Vancrest of Upper Sandusky

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF761Jan 15, 2026

  Based on observations, staff interviews, review of facility policy, and review of a medication reference guide, the facility failed to ensure medications were properly labeled with an open date to determine expiration dates and further failed to ensure expired medications were disposed of. This had the potential to affect all 89 residents residing in the facility. The facility census was 89.Findings include: 1. Observation on 01/13/26 at 9:22 A.M. of the Buckeye Hall medication cart revealed a bottle of GenTeal tears (for dry eyes) for Resident #90, with a delivery date of 10/18/25 and no open date. Concurrent interview with Registered Nurse (RN) #123 verified there was no open date on Resident #90's GenTeal tears to indicate when they should be discarded. 2. […]

• No harm, potential for more than minimal, widespreadF851Oct 26, 2023

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on the review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report, staffing schedule, posted daily staffing sheets, staff time sheets, and staff interview, the facility failed to submit accurate information in the PBJ in the third quarter of 2022. This had the potential to affect all residents. The facility census was 81. Findings Include: Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed the facility triggered for excessively low weekend staffing and not having licensed nursing coverage 24 hours a day in the third quarter of 2022. […]

• No harm, potential for more than minimal, patternF583Jan 15, 2026

  Based on observation and staff interview, the facility failed to ensure the confidentiality of residents' medical information. This affected 13 (#7, #11, #15, #17, #26, #36, #38, #55, #59, #62, #67, #83, and #87) of 13 residents who resided on the east hall. The facility census was 89.Findings include:Observation on 01/13/26 at 8:20 A.M. revealed Licensed Practical Nurse (LPN) #307 walked away from her medication cart on the East Hall for four minutes. LPN #307 left a sheet of paper laying on top of the medication cart, within view, that had the names, room numbers, and medical information, which included vital signs, blood sugar and laboratory (lab) results, and resident behaviors, for the 13 (#7, #11, #15, #17, #26, #36, #38, #55, #59, #62, #67, #83, and #87) residents who resided on the… […]

• No harm, potential for more than minimal, patternF656Jan 15, 2026

  Based on medical record review and staff interview, the facility failed to ensure comprehensive care plans were developed to address residents' needs. This affected four (#2, #64, #84 and #10) of four residents reviewed for care plans. The facility census was 89. Findings include:1. Review of the medical record for Resident #2 revealed she was admitted on [DATE]. Her diagnoses included dementia, hypertension, glaucoma, malnutrition, and a stage three pressure ulcer to her upper back. Her Braden assessment (used to predict the risk for pressure ulcers) revealed she was at risk for pressure ulcers. Review of the Minimum Data Set (MDS) assessment, dated 12/12/25, revealed Resident #2 was cognitively impaired and did not experience behaviors at the time of the assessment. […]

• No harm, potential for more than minimal, patternF679Jan 15, 2026

  Based on observation, review of the activity calendars, staff interview, and review of facility policy, the facility failed to ensure an adequate activities program on the memory care unit. This had the potential to affect 12 (#13, #14, #47, #53, #57, #60, #63, #68, #78, #80, #82, and #89) residents identified by the facility as residing on the memory care unit and regularly participating in activities. The facility census was 89.Findings include:Review of the Activity Calendar for 01/12/26 revealed the following scheduled activities on the memory care unit: 9:30 A.M. morning music, 10:30 A.M. just you and me, 1:00 P.M. hydration station, and 3:00 P.M. piano with Resident Council President.Observation on 01/12/26 from 9:00 A.M. through 10:40 A.M. […]