Vancrest Health Care Center

In the surveyor’s words

From the most serious findings on record at Vancrest Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Oct 13, 2022

  Based on medical record review, observation, staff and family interview, review of the hospital documentation, and policy review, the facility failed to ensure falls were investigated to determine the root cause analysis to reduce hazards, implement resident-specific interventions, and to reduce/eliminate falls and falls with major injury. This resulted in Actual Harm when Resident #16 experienced repeated falls resulting in a fractured left wrist on one event and a fractured left femur on another event with surgical repair without investigating and/or determining the cause of each fall. In between the two falls with fractures, Resident #16 fell and suffered a contusion to the left knee and the hip area. This affected one resident (#16) out of two residents reviewed for falls. […]

• No harm, potential for more than minimal, widespreadF727Dec 7, 2023

  Based on review of the nursing staffing schedules and staff interviews, the facility failed to have Registered Nurse coverage for eight consecutive hours on two days as required. This had the potential to affect all 69 residents residing in the facility. Facility census was 69. Findings include: Review of the nursing staffing schedules dated 11/14/23 to 11/20/23 revealed there was no Registered Nurse present in the facility on 11/18/23 or 11/19/23. Interview on 12/06/23 at 11:06 A.M. with Director of Nursing revealed the facility did not have Registered Nurse coverage in the facility as required on 11/18/23 or on 11/19/23. This deficiency is based on incidental findings discovered during the course of this complaint investigation.

• No harm, potential for more than minimal, patternF679May 1, 2025

  Based on observation, review of the activity calendar, record review, resident and staff interview, and policy review, the facility failed to offer a variety of activities to the residents which meet the resident's needs and preferences. This affected five (#18, #38, #43, #56, and #63) of five residents reviewed for activities. The facility identified 34 residents who regularly attended activities. The facility census was 70. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including congestive heart failure, sciatica right side, chronic kidney disease, and weakness. […]

• No harm, potential for more than minimal, patternF700Oct 13, 2022

  Based on observation, medical record review, staff interview, policy review, the facility failed to accurately assess residents and obtain consent for assist rails/transfer enablers. This affected 10 residents (#02, #06, #10, #18, #24, #30, #34. #37, #50, and #52) and had the potential to affect all residents in the facility. The facility census was 57. Findings include: Observation on 10/04/22 at 10:20 A.M. with State tested Nursing Assistant (STNA) #124 revealed the side rails on the beds of seven residents (#02, #06, #18, #34, #37, #50, and #52) were in the raised position and extended approximately two foot from the head board to two foot from the foot board on both sides of the bed. Interviews from 10:20 A.M. to 10:30 A.M. […]

• No harm, potential for more than minimal, isolatedF656May 1, 2025

  Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure resident care conferences were offered and provided routinely as required. This affected two (#6 and #7) of two residents reviewed for care conferences. The facility census was 70. Findings include: 1. Review of the medical record revealed Resident #6 was admitted on [DATE]. Diagnoses included hypertensive heart and chronic kidney disease with heart failure, chronic kidney disease stage, type two diabetes mellitus, and major depressive disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively intact. Review of the care plan conference documentation revealed Resident #6's last date of documented care conferences was 05/14/21. […]