Vancrest of New Carlisle

In the surveyor’s words

From the most serious findings on record at Vancrest of New Carlisle, in the surveyor’s own words.

• Actual harm, isolatedF686Dec 22, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF758Feb 16, 2023

  Based 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 admitted [DATE]. 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. […]

• No harm, potential for more than minimal, isolatedF563May 14, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF641Dec 22, 2025

  Based 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. Findings include: 1.Review of the medical record for Resident #42 revealed an admission date of 03/24/25 with medical diagnoses of diabetes mellitus, peripheral vascular disease, chronic kidney disease stage III, and hypertension. […]

• No harm, potential for more than minimal, isolatedF656Dec 22, 2025

  Based 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. […]