsubstantiated the allegation of neglect, citing Resident #50 was cognitively intact, did not verbalize complaints prior to her hospitalization, care was provided in accordance with her plan of care, documentation and staff interviews that showed the resident was routinely checked on and showed no signs of pain, mental anguish, or emotional distress, and the facility maintained that there was no evidence the resident was left on the bedpan for an extended period of time prior to her hospitalization.Review of CNA #303's written statement, dated 10/27/25, revealed she arrived for her normal night shift and received report from the previous shift. CNA #303 further stated the call light was engaged for Resident 366444 Page 3 of 6 366444 11/06/2025 Vancrest of Ada 600 West North Avenue Ada, OH 45810

F 0686 Level of Harm - Actual harm Residents Affected - Few #50's room at approximately 2:00 A.M., she assisted Resident #32 to the bathroom, and Resident #50 did not engage the call light but requested her fan be turned on and did not have any other needs. CNA #303 further stated the call light for Resident #50's room did not come back on for the remainder of the shift. Review of CNA #387's written statement, dated 10/27/25, revealed she arrived for her shift on 10/24/25 (dayshift) and obtained report from the previous shift and was not notified of Resident #50 being on the bedpan. CNA #387's stated she provided breakfast to Resident #50 and the resident had no further needs. At approximately 9:45 A.M. to 10:00 A.M., the nurses notified her that Resident #50 was on the bedpan and had redness on her buttocks from the bedpan. Review of LPN #322's written statement, dated 10/27/25, revealed she assisted a co-worker to obtain a urine sample for Resident #50 (on 10/24/25) when the two nurses noted Resident #50 was on the bedpan. LPN #322 further stated the bedpan was removed from under Resident #50 and there was a dark red, blanchable redness around her buttocks where the bedpan was. LPN #322's statement revealed Resident #50 reported third shift staff put her on the bedpan. Review of LPN #308's written statement, undated, revealed she worked the night shift on 10/23/25. Further review revealed LPN #308 assisted Resident #50 with care at approximately 12:00 P.M. At approximately 4:53 A.M., she administered medication to Resident #32 and Resident #50 requested to be put back to bed. LPN #308 had to re-oriented Resident #50 that she was already in bed. Review of LPN #425's written statement, undated, revealed she was informed by LPN #322 that Resident #50 was left on the bedpan by third shift and had indentation. Review of Resident #32's written statement, undated, revealed she was assisted to the bathroom at approximately 2:30 A.M. to 2:45 A.M. (on 10/24/25) by CNA #303, at which time Resident #50 was also assisted by CNA #303 to use the bedpan. Interview on 11/03/25 at 8:20 A.M. with the Administrator confirmed the facility investigated an allegation of neglect involving Resident #50 being left on a bedpan for an extended period of time but could not pinpoint how long she had actually been left on the bedpan. The Administrator stated the resident was cognitively intact and typically called for assistance, which she did not do that night; however, he acknowledged the resident had a decline that day. The Administrator stated they knew the resident was on the bedpan for longer than they would like. Interview on 11/03/25 at 11:27 A.M. with CNA #387 verified she worked on 10/24/25, started her shift at 6:00 A.M., and was assigned to provide care for Resident #50. CNA #387 stated she did not place Resident #50 on the bedpan at any time during that morning. CNA #387 further stated she received report from the previous shift and it was not reported that the resident was on the bedpan. Interview on 11/03/25 at 11:46 A.M. with CNA #314 verified she worked dayshift on 10/24/25, was assigned to complete resident showers for the day, and she did not place Resident #50 on the bedpan. CNA #314 further stated Resident #50 was due for a shower on 10/24/25 and she refused due to not feeling well. A telephone interview on 11/03/25 at 1:32 P.M. with CNA #319 verified she worked on 10/24/25, her shift started at 6:00 A.M., and she was assigned to the hall Resident #50 resided on. CNA #319 stated she did not put Resident #50 on the bedpan that morning and did not receive in report from the previous shift that the resident was on the bedpan. CNA #319 stated she observed Resident #50's buttocks later during her shift and her bottom was really red on the outer part of the left buttock. A telephone interview on 11/03/25 at 2:02 P.M. with LPN #322 revealed that on 10/24/25, sometime after breakfast, she assisted another nurse (LPN #341) in obtaining a urine sample from Resident #50. When she pulled the covers back from Resident #50, LPN #322 stated she noticed the resident was on the bedpan. LPN #322 further stated that when the bedpan was removed from under Resident #50, there was a dark, deep red ring on the resident's bottom. LPN #322 stated she asked Resident #50 how long she was on the bedpan and the resident did not know she was still on the bedpan, did not know how long she had been on it, and 366444 Page 4 of 6 366444 11/06/2025 Vancrest of Ada 600 West North Avenue Ada, OH 45810

F 0686 Level of Harm - Actual harm Residents Affected - Few stated that someone from third shift put her on the bedpan. LPN #322 further stated she interviewed the CNAs that were working that morning and both of them denied assisting Resident #50 onto the bedpan from the beginning of their shift (at 6:00 A.M.) and were not aware she was on the bedpan. LPN #322 further stated she reported the incident to LPN #425 and was instructed to monitor the redness. LPN #322 stated she reported to LPN #341, who was assigned to care for the resident, the direction from LPN #425. LPN #322 confirmed she did not complete an assessment of the wound.A follow-up interview on 11/03/25 at 3:04 P.M. with the Administrator revealed the facility unsubstantiated the allegation of neglect because they could not pinpoint the length of time Resident #50 was left on the bedpan. The Administrator stated, because he was not clinical, he could not determine how long was too long to be left on a bedpan, but he confirmed two hours would be too long. Review of the staff statements, NP visit notes, and staff interviews with the Administrator revealed, at a minimum, Resident #50 was on the bedpan from at least 6:00 A.M. on 10/24/25, when day shift staff arrived and reported they did not place the resident on the bedpan, until approximately 10:20 A.M. (nearly 4.5 hours) when the licensed nurses collected the urine sample to complete the UA as ordered by NP #415 due to a change in condition experienced by the resident. The facility was unable to determine which staff placed Resident #50 on the bedpan.A telephone interview on 11/03/25 at 3:52 P.M. with CNA #303 verified she worked the night shift on 10/23/25 (10:00 P.M. on 10/23/25 to 6:00 A.M. on 10/24/25) and was assigned to care for Resident #50. CNA #303 denied she put the resident on the bedpan. CNA #303 stated she responded to the call light for Resident #50's roommate during the shift, but Resident #50 did not have any needs.A telephone interview on 11/04/25 at 9:45 A.M. with LPN #341 revealed she worked on 10/24/25 and discovered Resident #50 on the bedpan when she and another nurse (LPN#322) went to collect a UA for the resident. LPN #341 confirmed Resident #50 was confused that day and could not recall when she was placed on the bedpan or by whom. LPN #341 stated Resident #50 was removed from the bedpan and both sides of her bottom were red. LPN #341 verified she did not document the wound characteristics and did not monitor it throughout her shift.Interview on 11/05/25 at 7:51 A.M. with Resident #32 (roommate of Resident #50) revealed the resident was cognitively intact and able to be interviewed. Resident #32 stated that on 10/23/25 at approximately 2:30 A.M. to 2:45 A.M., she turned on the call light and CNA #303 responded and assisted her to the restroom. Resident #32 further stated that while she was in the bathroom, she could hear CNA #303 and Resident #50 talking and Resident #50 requested to use the bedpan. Resident #32 stated the aides did shift change rounds outside the residents' rooms. She stated she was awake and heard the report from night shift to day shift and she did not hear the night shift aide report that Resident #50 was on the bedpan. Resident #32 stated she was in the room when the day shift nurses took Resident #50 off the bedpan and overheard one of them comment about the bright redness to the resident's bottom. Resident #32 stated Resident #50 had fallen asleep on the bedpan before, but staff had always returned to check on her.Interview on 11/05/25 at 8:12 A.M. with the Director of Nursing (DON) revealed the facility's process for new skin impairments was to file an incident report, obtain measurements of the new skin impairment, make notification (to the physician/family/responsible party/DON), and obtain orders for treatment of the skin impairment. Further interview with the DON verified the facility procedure was not followed when the new skin impairment was identified on Resident #50's buttocks on 10/24/25. The DON stated she was not aware of Resident #50's skin impairment until the Administrator notified her of it on 10/27/25. Interview on 11/05/25 at 8:18 A.M. with NP #420 revealed she had provided wound care for previous wounds that Resident #50 had, and those wounds had resolved. NP #420 confirmed Resident #50 had no unhealed pressure ulcers prior to the new wound identified on 10/24/25. NP #420 reviewed the wound 366444 Page 5 of 6 366444 11/06/2025 Vancrest of Ada 600 West North Avenue Ada, OH 45810

F 0686 Level of Harm - Actual harm Residents Affected - Few photographs from the hospital and stated a DTI was a type of pressure ulcer and she would have classified the wound on Resident #50's bilateral buttocks as a DTI pressure ulcer as a result of pressure from an object (bedpan). NP #420 confirmed she was not notified of Resident #50's wound and just learned of it during this interview. A telephone interview on 11/05/25 at 10:37 A.M. with LPN #310 revealed she received in report on the morning of 10/25/25 that Resident #50 had been left on the bedpan and had a pressure ring. LPN #310 confirmed she did not monitor or assess the wound during her shift. LPN #310 stated the resident was not doing well and she contacted the physician and received an order to send her to the ED for further evaluation and treatment. LPN #341 stated that when she called in report to the hospital, prior to the resident arriving here, they asked her about any wounds, and she reported the resident's wounds on her bottom from being left on the bedpan. Interview on 11/05/25 at 10:52 A.M. with NP #415 verified Resident #50 was seen on 10/24/25 for an acute illness when the resident's roommate reported to her that Resident #50 had been talking out of her mind and the staff confirmed the resident had not been feeling well. NP #415 further stated Resident #50 was arousable and was able to answer questions, but she was not her usual self and typically they would banter back and forth and this did not occur during the visit. NP #415 stated she ordered further testing and treatment for a suspected UTI. NP #415 stated she would have still been in the facility at the time the DTI was discovered on Resident #50 on 10/24/25 and confirmed she was not notified of the skin impairment and just learned of it during this interview. During a follow-up interview on 11/05/25 at 4:00 P.M. with Resident #32, the resident stated Resident #50's bedpan was usually kept in a bag in the bathroom and while she was using the bathroom (during the early morning of 10/24/25), CNA #303 came and got the bedpan for Resident #50. Review of the facility policy titled, Pressure Ulcer Risk Assessment and Management, revised October 2016, revealed it was the facility policy to assess all residents on admission and regularly thereafter to determine the presence of skin conditions and/or areas of skin compromise, and to identify potential risk factors for their development. The intent was that a resident would not develop pressure areas unless the resident's clinical condition demonstrated that they were unavoidable. Responsibilities of the floor nurse would include obtaining measurements (width, length, and depth), updating the physician, and application of appropriate treatments. Review of the facility policy titled, Skilled Nursing Facility Wound Care Policy, undated, revealed the facility would follow the requirements set forth by the Ohio Department of Health (ODH) and the Centers for Medicare and Medicaid (CMS) Federal Regulations for treatment and services to prevent/heal pressure ulcers to ensure residents were not developing avoidable wounds while in the facility and received appropriate treatment and services for existing wounds. This deficiency represents non-compliance investigated under Complaint Number 2655902. 366444 Page 6 of 6