Vancrest Of Ada

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 REDACTED] 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.

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:

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Event ID:

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

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 0686 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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