Vancrest Health Care Ctr Of Ho

Based on observation, staff interview, and review of facility policy, the facility failed to ensure the snack/nourishment refrigerator for the 300 Hall and 400 Hall nurses' stations was maintained with properly dated and labeled food and beverage items to prevent the potential for foodborne illness. The facility identified thirty-one residents (#1, #4, #9, #14, #16, #17, #18, #19, #20, #23, #24, #26, #27, #28, #29, #30, #31, #32, #33, #36, #39, #40, #42, #44, #46, #48, #50, #55, #57, #59, and #67) who receive nourishments from the refrigerator. The facility census was 56.Findings include:Observation on 02/18/26 at 1:58 P.M. of the 300 Hall and 400 Hall nurses' station refrigeration unit revealed salami and pepperoni stored in unlabeled and undated plastic bags with a visible white film and and mold like substance observed. Further observation revealed outdated yogurt cups; expired fruit cups; expired pudding cups; Mexican food in a leftover container was uncovered and not dated; leftover containers not labeled with a resident name or date; one glass of orange juice was left open to…

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 resident interview, observation, medical record review, the review of dietary meal ticket, staff interview, and review of facility policy, the facility failed to honor residents' food preferences. This affected one (#49) of two residents reviewed for preferences. The facility census was 56. Findings include:Review of the medical record for Resident #49 revealed an admission date of 12/10/25. Diagnoses included fracture of superior rim of left pubis, subsequent encounter for fracture with routine healing, chronic atrial fibrillation, unspecified diastolic (congestive) heart failure, and chronic kidney disease.Review of the Minimum Data Set (MDS) assessment, dated 12/12/25, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Interview with Resident #49 on 02/17/26 at 8:30 A.M. revealed she did not like sausage and the facility kept serving her sausage. Concurrent observation of Resident #49's breakfast meal tray revealed she was served sausage with her breakfast. Resident #49 stated the facility was…

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 observations, resident interview, staff interviews, and review of facility policy, the facility failed to ensure enteral tube feedings were correctly labeled and dated. This affected one (#20) of one resident reviewed for enteral tube feedings. The facility census was 56.Findings include:Review of the medical record for Resident #20 revealed he was admitted on [DATE]. His diagnoses included dysphagia (difficulty swallowing) following a stroke, right-sided paralysis, aphasia (difficulty speaking), intracerebral hemorrhage, seizures, neurogenic bladder, and protein-calorie malnutrition.Review of the admission Minimum Data Set (MDS) assessment, dated 11/11/25, revealed Resident #20 was cognitively intact and did not display any behaviors at the time of the assessment. Resident #20 received 51% or more of his nutrition from a feeding tube.Review of the physician orders for Resident #20 revealed an order dated 02/09/26 for a puree diet and an order dated 02/11/26 for Jevity 1.5 (nutritional formula) to be…

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 observation, staff interview, medical record review, and review of the facility policy, the facility failed to obtain an order for oxygen therapy. This affected one (#64) of one resident reviewed for oxygen therapy. The facility identified nine residents (#25, #27, #41, #43, #47, #51, #53, #55, and #64) who received oxygen therapy. The facility census was 56.Findings include:Review of the medical record for Resident #64 revealed an admission date of 02/16/26 with admitting diagnoses of fall with displaced rib fractures of ribs seven through eleven.Review of the hospital Community Referral Form (CRF) dated 02/16/26 for Resident #64 revealed no orders for supplemental oxygen therapy.Review of the admission physician orders for Resident #64 revealed no orders for oxygen therapy.Observation on 02/17/26 at 11:00 A.M. of Resident #64 revealed the resident was resting in bed with oxygen in place and running at three l/m via nasal cannula (NC).Interview on 02/17/26 at 1:54 P.M. with Licensed Practical Nurse (LPN) #230 verified Resident #64 received oxygen therapy at three liters…

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 observation, medical record review, staff interview and policy review the facility failed to wear proper personal protective equipment (PPE) upon entry into a contact precautions room. This affected two (#10 and #47) of two residents reviewed for transmission-based precautions (TBP). The facility census was 56.Findings include: 1. Review of the medical record for Resident #10 revealed the resident was admitted to the facility on [DATE]. Diagnoses included sepsis of unspecified organism, muscle weakness, unsteadiness of feet, hypomagnesium, urinary tract infection (UTI), and unspecified dementia. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive deficits. Resident #10 required substantial/maximum assistance with activities of daily living (ADLs). Review of the physician orders revealed an order dated 02/16/26 contact precautions for urine. Observation on 02/17/26 at 9:05…

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 facility policy, the facility failed to ensure treatments were implemented timely for pressure ulcers. This affected one (#46) of three residents reviewed for pressure ulcers. The facility census was 49. Findings include: Review of the medical record revealed Resident #46 was admitted to the facility on [DATE]. Diagnoses included cerebral infarction due to thrombosis of left middle cerebral artery, hemiplegia right dominant side, spinal stenosis, major depressive disorder recurrent, pressure ulcer of the right heel, gastrostomy status, acute cystitis without hematuria, hyperlipidemia, and atherosclerotic heart disease of native coronary artery without angina pectoris. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was moderately cognitively impaired, dependent for all care, and had a stage three pressure ulcer. Review of the admission nursing assessment dated [DATE] revealed Resident #46 readmitted to the facility after a…

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, resident interview, staff interview, and facility policy, the facility failed to ensure communication with dialysis treatment center and and failed to provide ongoing monitoring/assessment of the dialysis access site. This affected one (#150) of one resident reviewed for dialysis. The census was 49. Findings include: Review of the medical record revealed Resident #150 was admitted on [DATE]. Diagnoses included abscess of liver, acute kidney failure, cognitive communication deficit, chronic kidney disease stage 3, vascular dementia, major depressive disorder, type two diabetes mellitus with hyperglycemia, and hyperlipidemia. Review of physician orders dated 10/07/24 revealed Resident #150 received outpatient dialysis on Monday, Wednesday, and Fridays. Review of the most recent care plan dated 10/16/24 revealed Resident #150 was care planned for dialysis with interventions. None of the interventions included monitoring of the dialysis access site. Interview on 10/16/24 at 11:12 A.M.…

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 observation, staff interview, and review of the menu spreadsheet, review of recipe, review of resident diet list, the facility failed to ensure pureed protein was prepared following the recipe to ensure adequate protein was provided. This affected one (#19) of one resident identified on a pureed diet. Additionally, the facility failed to ensure appropriate scoop sizes were used to serve protein portions to Resident #19 on a pureed diet, and to 11 (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) residents identified on a mechanical soft diet. The facility census was 44. Findings include: 1. Review of Resident #19's medical record revealed an admission date of 09/02/19. Diagnoses included dementia with psychotic disturbance and hemiplegia and hemiparesis following a cerebral vascular accident. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 had a low cognitive function. Review of a physician order dated 12/20/21 revealed Resident #19 received a…

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 observation, staff interview, review of resident diet list, and review of policy, the facility failed to ensure hand hygiene was practiced during the preparation of mechanical soft food. This had the potential to affect 11 residents (#2, #4, #9, #17, #23, #24, #26, #35, #36, #38, and #40) identified on a mechanical soft diet. The facility census was 44. Findings include: Observations on 09/20/23 beginning at 11:03 A.M., revealed [NAME] #301 wearing gloves and handling tongs to pick up patties of veal parmesan to prepare mechanical soft textured food. Interview at that time with [NAME] #301 stated there were 11 residents on a mechanical soft diet, and she prepared the patties of veal parmesan in batches to not overload the food processor. Continued observation revealed [NAME] #301 placing four patties in the food processor, closing the lid, pressing the start button, pressing the stop button, opening the lid, using a spatula lying on the countertop to push the food lower into the food processor, picking up a carafe of hot water and pouring the water into the food processor,…

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 observation, medical record review, staff interview, resident interview, and policy review, the facility failed to ensure residents who were dependent on staff for activities of daily living were provided with nail care. This affected three (#4, 19 and #26) of three residents reviewed for assistance with activities of daily living. The facility census was 44. Findings include: 1. Review of Resident #4's medical record revealed an admission date of 03/03/22, with diagnosis including dementia with mood disturbance, cerebral infarction, psychosis, and macular degeneration. Review of Resident #4's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a cognitive deficit and required extensive assistance for personal hygiene. Review of Resident #4's most recent care plan revealed the resident had an activity of daily living (ADL) self-care performance deficit related to decreased strength and endurance, impaired cognition related to dementia. Interventions were to provide limited…

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 staff interview, record review, and review of the facility's Hospice Agreement, the facility failed to ensure coordination of care between the facility and Hospice provider. This affected one (#43) of one resident reviewed for Hospice care. The facility identified one resident in the facility was under Hospice care. The facility census was 44. Findings include: Review of the medical record for Resident #43 revealed an admission date of 01/04/23, with diagnoses of dementia, hemiplegia, and hemiparesis. Review of the modified quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #43 had impaired cognition and required extensive assistance of two people for bed mobility, dressing, was totally dependent on two people for transfers, and required extensive assistance of one person for eating. Review of a physician order dated 05/26/23 revealed Resident #43 was admitted to hospice. Review of the facility's current care plan for Resident #43 revealed she received Hospice services.…

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 record review, resident interview, staff interview, Certified Nurse Practitioner interview, and review of the policy, the facility failed to ensure behavior interventions of non pharmacological interventions were implemented prior to increasing antipsychotic medication doses. This affected one (#18) of five residents reviewed for psychotropic medications. The facility census was 44. Findings include: Review of the medical record for Resident #18 revealed an admission date of 05/03/19, with diagnoses of schizoaffective disorder and traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 had intact cognition and required supervision with one person assistance for transfers and locomotion. Further review revealed no physical or verbal behaviors towards others or not toward others, no rejection of care. Review of the behavior care plan initiated 05/19/18 revealed Resident #18 had a traumatic brain injury, schizoaffective disorder, impaired…

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.