Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vancrest Of New Carlisle during CMS and state inspections, most recent first.
A facility failed to complete comprehensive wound assessments when skin breakdown was first identified for one resident who later developed an unstageable coccyx pressure ulcer and a Stage III heel ulcer. The record showed skin issues on multiple observation reports without corresponding wound assessments or timely weekly skin documentation. The facility also failed to follow physician wound orders for another resident’s left dorsal foot wound, with the wound initially documented on the wrong foot and treated with the wrong wrap, and it later worsened to a DTI.
Inaccurate MDS coding affected two residents reviewed for meds. One resident’s MDS incorrectly indicated anticoagulant use despite only an antiplatelet order being present, and another resident’s MDS incorrectly marked diuretics as not received even though orders for Lasix and Zaroxolyn were active. QA staff confirmed both MDS assessments were coded in error, and the RAI manual states Section N is used to record select meds received during the 7-day look-back period.
Failure to develop a comprehensive care plan for a resident with pressure ulcers. A resident with paraplegia, COPD, ASHD, and anxiety was assessed as having moderate cognitive impairment and needing substantial to maximum staff assistance for ADLs, with no skin breakdown noted on the admission MDS. Wound physician notes later documented an unstageable coccyx pressure ulcer, a Stage III left heel pressure ulcer, and ongoing Stage IV coccyx involvement, but the record contained no documentation of a person-centered comprehensive care plan for either wound; the DON confirmed this.
Missed care conferences and delayed care plan update: Two residents did not have quarterly care conferences that included the resident and/or representative, and one resident’s care plan was not updated after a change in MDS/status to reflect hospice services. One resident had intact cognition with significant ADL dependence, another had dementia and other medical issues, and the third had COPD-related diagnoses, intact cognition, and required a Hoyer lift.
Inaccurate Controlled Medication Count: An LPN and the DON confirmed a discrepancy in the controlled count for a resident’s Lyrica 150 mg capsules, with the count sheet showing fewer capsules than the medication card. The LPN stated she had counted with the night nurse and both signed the count as correct at the start of the shift. The resident, who had diagnoses including depression, renal artery atherosclerosis, and fibromyalgia, denied increased pain or discomfort when the discrepancy was identified.
A resident with DM, ASHD, delusional disorder, anxiety, and depression had a scheduled Sertraline dose reduction identified during the monthly med review. The physician approved the decrease from 175 mg to 150 mg, but the order was not started until later, and the DON confirmed the delay.
An LPN found a resident’s Lantus pen was undated during observation, and the date line was blank. The resident had diabetes mellitus, stroke, and vascular dementia. Manufacturer instructions stated the insulin pen may be used for four weeks after the first dose and then must be discarded even if insulin remains.
Inaccurate and missing charting affected three residents. One resident’s record lacked documentation supporting skin assessments and wound evaluations despite shower sheets showing skin issues, another resident’s chart was missing multiple physician/NP progress notes despite repeated visits, and a third resident’s wound records contained inconsistent and incorrect location/type documentation. The DON confirmed several of the documentation errors and omissions.
Failure to Follow EBP and Hand Hygiene During Foley Catheter Care: A resident with a Foley catheter and diagnoses including quadriplegia and bladder dysfunction received incontinence care and catheter care without proper EBP use. A CNA did not don a gown, did not perform hand hygiene after removing gloves and before putting on new gloves, and later repositioned the resident and pulled up covers while wearing the same gloves used during catheter care; no PPE cart was available outside or inside the room.
The facility failed to provide written notification of room changes to three residents, despite policy requirements. A resident with severe cognitive impairment and another who was cognitively intact were moved without documented written notice. Social Service staff confirmed verbal notifications were given, but no written documentation was provided, leading to non-compliance with facility policy.
A facility failed to provide accurate medical information during a resident's transfer to the hospital. The resident, with severe cognitive impairment and a recent VP shunt placement, was sent to the ED after a fall. The facility did not update the medical record with the new diagnosis or communicate the resident's medical status to the ED, leading to a deficiency finding.
A resident with severe cognitive impairment and multiple medical conditions, including a VP shunt for obstructive hydrocephalus, did not have a comprehensive care plan addressing the shunt. The facility failed to document this critical aspect of care, as confirmed by an RN, despite following the RAI manual for care planning.
Failure to complete wound assessments and follow wound treatment orders
Penalty
Summary
The facility failed to complete comprehensive wound assessments when skin breakdown was first identified for Resident #36, who was admitted with paraplegia, COPD, atherosclerotic heart disease, and anxiety and was assessed as high risk for skin breakdown on the Braden scale. The admission nursing evaluation documented intact skin, but subsequent shower/skin observation reports noted a sore to the bottom and skin issues to the midline spine, left heel, and buttocks/coccyx area. The medical record did not contain documentation supporting comprehensive wound assessments for the skin issues noted on 09/12/25, 09/14/25, 09/19/25, or 09/23/25, and weekly skin assessments were not documented until 10/21/25. Resident #36’s wound physician notes later documented an unstageable pressure ulcer to the coccyx and a Stage III pressure ulcer to the left heel. The coccyx wound was first documented by the wound physician as an unstageable pressure ulcer measuring 10 cm by 4 cm by 0.1 cm with 100% slough, and a later note documented poor healing potential, 100% slough, moderate serous exudate, and debridement. The left heel wound was later documented as a Stage III pressure ulcer measuring 3 cm by 2 cm by 0.1 cm. The record also showed a later note indicating the heel had healed while the coccyx wound continued as a Stage IV pressure ulcer. The facility also failed to ensure physician wound treatment orders were followed for Resident #02, who was admitted with a chronic ulcer of the left heel, COPD, PVD, and atherosclerosis and had intact cognition. The physician orders for the left dorsal foot wound included cleansing with sterile saline, applying puracol and mupirocin, covering the wound, and avoiding small stretch gauze. However, the wound documentation initially identified the wound on the right dorsal foot instead of the left dorsal foot, and the initial treatment was documented as monitoring. The DON confirmed the wound was actually on the left foot and that staff used conforming gauze instead of the ordered ACE wrap, and the wound was later documented as a deep tissue injury on the left dorsal foot with increased size on the next assessment.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to ensure MDS assessments were coded accurately for two residents reviewed for medications. For one resident with diagnoses including diabetes mellitus, peripheral vascular disease, chronic kidney disease stage III, and hypertension, a quarterly MDS dated 09/11/25 indicated moderate cognitive impairment, substantial to maximum assistance for bed mobility, partial to moderate assistance for transfers, dependence for bathing and toilet hygiene, and that the resident received an anticoagulant and an antiplatelet medication. The medical record showed an order for clopidogrel 75 mg daily for prevention, but no documentation supporting an anticoagulant order. The QA nurse confirmed the resident had not received an anticoagulant during the review period and that the MDS was coded in error. For another resident with diagnoses including Type 2 DM, atherosclerotic heart disease, delusional disorders, anxiety, and depression, the quarterly MDS showed a BIMS score of 13, set-up assistance for eating, and moderate assistance with bed mobility and transfers. Section N of the MDS marked diuretics as not received during the 7-day look-back period, but the physician orders included Lasix 40 mg daily and Zaroxolyn 2.5 mg every Monday, Wednesday, and Friday. The QA nurse verified the resident did receive diuretic medication during the look-back period and that the MDS had been inaccurately coded. The RAI 3.0 User's Manual stated Section N is intended to record the number of days during the last 7 days that select medications were received.
Failure to Develop Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for one resident with pressure ulcers. Resident #36 was admitted with diagnoses including paraplegia, COPD, atherosclerotic heart disease, and anxiety. The admission MDS dated 09/15/25 indicated moderate cognitive impairment and substantial to maximum staff assistance was required for bathing and bed mobility, with dependence on staff for transfers and toilet hygiene. That assessment also indicated the resident did not have any skin breakdown. Subsequent wound physician documentation showed that Resident #36 had an unstageable pressure ulcer to the coccyx on 09/17/25, and on 09/24/25 the resident was seen for an unstageable coccyx pressure ulcer and a Stage III pressure ulcer to the left heel. A later wound physician note dated 12/17/25 stated the resident continued with a Stage IV coccyx pressure ulcer. Review of the medical record found no documentation that the facility developed a person-centered comprehensive care plan for the coccyx or left heel pressure ulcers, and the DON confirmed this during interview. The facility policy stated that comprehensive person-centered care plans with measurable objectives and timetables were to be developed and implemented for each resident.
Missed Care Conferences and Delayed Care Plan Update
Penalty
Summary
The facility failed to conduct quarterly care conferences that included residents and/or their resident representatives for two residents reviewed for care conferences. One resident was admitted with diagnoses including a non-pressure chronic ulcer of the left heel, COPD, PVD, and atherosclerosis, had a BIMS score of 14, and required extensive assistance with ADLs; the resident stated she could not recall having a care conference since admission, and the SSD verified no care conference had been held since admission. Another resident was admitted with diagnoses including anemia, right femur fracture, cerebral infarctions, dementia, and hypertension; the care conference note showed staff attendance by Social Services, the Unit Manager, Activity Director, and Dietary staff, but there was no documentation that the resident or representative was present. The resident stated she was not aware of any care conferences, and the SSD confirmed the resident and representative were not present for the conference. The facility also failed to timely update a resident’s care plan after a change in comprehensive assessment and status. The resident was admitted with chronic respiratory failure with hypoxia, pan lobular emphysema, COPD, asthma, and bipolar disorder, later elected hospice for end-stage COPD, and had a significant change MDS showing intact cognition with a BIMS score of 14 and need for cueing, one-person setup for ADLs, and a Hoyer lift for transfers. Review of the care plan showed it had not been revised to include hospice services, and the MDS Coordinator confirmed hospice was not part of the care plan. After surveyor intervention, the DON stated the care plan was updated to include hospice services.
Inaccurate Controlled Medication Count
Penalty
Summary
The facility failed to ensure an accurate narcotic count for Resident #17, who was admitted on 02/13/24 with diagnoses including depression, artherosclerosis of the renal artery, and fibromyalgia and remained at the facility. During observation and record review on 12/22/25 at 9:51 A.M. with an LPN, the controlled medication narcotic count sheet for Lyrica 150 mg capsules showed five capsules remaining, while the medication card showed six capsules remaining. The LPN verified the discrepancy at the time of the observation and stated she had counted with the night nurse and both had signed the count as correct at the start of her shift. The DON observed and confirmed the discrepancy at 9:57 A.M. The progress note documented that the CNP was notified of the count discrepancy, the resident denied increased pain or discomfort, and the unit nurse would monitor for increased pain throughout the shift. The facility policy for controlled substances required nursing staff to count controlled medication inventory at the end of each shift using personnel access and usage records, MARs, declining inventory records, and destruction or waste records, and to report discrepancies to the DON.
Delayed Implementation of Sertraline Dose Reduction
Penalty
Summary
Ensure each resident’s drug regimen was free from unnecessary drugs was not met when the facility failed to follow a medication reduction order in a timely manner for Resident #33. The resident was admitted on 08/09/22 with diagnoses including Type Two Diabetes Mellitus, atherosclerotic heart disease, delusional disorders, anxiety, and depression. The quarterly MDS showed a BIMS score of 13, indicating intact cognition, and the resident required set up for eating, moderate assistance with bed mobility, and transfers. The July monthly medication review documented that Resident #33 was due for a trial dose reduction of Sertraline 175 mg daily per CMS regulation. The physician agreed, and an order was written and signed on 07/29/25 to decrease Sertraline to 150 mg daily, but the physician order review showed the reduced dose was not started until 08/15/25. The DON verified in interview that the 07/29/25 order to decrease Sertraline to 150 mg was not implemented until 08/15/25.
Undated Lantus Pen
Penalty
Summary
The facility failed to ensure Lantus, a long lasting insulin, was dated upon opening for Resident #50. Resident #50 was admitted on 06/22/23 with diagnoses including diabetes mellitus, stroke, and vascular dementia and remained at the facility. During an observation and interview on 12/22/25 at 9:51 A.M., an LPN found the Lantus pen for Resident #50 was undated and verified that the date line was blank. The LPN acknowledged the pen should have been dated when opened so it could be used in a timely manner. The manufacturer’s instructions reviewed by surveyors stated that Lantus can be used for four weeks after the first dose and should then be discarded even if insulin remains in the pen.
Inaccurate and Missing Medical Record Documentation
Penalty
Summary
The facility failed to ensure medical records contained accurate documentation for three residents. For one resident admitted with paraplegia, COPD, atherosclerotic heart disease, and anxiety, the record showed an admission MDS indicating moderate cognitive impairment and no skin breakdown, along with skilled nursing notes stating no skin issues. However, shower/skin observation sheets documented skin issues on the bottom, midline spine, buttocks, and left heel, and the record did not contain documentation supporting weekly skin assessments from admission until later in the stay. The DON confirmed the record lacked documentation to support evaluation of the coccyx wound until several days after the skin issue was noted, lacked documentation of a left heel wound evaluation until later, and had no documentation supporting evaluation of the midline spine skin issue. The DON also confirmed the skilled notes did not document the skin breakdown reflected on the shower sheets. For another resident admitted with metabolic encephalopathy, malnutrition, quadriplegia, neuromuscular bladder dysfunction, and dysuria, the record contained an annual MDS showing intact cognition and dependence for all ADLs, but the chart did not include physician or NP progress notes after a single physician note in July. The DON stated the resident was seen multiple times by the physician or NP over several months, but the medical record did not contain the progress notes for those visits. For a third resident admitted with a chronic left heel and mid-foot ulcer, COPD, PVD, and atherosclerosis, the record contained inconsistent wound documentation. The chart identified the left heel wound as an unstageable pressure ulcer, then later as a diabetic ulcer and a surgical wound after debridement, and also documented a deep tissue injury to the right dorsal foot through early September. During observation, staff and the resident confirmed there had been no wound to the right foot since admission, and the DON verified the wound was actually on the left heel and that the wound type had been documented incorrectly.
Failure to Follow EBP and Hand Hygiene During Foley Catheter Care
Penalty
Summary
The facility failed to follow infection control procedures during indwelling catheter care for one resident out of two reviewed for infection control procedures. The resident had an admission date of 11/03/22 and diagnoses including metabolic encephalopathy, quadriplegia, lumbar spinal stenosis, and neuromuscular dysfunction of the bladder. The annual MDS dated 10/08/25 indicated the resident was cognitively intact, dependent on staff for all activities of daily living, and had an indwelling catheter. Physician orders included Enhanced Barrier Precautions for the Foley catheter every shift and Foley catheter care every shift. During observation on 12/18/25, a CNA prepared supplies for catheter care, explained the procedure to the resident, and used hand sanitizer and gloves. The CNA completed incontinence care after the resident had a bowel movement, removed her gloves, and then applied new gloves before performing indwelling catheter care. The observation showed an EBP sign on the door but no PPE cart inside or outside the room. The CNA did not don a gown during incontinence or catheter care, did not perform hand hygiene after removing gloves and before putting on new gloves, and later assisted the resident with repositioning and pulled up the covers while wearing the same gloves used during catheter care and application of skin barrier cream. The CNA confirmed the resident had an EBP sign posted, no PPE cart was present, she had not worn a gown, and she had not performed hand hygiene between glove changes.
Failure to Provide Written Notification of Room Changes
Penalty
Summary
The facility failed to provide written notification of room changes to residents or their representatives, affecting three residents. Resident #75, who had severe cognitive impairment and multiple medical diagnoses, was moved to a different room without documented written notice. Although discussions about the room change were held with the resident's daughter, there was no evidence of written notification provided before the move. Similarly, Resident #56, who was cognitively intact and required assistance with daily activities, was moved to a new room on the same day he and his daughter were verbally informed, but without any documented written notice. Resident #06, who had severe cognitive impairment and multiple medical conditions, was also moved to a different room without documented written notice. The facility's policy requires reasonable advance written notice for room changes, but this was not adhered to in these cases. An interview with Social Service staff confirmed the lack of written documentation, as they relied on verbal notifications and progress notes. This deficiency was identified during a complaint investigation, highlighting non-compliance with the facility's policy and residents' rights.
Failure to Provide Accurate Medical Information During Hospital Transfer
Penalty
Summary
The facility failed to provide accurate medical information for a resident during a transfer to the hospital, which was identified as a deficiency. The resident, who had severe cognitive impairment and required varying levels of assistance for daily activities, was admitted with multiple medical diagnoses, including a recent ventriculoperitoneal (VP) shunt placement for obstructive hydrocephalus. However, the facility did not update the resident's medical record to include this new diagnosis or develop a comprehensive care plan reflecting the VP shunt. When the resident was sent to the emergency department (ED) following a fall and change in condition, the facility did not document any communication with the ED regarding the resident's medical status or diagnoses, including the recent VP shunt placement. The Director of Nursing confirmed that the nurse did not call the ED to provide an update, and the necessary documentation was not included in the resident's medical record. This oversight was part of a complaint investigation and was identified as a deficiency.
Failure to Develop Comprehensive Care Plan for Resident with VP Shunt
Penalty
Summary
The facility failed to develop a comprehensive, resident-centered care plan for a resident with significant medical needs. The resident, who had severe cognitive impairment and required varying levels of assistance for daily activities, was admitted with multiple medical diagnoses, including disorders of the brain, dementia, and a diaphragmatic hernia. Notably, the resident had undergone a ventriculoperitoneal (VP) shunt placement to treat obstructive hydrocephalus, a critical medical condition requiring careful management. Despite these complex needs, the facility did not document a care plan addressing the VP shunt, which is essential for ensuring appropriate care and monitoring. During an interview, a registered nurse confirmed the absence of documentation for the VP shunt in the resident's medical record and acknowledged that the facility follows the Resident Assessment Instrument (RAI) manual for developing comprehensive care plans. The RAI manual mandates that care plans include measurable objectives and timetables tailored to each resident's medical, nursing, and psychological needs. The deficiency was identified during a complaint investigation, highlighting a lapse in the facility's adherence to required care planning protocols.
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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 New Carlisle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dayspring Of Miami Valley Hlth Care Center & Rehab | 6.9 mi | ★★★★★ | 0 | 0 |
| Laurels Of Huber Heights The | 7.9 mi | ★★★★★ | 4 | 0 |
| Trinity Community At Fairborn | 8.4 mi | ★★★★★ | 2 | 0 |
| Wright Rehabilitation And Healthcare Center | 8.7 mi | ★★★★★ | 10 | 0 |
| Momentous Health At Vandalia | 8.8 mi | ★★★★★ | 19 | 0 |
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