Vancrest of New Carlisle

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure residents had the right to visitors per their preference. This affected one resident (#17) of three residents reviewed for resident rights. The facility census was 73. Findings Include: Review of Resident #17's record revealed Resident #17 admitted to the facility on [DATE] with diagnoses including cerebral infarction due to embolism of unspecified cerebral artery, chronic obstructive pulmonary disease, morbid obesity due to excess calories, type two diabetes mellitus without complications, schizoaffective disorder and polyneuropathy. Resident #17 was her own responsible party. Review of Resident #17's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact. Interview on 05/14/26 at 10:55 A.M. [...]

Inspectors wroteBased on review of medical records, staff interviews, and review of facility policies, the facility failed to complete comprehensive wound assessments upon identification of skin breakdown which resulted in actual harm when Resident #36 developed an unstageable pressure ulcer [a pressure ulcer where the ulcer is not stageable due to coverage of the wound bed by slough and or eschar] to the coccyx and a Stage III pressure ulcer (a pressure ulcer where there is full thickness tissue loss, subcutaneous fat may be visible, but bone tendon or muscle is not exposed) to the left heel. [...]

Inspectors wroteBased on medical record review, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, version 1.20.1 dated October 2025, the facility failed to ensure Minimum Data Set (MDS) assessments were coded accurately. This affected two (#42 and #33) residents out of six residents reviewed for medications. The facility census was 77.

Inspectors wroteBased on observations, staff and resident interviews, medical record review and review of facility policy, the facility failed to develop a person centered comprehensive assessment for one (#36) out of 18 residents reviewed. The census was 77. Review of the medical record for Resident #36 revealed an admission date of 09/09/25 with medical diagnoses of paraplegia, chronic obstructive pulmonary disease, atherosclerotic heart disease, and anxiety. Review of the medical record for Resident #36 revealed an admission Minimum Data Set (MDS) assessment, dated 09/15/25, which indicated Resident #36 had moderate cognitive impairment and required substantial/maximum staff assistance for bathing, bed mobility, and was dependent upon staff for transfers and toilet hygiene. The MDS indicated Resident #36 did not have any skin breakdown. [...]

Inspectors wroteBased on record review, staff interviews and facility policy the facility failed to conduct quarterly care conferences to include residents and/or resident representatives as required. This affected two (#2, #3) of two reviewed for care conferences. The facility also failed to timely update a resident care plan after there was a change in the residents comprehensive assessment and status. This affected one (#9), of 18 reviewed for care planning. The facility census was 77.

Inspectors wroteBased on observation, staff interview, narcotic count record review, and facility policy review, the facility failed to ensure an accurate narcotic count. This affected one (#17) of five reviewed for medications. The census was 77.

Inspectors wroteBased on medical record review, staff interview, and pharmacy reconciliation review the facility failed to ensure a medication reduction order was followed in a timely manner. This affected one Resident (#33) of five reviewed for medication reconciliation. The census was 77.

Inspectors wroteBased on observations, staff interviews and manufacturer's instructions, the facility failed to ensure Lantus (long lasting insulin) was dated upon opening to ensure it was used in a timely manner. This affected one Resident (#50) of five reviewed for medication. The facility census was 77.

Inspectors wroteBased on medical record reviews and staff interviews, the facility failed to ensure the medical record contained accurate documentation. This affected three (#36, #08, and #02) residents out of 18 records reviewed. The facility census was 77.

Inspectors wroteBased on medical record review, observations, staff interview, and review of facility policies, the facility failed to follow infection control procedures during indwelling catheter care. This affected one (#08) resident out of two residents reviewed for infection control procedures. The facility census was 77.

Inspectors wroteBased 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.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide accurate resident medical information when transferred to a hospital. This affected one (#75) resident out of the three residents reviewed for change of condition. The facility census was 73.

Inspectors wroteBased on medical record review, staff interview, and review of the Resident Assessment Instrument (RAI) manual, the facility failed to develop a resident centered comprehensive care plan. This affected one (#75) resident out of five residents reviewed for comprehensive care plans.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to to provide non-pharmaceutical interventions prior to administering an as needed medication for one (#212) of five residents reviewed for unnecessary medications. The census was 65. Findings Include: Review of the medical record for Resident #212 revealed an admission date of 01/27/23. Diagnoses included cerebrovascular accident, dementia without behavioral disturbance, cerebral infarction, transient ischemic attack, type two diabetes mellitus, and anxiety disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 02/03/23, revealed Resident #212 had severe cognitive impairment. Review of the care plan dated 02/14/23 revealed Resident #212 had potential risk for altered behavior patterns, disruptive interactions, disruptive verbally, resistive to care, dementia, and anxiety. [...]

Inspectors wroteBased on record review, interviews, observations, and policy review, the facility failed to provide a resident with the appropiate chair to enable the resident to safely get out of bed. This affected one (#28) of one resident reviewed for assistive devices. The facility census was 65.

Inspectors wroteBased on video observation, review of QSO memos, medical record review, resident family interview, staff interview, and facility policy review, the facility failed to accurately and appropriate express/inform resident representatives of visitation guidelines. This affected one (Resident #209) of three residents reviewed for observations. The census was 65. Findings Include: Observation of video provided by Resident #209 family, recorded date unknown, revealed a three minute and two second video, a nurse supervisor, later identified as Licensed Practical Nurse (LPN) #128, told the family of Resident #209 that they had to follow Center for Medicare and Medicaid (CMS) guidelines when it came to visiting in the facility. The guidelines that she gave were the family had to keep a mask on at all times and not to go in other resident rooms. She did not specify any other visitation guidelines. [...]

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure the Ombudsmen was notified for hospital discharges. This affected two (#28 and #50) out of three residents reviewed for discharges. The facility census was 65.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete a thorough baseline care plan two (#116 and #121) of 16 resident care plans reviewed. The census was 65. Findings Include: 1. Review of the medical record revealed Resident #116 was admitted to the facility on [DATE]. Diagnoses included low back pain, congestive heart failure, type II diabetes, hypertensive heart disease, dementia without behavioral disturbances, mood disturbances, and anxiety, wheezing, peripheral vascular disease, cerebrovascular disease, muscle weakness, difficulty in walking, acute kidney failure, atherosclerotic heart disease, major depressive disorder, anxiety disorder,a nd hyperlipidemia. Review of admitting medical records, it was identified that her family stated she had suicidal ideations prior to being admitted to the facility. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed follow physician orders regarding the use of oxygen and monitoring oxygen saturation levels. This affected one (Resident #57) of four residents reviewed for respiratory care. The census was 65. Findings Include: Review of the medical record revealed Resident #57 was admitted to the facility on [DATE]. Diagnoses included pneumonia, chronic obstructive pulmonary disease, acute respiratory failure, bacteremia, panobular emphysema, dementia, peripheral vascular disease, anxiety disorder, other chronic pain, and personal history of pulmonary embolism. Review of the Minimum Data Set (MDS) assessment, dated 12/09/22, revealed he was cognitively intact. [...]