Health inspection·January 19, 2023

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and policy review, the facility failed to ensure a dependent resident received timely personal hygiene care. This affected one resident (#11) out of two residents reviewed for activities of daily living (ADL). The facility identified all 24 residents required assistance from staff with bathing and dressing. The facility census was 24. Residents Affected - Few Findings include: Review of the medical record for Resident #11 revealed an admission date of 01/31/20. Diagnoses included Alzheimer's disease, restlessness and agitation, and cognitive communication deficit. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had impaired cognition and required extensive assistance of one person for personal hygiene. Review of the current care plan for Resident #11 revealed an ADL self-care deficit related to chronic pain, osteoarthritis, Alzheimer's, dementia, and need for limited assistance in ADL function. Interventions included extensive assistance of one person for personal hygiene. Review of the bathing schedule revealed Resident #11 received a shower on 01/16/23. Observations on 01/17/23 at 9:45 A.M. revealed Resident #11 was dressed and sitting on her bed playing cards. Resident #11 had several long, white hairs coming from her chin. Subsequent observation on 01/18/23 at 8:54 A.M. revealed Resident #11 sitting in her recliner and playing cards. Resident #11 remained with several long, white hairs coming from her chin. Observation and interview on 01/19/23 at 8:08 A.M. with the Director of Nursing (DON) revealed Resident #11 was in her room and Resident #11 had long white hairs coming from her chin. The DON verified the hairs were present and visible. The DON said the State Tested Nurse Aides (STNAs) were expected to provide shaving for residents. Interview on 01/19/23 at 8:12 A.M., with STNA #342 verified she had shaved Resident #11 in the past and Resident #11 had not resisted care. Interview on 01/19/23 at 10:44 A.M., with STNA #358 verified Resident #11 had some hairs coming from her chin which were long enough to shave. Review of the facility policy titled Activities of Daily Living AM/PM Care, undated revealed residents were assisted at appropriate level for mouth care, hair care, and shaving, etc. 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: 366468 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 366468 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vancrest of Payne 650 North Main Street Payne, OH 45880 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)