Facility Watch Inspection records for every certified US nursing home

Vancrest-Upper Valley

3232 North County Road 25a
Troy, OH 45373
(937) 440-7663

CCN
365735
Certified beds
127
Ownership
Non profit - Corporation
Chain
Vancrest Health Care Centers

Nurse staffing

3.28
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.41 hours per resident per day

Nursing staff turnover: 38% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected July 25, 2024

13 citations · Health
B
F0582 No actual harm with potential for minimal harm · Pattern

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0552 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0585 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0637 No actual harm with potential for more than minimal harm · Isolated

Assess the resident when there is a significant change in condition

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0690 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0700 No actual harm with potential for more than minimal harm · Isolated

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0756 No actual harm with potential for more than minimal harm · Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0757 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0761 No actual harm with potential for more than minimal harm · Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Deficient, Provider has date of correction · corrected August 23, 2024
D
F0880 No actual harm with potential for more than minimal harm · Isolated

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected August 23, 2024

Inspected November 23, 2021

11 citations · Health
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected December 13, 2021
D
F0569 No actual harm with potential for more than minimal harm · Isolated

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Deficient, Provider has date of correction · corrected December 13, 2021
D
F0578 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Deficient, Provider has date of correction · corrected December 13, 2021
D
F0580 No actual harm with potential for more than minimal harm · Isolated

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Deficient, Provider has date of correction · corrected December 13, 2021
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected December 13, 2021
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected December 13, 2021
D
F0688 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Deficient, Provider has date of correction · corrected December 13, 2021
D
F0758 No actual harm with potential for more than minimal harm · Isolated

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Deficient, Provider has date of correction · corrected December 13, 2021
D
F0761 No actual harm with potential for more than minimal harm · Isolated

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Deficient, Provider has date of correction · corrected December 13, 2021
D
F0770 No actual harm with potential for more than minimal harm · Isolated

Provide timely, quality laboratory services/tests to meet the needs of residents.

Deficient, Provider has date of correction · corrected December 13, 2021
D
F0921 No actual harm with potential for more than minimal harm · Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Deficient, Provider has date of correction · corrected December 13, 2021

Inspected August 22, 2019

8 citations · Health
C
F0607 No actual harm with potential for minimal harm · Widespread

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Deficient, Provider has plan of correction · corrected September 16, 2019
D
F0550 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected September 16, 2019
D
F0569 No actual harm with potential for more than minimal harm · Isolated

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Deficient, Provider has date of correction · corrected September 16, 2019
D
F0578 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Deficient, Provider has date of correction · corrected September 16, 2019
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected September 16, 2019
D
F0883 No actual harm with potential for more than minimal harm · Isolated

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Deficient, Provider has date of correction · corrected September 16, 2019
E
F0770 No actual harm with potential for more than minimal harm · Pattern

Provide timely, quality laboratory services/tests to meet the needs of residents.

Deficient, Provider has date of correction · corrected September 16, 2019
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected September 16, 2019

Penalties

DateTypeAmount
August 14, 2023Fine$4,233