Vancrest Health Care Center Of Eaton

Based on observation, staff interview, and review of the facility policy, the facility failed to store food in a sanitary manner. This had the potential to affect all residents receiving meals from the facility kitchen. The facility census was 69 residents. Findings include: Observation on 02/23/26 at 10:10 A.M. of the walk-in freezer revealed it contained the following: a bag of ham in a zip lock bag with an expiration date of 05/29/24, two loaves of rye bread without expiration dates, a bag of opened and undated French fries. Observation on 02/23/26 at 10:20 A.M. of the reach in refrigerator revealed it contained a box of waffles opened and undated and a bag ravioli that was opened, undated, and had an expiration date of 08/03/25. Interview on 02/23/26 at 10:25 A.M. with Facility [NAME] (FC) # 202 verified the items in the walk-in freezer and the reach-in refrigerator should have been dated upon opening and discarded when expired. Review of the facility policy titled Storage of Staples dated January 2022 revealed frozen foods should not be stored in a frozen state for more than…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility documents and staff interview, the facility failed to conduct a complete assessment of the facility's risk for tuberculosis (TB.) This had the potential to affect all of the residents residing in the facility. The facility census was 69 residents.Findings include: Review of the facility's TB risk assessment worksheet revealed it was undated and unsigned, and many portions of the form were not completed. The following areas were not addressed: indication of the risk level for TB (low, moderate, or ongoing transmission), number of beds in the facility, indication if there was a high incidence of immunocompromised patients or healthcare workers in the facility. Interview on 02/25/26 at 11:40 A.M. with Registered Nurse (RN) #257, the designated Infection Preventionist (IP) for the facility, the Administrator, and the Director of Nursing (DON) confirmed the facility was a low-risk setting and had no current or recent cases of TB. RN #257 stated when she assumed the IP role she did not complete the TB risk assessment form in its entirety. Review of the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to equitably credit interest earned from the shared resident trust account to individual resident trust accounts. This affected four (Residents #8, #39, #46 and #51) of 42 residents who had accounts with the facility. The facility census was 69 residents.Findings include: Review of resident trust account statements for Residents #8, #39, #46 and #51 revealed interest was added to the accounts randomly and was not calculated based on the balance of funds in the accounts. Interview on 02/26/26 at 3:07 P.M. with Social Services Director (SSD) #253 and Assisted Living Director (ALD) #227 confirmed the facility did not add interest to individual resident accounts based on the balance of funds in the account. Interest was awarded to accounts monthly by alphabetical lists. SSD #253 confirmed they broke up the accounts managed by the facility into fourths and rotated through each list quarterly applying interest. SSD #253 and ALD #227 confirmed there were no calculations made of account balances and interest was awarded based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure medications were secure. This affected one (Resident #40) and had the potential to affect three residents identified by the facility as being cognitively impaired and independently mobile. The facility census was 69 residents. Findings include:Review of the medical record of Resident #40 revealed an admission date of 01/06/26 with diagnoses including type two diabetes mellitus, spinal stenosis, anxiety disorder, and overactive bladder. Observation on 02/23/26 at 3:20 P.M. revealed Registered Nurse (RN) #262 entered Resident #40's room with a medication cup with various medications and a small tub of vanilla pudding. RN #262 placed the items on the overbed table and walked out of the room, closing the door behind her. Resident #40 began to take the medications, using pudding. RN #262 then returned to the room with a glass of water. Interview on 02/23/26 at 3:21 P.M. with RN #262 confirmed she had left the medications unattended on Resident #40's overbed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to perform proper incontinence care. This affected one (Resident #69) of one resident reviewed for incontinence care. The facility census was 69 residents. Findings include:Review of the medical record for Resident #69 revealed an admission date of 12/15/25 with diagnoses including end stage renal disease, chronic combined congestive heart failure, and hemiplegia and hemiparesis following a stroke. Review of the Minimum Data Set (MDS) assessment for Resident #69 dated 12/22/25 revealed the resident was cognitively impaired, was dependent on staff for toileting, and had an indwelling urinary catheter. Observation on 02/26/26 at 10:20 A.M. of catheter care for Resident #69 per Certified Nursing Assistants (CNAs) #269 and #285 revealed the aides removed the incontinent brief and used a disposable wipe to cleanse the resident's peri area separating the labia and wiping from the front to back. CNA #269 then arranged the wipe to a different section before wiping again.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, staff interview, and resident interview, the facility failed to ensure only licensed staff administered oxygen to residents and that oxygen tubing was handled in a sanitary manner. This affected one (Resident #49) of 14 facility-identified residents receiving oxygen. The facility failed also failed to ensure oxygen tubing was dated. This affected two (Residents#13 and #22) of 14 facility-identified residents receiving oxygen. The facility census was 69 residents. Findings include: 1.Review of the medical record of Resident #49 revealed an admission date of 10/23/25 with diagnoses include acute and chronic respiratory failure, pulmonary fibrosis, and interstitial lung disease. Review of the physician's orders for Resident #49 revealed an order dated 10/31/25 for continuous oxygen at three liters per minute via nasal cannula. Review of the Minimum Data Set (MDS) assessment for Resident #49 dated 12/28/25 revealed the resident cognitively impaired and received oxygen. Observation on 02/23/26 at 11:59 A.M. revealed Resident #49 was seated in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of hospice visit logs, facility staff interview, hospice staff interview, and review of hospice contracts, the facility failed to ensure hospice documentation was sufficient and available for review by facility staff to ensure assessments, treatments and care planning were provided per plan of care. Additionally, the facility failed to jointly collaborate with hospice to develop resident care plans. This affected two (Residents #23 and #58) of two residents reviewed for hospice services. The census was 69 residents.Findings include: 1.Review of the medical record for Resident #58 revealed an admission on [DATE] with diagnoses including non-Hodgkin's lymphoma and heart failure. Review of the Minimum Data Set (MDS) assessment for Resident #58 dated 01/31/26 for the resident revealed the resident had impaired cognition, was dependent on staff for activities of daily living (ADLs), and received hospice services. Review of the hospice plan of care for Resident #58 dated 12/13/25…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observations, staff interview, review of facility policy and review of Centers for Disease and Prevention (CDC) guidelines, the facility failed to ensure infection control procedures were followed during incontinence care. This affected one (#11) out of three residents reviewed for incontinence care. The facility census was 71. Findings include: Review of medical record for Resident #11 revealed admission date of 07/11/24. Diagnoses include dementia without behavior and type two diabetes mellitus. Review of Resident #11's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had a Brief Interview Mental Status (BIMS) score of 11 indicating impaired cognition. Resident #11 required moderate assistance with toileting hygiene, was independent with eating moderate assistance for transfers, supervision for bed mobility. Resident #11 was always in urine and bowel. Observation of incontinence care for Resident #11 on 01/07/25 at 9:37 A.M. revealed Certified Nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure as needed (PRN) antipsychotic medications prescribed were limited to 14 days. Additionally, the facility failed to re-evaluate a resident for continued use of PRN antipsychotic medication. This affected one (Resident #14) of five residents reviewed for psychotropic medications. Additionally, the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected one (Resident #15) of five residents reviewed for pharmacy recommendation response. The facility's census was 49. Findings include: 1. Medical record review for Resident #14 revealed an admission date of 07/15/22. Resident #14 was discharged on 08/04/22 and returned on 09/06/22 with diagnoses including but not limited to respiratory failure, interstitial pulmonary disease, pulmonary fibrosis, peripheral vascular disease, paroxysmal fibrillation, chronic diastolic congestive heart failure,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interview, and review of facility policy, the facility failed to ensure medication carts were secured when unattended. This had the potential to affect four (Residents #4, #12, #26, and #42) identified by the facility as confused and independently mobile residing on the South unit. The facility census was 49. Findings included: Observation on 01/09/23 at 12:20 P.M. revealed the medication cart located on the South unit was unlocked and unattended. Licensed Practical Nurse (LPN) #119 was in a resident's room. Interview on 01/09/23 at 12:30 P.M. with LPN #119 verified the medication cart was unlocked and unattended while she was in a resident's room. Observation on 01/11/23 at 11:21 A.M. revealed the medication cart located on the South unit was unlocked and unattended. Interview on 01/11/23 at 11:29 A.M. with Licensed Practical Nurse (LPN) #119 verified the medication cart was unlocked and unattended in the unit hallway LPN #119 verified the medication cart should be locked when unattended. Review of the facility policy titled Storage of Medication dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, policy review, staff interview, review of center for disease control (CDC) guidance the facility failed to provide pneumonia vaccinations according to current CDC guidelines. This directly affected five Residents (#17, #19, #23, #26 and #117) of five reviewed for immunizations. This had the potential to affect any resident eligible to receive the pneumococcal vaccination series by the physician. The total facility census was 65. Findings include: 1. Review of the medical record revealed Resident #17 was admitted on [DATE] and received the PPSV23 on 10/22/15, prior to admission. 2. Review of the medical record revealed Resident #19 was admitted on [DATE] and had received a Pneumococcal Polysaccharide Vaccine (PPSV)23 vaccination on 08/09/17, prior to admission. 3. Review of the medical record revealed Resident #23 was admitted on [DATE] and had a historical Pneumococcal Conjugate Vaccine (PCV)13 vaccination on 02/20/18, prior to admission. 4. Review of the medical record revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on closed medical record review, hospital documentation review, physical therapy progress notes, staff interview, and policy review, the facility failed to ensure the physician was notified timely of the resident's hypotensive BP assessments. This affected one (Resident #66) of one resident reviewed for hospitalization. The census was 65. Findings include: Review of the closed medical record revealed Resident #66 was admitted to the facility on [DATE]. Diagnoses included disorder involving immune mechanism, hypertension, atrial fibrillation, congestive heart failure, peripheral vascular disease, kidney transplant status, chronic kidney disease, complete atrioventricular block, left bundle branch block, and presence of a cardiac pacemaker. The resident was discharged to the hospital on [DATE]. Review of hospital documentation dated 06/26/19, prior to Resident #66's admission to the facility revealed her BP was 104/59. Review of Resident #66's BP assessments revealed on 06/26/19 the residents BP was 110/60.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.