Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vancrest Health Care Ctr Of Ho during CMS and state inspections, most recent first.
Improperly Stored and Undated Nourishment Items in Nurses' Station Refrigerator: The snack/nourishment refrigerator at the nurses' stations contained multiple unlabeled, undated, expired, and spoiled food items, including deli meats with mold-like substance, expired dairy and fruit cups, uncovered leftovers, and open beverages. An LPN confirmed the refrigerator was used for residents on the hallways and that all food items should be dated and labeled, including items used during med passes. Facility policy required refrigerated food to be labeled with the resident's name, contents, and date received, and to be discarded when expired or spoiled.
Failure to honor a resident's food preferences: A cognitively intact resident with multiple chronic diagnoses reported that staff kept serving sausage despite her dislike of it. Observation of the breakfast tray and review of the dietary meal ticket confirmed sausage and gravy were served even though the ticket identified the resident did not like sausage, and a CNA verified the meal was provided as served.
Unlabeled and Undated Enteral Tube Feedings: A resident with dysphagia, stroke-related deficits, aphasia, and malnutrition received tube feeding, but observation found feeding bags hanging in the room that were not labeled or dated. The DON confirmed the issue, and an LPN stated tube feedings should be labeled with the formula name, date, and time hung and used or discarded within 24 hours per facility policy.
Failure to obtain an order for oxygen therapy: A resident admitted with displaced rib fractures was observed receiving oxygen via NC at 3 L/min even though the hospital referral form and admission orders did not include oxygen. An LPN confirmed the resident was on oxygen without a physician order, and the oxygen order was not written until the next day. The baseline care plan also initially lacked oxygen therapy documentation and was later updated.
Failure to use required PPE for contact precautions: Staff entered two residents’ rooms without donning gowns, and in one instance without gloves, despite signage directing gloves and gowns before room entry. One resident had severe cognitive deficits and was on contact precautions for urine with IV antibiotics ordered; the other had intact cognition and was on contact precautions for ESBL in urine. An LPN and CNAs were observed entering the rooms without proper PPE, and the facility policy required disposable gloves and a gown upon entering a contact precautions room.
A resident with multiple health issues, including a stage three pressure ulcer, was readmitted to the facility with a new unstageable pressure ulcer on the right heel. Despite the presence of offloading boots and an air mattress, no treatment orders were implemented for ten days. The facility's policy requires timely treatment for pressure areas, but this was not followed, resulting in a delay in care.
A facility failed to ensure communication with a dialysis center and did not monitor a resident's dialysis access site. The resident, with chronic kidney disease, received dialysis thrice weekly, but the care plan lacked site monitoring interventions. Interviews confirmed no communication with the dialysis center, and the DON acknowledged the absence of a monitoring order, violating facility policy.
Improperly Stored and Undated Nourishment Items in Nurses' Station Refrigerator
Penalty
Summary
The facility failed to ensure the snack/nourishment refrigerator at the 300 Hall and 400 Hall nurses' stations was maintained with properly dated and labeled food and beverage items. During observation, salami and pepperoni were found stored in unlabeled and undated plastic bags with a visible white film and mold-like substance. Surveyors also observed outdated yogurt cups, expired fruit cups, expired pudding cups, Mexican food in a leftover container that was uncovered and not dated, leftover containers without a resident name or date, one glass of orange juice left open to the air with no lid, label, or date, a bag of shredded cheese that was not labeled or dated and appeared melted inside the bag, and an unlabeled and undated frozen dinner meal stored in the refrigerator drawer. The Social Worker and Administrator verified these observations, and an LPN confirmed the refrigerator was used for residents on the 300 and 400 hallways. The LPN stated there were currently no residents on those hallways who did not consume food orally and further verified that all food items should be dated and labeled, including food items used during medication passes. The facility policy titled, Food Brought in by Families/Visitors, stated that food requiring refrigeration shall be labeled with the resident's name, contents, and the date received, stored in a designated refrigerator, and discarded according to manufacturer guidelines, expiration dates, food labels, or upon evidence of spoilage.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences by serving sausage despite the resident's stated dislike of sausage. Resident #49 was admitted with diagnoses including fracture of the superior rim of the left pubis, chronic atrial fibrillation, diastolic congestive heart failure, and chronic kidney disease. The resident's MDS assessment showed a BIMS score of 15, indicating cognitive intactness. During interview, the resident stated the facility kept serving sausage even though she did not like it and said the facility was aware of her preference. On observation of the resident's breakfast tray, sausage and gravy over biscuits were served along with cereal, a fried egg, juice, almond milk, and hot water for tea. Review of the dietary meal ticket also showed the resident disliked sausage. A CNA verified that the resident received sausage and gravy for breakfast, and later observation showed the resident ate the cereal and fried egg but did not eat the sausage and gravy. The facility policy titled Resident Food Preferences stated that nursing staff would document the resident's food and eating preferences.
Unlabeled and Undated Enteral Tube Feedings
Penalty
Summary
The facility failed to ensure enteral tube feedings were correctly labeled and dated for one resident receiving tube feeding. Resident #20 was admitted with diagnoses including dysphagia following a stroke, right-sided paralysis, aphasia, intracerebral hemorrhage, seizures, neurogenic bladder, and protein-calorie malnutrition. The admission MDS indicated the resident was cognitively intact, had no behaviors at the time of assessment, and received 51% or more of nutrition from a feeding tube. Physician orders included a puree diet and Jevity 1.5 to be administered nightly from 9:00 P.M. to 5:00 A.M. at 60 mL per hour with water boluses before and after the feeding. During observation, the resident’s enteral tube feeding was hanging in the room with one bag containing 600 mL of light brown fluid and another bag containing 1000 mL of clear liquid, and neither bag was labeled or dated. The DON confirmed the bags were not labeled to indicate what they contained and should have been. An LPN stated that tube feedings should be labeled with the formula name, date, and time hung, and that once a formula is hung it must be used or discarded within 24 hours. The facility policy also stated enteral tube feedings would be labeled with the date and time they were hung and administered or discarded within 24 hours.
Failure to Obtain Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician order for oxygen therapy for a resident admitted with fall-related displaced rib fractures of ribs seven through eleven. The resident's hospital Community Referral Form and admission physician orders did not include supplemental oxygen orders, yet the resident was observed resting in bed with oxygen in place at 3 L/min via nasal cannula. An LPN later confirmed the resident was receiving oxygen at 3 L/min and did not have a physician order for it. The resident's oxygen order was not written until the following day, and the baseline care plan initially did not include oxygen therapy. The baseline care plan was later updated to reflect oxygen at 3 L/min and then changed to 2 L/min. An LPN stated the oxygen-related documentation was added to the baseline care plan after admission to show the resident had arrived with oxygen in place, and the DON verified the oxygen order had not been obtained and written until after the resident had already been receiving oxygen.
Failure to Use Required PPE for Contact Precautions
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not wear the required PPE upon entry into contact precautions rooms. Resident #10 was admitted with diagnoses including sepsis, muscle weakness, unsteadiness of feet, hypomagnesium, UTI, and unspecified dementia, and had a BIMS score of three indicating severe cognitive deficits. The physician ordered contact precautions for urine, and signage outside the room directed staff to put on gloves and a gown before entry. However, LPN #291 and LPN #230 entered the room without gowns, and LPN #230 later confirmed a gown was not donned before entry. Both LPNs stated they administered the resident’s medications, including IV antibiotics. Resident #47 was admitted with diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, Type II diabetes mellitus, and cellulitis, and had intact cognition on the MDS. A physician order placed the resident on contact precautions for ESBL in urine, and signage outside the room directed staff to don gloves and a gown before entering. No PPE was available outside the room, and CNA #269 and CNA #242 entered without donning PPE; both were wearing gloves only and later donned gowns from inside the room. During the same observation, LPN #291 entered the room without a gown or gloves, obtained gloves from the bathroom, and checked the resident’s blood sugar. The administrator confirmed the signage required PPE before room entry, and the facility policy stated staff were to wear disposable gloves and a gown upon entering a contact precautions room.
Failure to Implement Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure timely implementation of treatments for pressure ulcers, affecting a resident who was readmitted after a hospital discharge. The resident, who had multiple diagnoses including cerebral infarction, hemiplegia, and a stage three pressure ulcer, was found to have a new unstageable pressure ulcer on the right heel upon readmission. Despite the presence of offloading boots and an air mattress, no treatment orders were in place for the right heel ulcer until ten days after readmission. The medical record review and staff interviews confirmed that the resident had a suspected deep tissue injury on the right heel, which was not addressed with treatment orders until a wound nurse practitioner consultation occurred. The facility's policy on pressure ulcer risk assessment and management requires that residents with pressure areas receive treatment and services to promote healing, with treatment orders obtained by the floor nurse. However, this protocol was not followed, leading to a delay in treatment for the resident's pressure ulcer.
Failure in Dialysis Care Communication and Monitoring
Penalty
Summary
The facility failed to ensure proper communication with the dialysis treatment center and did not provide ongoing monitoring and assessment of the dialysis access site for Resident #150. This resident, who was admitted with multiple diagnoses including acute kidney failure and chronic kidney disease stage 3, was scheduled for outpatient dialysis three times a week. However, the care plan did not include interventions for monitoring the dialysis access site, and there was no physician order for such monitoring. Interviews with Resident #150 and staff revealed that no paperwork was provided to the resident for dialysis, and no communication was sent to the dialysis center. The Director of Nursing confirmed the absence of a physician order for monitoring the dialysis access site. The facility's policy on dialysis care, which requires ongoing assessment and communication with the dialysis facility, was not followed, leading to this deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Holgate
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lutheran Home | 8.6 mi | ★★★★★ | 0 | 0 |
| Northcrest Rehab And Nursing Center | 10.2 mi | ★★★★★ | 1 | 0 |
| Laurels Of Defiance The | 12.7 mi | ★★★★★ | 0 | 0 |
| Brookview Healthcare Center | 13.1 mi | ★★★★★ | 3 | 0 |
| Meadows Of Leipsic | 13.6 mi | ★★★★★ | 7 | 0 |
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