Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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-upper Valley during CMS and state inspections, most recent first.
A resident in a persistent vegetative state was prescribed Augmentin for a bacterial infection, but the facility failed to notify the resident's representative about the new antibiotic order and its purpose. The representative was informed only days later without details on the medication's name or duration. The DON confirmed the lack of documentation and absence of a notification policy.
A resident reported missing blankets after returning from a hospital stay, suspecting they were taken by a discharged roommate's family. Social Service staff made an initial call to the family but did not follow up or document the grievance, contrary to the facility's Lost and Found policy requiring immediate investigation and reporting to the DON.
A facility failed to complete a timely significant change MDS assessment for a resident who experienced a decline in condition, including a Stage III pressure ulcer and significant weight loss. Despite these changes, the necessary assessment was not conducted between May and July, as confirmed by the QA nurse. The facility's policy and the RAI manual require a comprehensive assessment when a significant change impacts multiple health areas.
A facility failed to implement a care plan for a resident with dementia and Alzheimer's, who was at high risk for wandering. Despite assessments indicating this risk, the care plan lacked focus and interventions for wandering or residing on a secure unit. An LPN confirmed these omissions.
A facility failed to follow proper mechanical lift protocols during a resident's transfer, as only one STNA was present instead of the required two. The resident, with impaired cognition and multiple health issues, was dependent on staff for transfers. This action was against the resident's care plan and the facility's policy, leading to a deficiency.
A facility failed to provide medical justification for the continued use of an indwelling catheter for a resident admitted with urinary obstruction. The resident, with moderate cognitive impairment and multiple health conditions, had a history of bladder continence and required assistance with toileting. The facility lacked documentation supporting the catheter's use and did not attempt to discontinue it, as confirmed by the DON.
A facility failed to assess and document the need for bed rails for a resident receiving hospice care. Despite the use of bed rails being noted in a consent form, there were no physician orders or assessments, and the form lacked necessary signatures. Observations confirmed the use of bed rails, but they were not coded in the MDS assessments. The facility's policy required assessments and evaluations that were not completed, leading to the deficiency.
A facility failed to respond promptly to pharmacy recommendations for a resident with multiple diagnoses, including Parkinson's and dementia. Despite a physician's approval for lab tests, the necessary vitamin and iron panels were delayed by three months, affecting the resident's care. The DON confirmed the oversight, indicating a lapse in medication management.
A resident with a history of renal cancer and an acquired absence of a kidney was prescribed Macrodantin indefinitely to prevent UTIs, despite experiencing only nocturnal urination without other UTI symptoms. The medication was continued based on a urologist's recommendation, even though the resident had four UTIs in the past year.
A significant medication error occurred when an LPN failed to prime an insulin pen before administering insulin to a resident with diabetes. The facility's policy and manufacturer instructions require a two-unit air shot to ensure proper dosing, which was not performed, resulting in a deviation from proper medication administration procedures.
A resident was found with a medication cup left unsupervised on their bedside table, as the LPN left to get supplies for an IV medication. The resident, who was alert and oriented, had a history of joint replacement and other conditions. The facility's policy requires medications to be administered safely and timely, which was not followed.
A resident with open wounds was placed under Enhanced Barrier Precautions (EBP) due to infection risk, but a State tested Nursing Aide (STNA) failed to wear the required personal protective equipment (PPE) while providing personal care. The STNA confirmed not following the EBP protocols, and the Infection Control Preventionist (ICP) reiterated the facility's policy requiring PPE for residents under EBP.
The facility failed to provide two residents with the required SNF ABN and NOMNC. For one resident, the last covered day of Part A service was noted, but the form was not signed by the resident or family, and there was no verification of notification. Similarly, another resident's last covered day was documented without signatures or proof of notification. These deficiencies affected two of the three residents reviewed.
Failure to Notify Resident Representative of Antibiotic Order
Penalty
Summary
The facility failed to notify the representative of a resident in a persistent vegetative state about a new antibiotic order and the reason for its use. The resident, who had diagnoses including quadriplegia, chronic respiratory failure, anoxic brain damage, and a tracheostomy, was prescribed Augmentin for a bacterial infection following an examination that revealed redness and swelling of the right jaw and swollen glands. Despite the initiation of this treatment, there was no documentation in the medical record indicating that the resident's representative was informed about the antibiotic order or its purpose. The resident's representative reported being informed of the antibiotic treatment only a few days after it had started and was not provided with details about the medication's name or duration. The Director of Nursing confirmed the absence of documentation regarding the notification of the resident's representative and acknowledged that the facility lacked a policy for notifying residents or their representatives about changes in medical orders.
Failure to Resolve Resident's Grievance on Missing Property
Penalty
Summary
The facility failed to promptly resolve a grievance related to missing property for a resident. The resident, who was cognitively intact and had diagnoses including diabetes mellitus with diabetic peripheral angiopathy, peripheral vascular disease, and congestive heart failure, was hospitalized in early June 2024. During her absence, her roommate was discharged, and the roommate's family packed and took home the roommate's belongings. Upon returning to the facility, the resident noticed that three of her blankets were missing and reported this to Social Service. Social Service staff confirmed that the resident had informed them about the missing blankets and suspected that the roommate's family had taken them. Although a call was made to the roommate's family, no follow-up was conducted after leaving a message, and the grievance was neither documented in the grievance log nor in the resident's medical record. The facility's policy on Lost and Found requires that complaints of missing items be reported to the DON and that such reports are immediately investigated, which was not adhered to in this case.
Failure to Complete Timely Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change Minimum Data Set (MDS) assessment in a timely manner for a resident who experienced a significant change in condition. The resident, who was cognitively intact, had been admitted with multiple diagnoses including a nondisplaced intertrochanteric fracture, diabetes mellitus, peripheral vascular disease, and congestive heart failure. The resident was initially assessed as requiring varying levels of assistance with activities of daily living (ADLs) and did not have a pressure ulcer or weight loss. However, subsequent assessments revealed a decline in the resident's condition, including the development of a Stage III pressure ulcer and significant weight loss. Despite these changes, the facility did not complete a significant change MDS assessment for the resident between May and July. The Quality Assurance nurse confirmed that the facility had not conducted the necessary assessment following the resident's significant weight loss, the emergence of a Stage III pressure ulcer, and a decline in two or more ADLs. The facility's policy and the Resident Assessment Instrument (RAI) manual both require a comprehensive assessment when a significant change in a resident's condition occurs, impacting more than one area of health status. The RAI manual specifies that a significant change MDS is warranted when the resident's condition is not expected to return to baseline within two weeks and involves a decline in multiple areas, including ADLs, weight loss, and the emergence of a new pressure ulcer.
Failure to Implement Care Plan for Wandering Risk
Penalty
Summary
The facility failed to develop and implement a care plan for a resident with a known risk of wandering and residing on a secure unit. The resident, admitted on 05/13/24, had diagnoses of dementia with behavioral disturbance and Alzheimer's disease. The admission Minimum Data Set (MDS) assessment and a Wandering Risk assessment both indicated that the resident was at high risk for wandering. However, a review of the resident's care plan revealed no focus area or interventions addressing the risk of wandering or the need for residing on a secure unit. This deficiency was confirmed during an interview with an LPN, who verified the absence of these critical elements in the care plan.
Failure to Follow Mechanical Lift Protocols
Penalty
Summary
The facility failed to adhere to proper mechanical lift protocols during the transfer of a resident from bed to wheelchair, resulting in a deficiency. The resident involved had a history of cerebral infarction, diabetes mellitus type two, obesity, and heart disease, and was dependent on staff for transfers due to impaired cognition. According to the resident's care plan, transfers were to be conducted using a Hoyer lift with the assistance of two staff members to prevent falls and injuries related to mobility. During an observation, a State tested Nurse Aide (STNA) was seen using the mechanical lift to transfer the resident without the assistance of another staff member, contrary to the care plan and facility policy. The STNA confirmed that she was the only staff member present during the transfer, acknowledging the requirement for two staff members as per the resident's care plan and the facility's 'Mechanical Lift Policy'. This oversight in following established protocols led to the identified deficiency.
Lack of Medical Justification for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had a valid medical justification for its use. This deficiency affected one resident who was admitted with an indwelling catheter due to urinary obstruction while hospitalized. However, the medical record did not contain documentation to support the continued use of the catheter, nor was there evidence that the facility attempted to discontinue it. The resident had a history of bladder continence, used a urinal, and required extensive assistance with toileting. The resident, who had moderate cognitive impairment and was dependent on staff for toileting, was admitted with several diagnoses, including right above the knee amputation, atrial fibrillation, diabetes mellitus, hypertension, peripheral vascular disease, and anemia. Despite these conditions, the facility did not have a policy related to the use of indwelling catheters, only on how to care for them. The Director of Nursing confirmed the lack of documentation for medical justification and the absence of attempts to discontinue the catheter.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to assess the need for bed rails for a resident, identified as Resident #21, who was admitted to the facility and began receiving hospice services. The resident had multiple diagnoses, including Alzheimer's disease and dementia, and was under the care of a medical Power of Attorney (POA), their daughter. Despite the use of bed rails being documented in a consent form, there was no indication of the purpose, release schedule, or physician orders for the bed rails. Additionally, the consent form lacked signatures from the POA or a physician. The resident's care plans included the use of bed rails for bed mobility, but no physician orders or assessments for bed rails were found in the medical records. Observations and interviews revealed that the bed rails were in use, but the facility's documentation did not reflect this. A State tested Nurse Aide confirmed the use of bed rails during care, and a Quality Assurance Nurse verified that the bed rails were not coded in the Minimum Data Set (MDS) assessments. The facility's policy on bed safety and bed rails required specific criteria to be met before their use, including resident assessment and interdisciplinary team evaluation, which were not completed for this resident. The lack of proper assessment and documentation led to the deficiency identified by the surveyors.
Delayed Response to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely response to pharmacy recommendations for a resident, leading to a deficiency in medication management. The resident, who was admitted with diagnoses including Parkinson's disease, depression, anxiety, vascular dementia, and unspecified psychosis, was receiving an antipsychotic medication. The pharmacist recommended that vitamin B12 level, vitamin D level, and an iron panel be completed for the resident. The physician agreed to have these labs drawn at the next laboratory draw. However, the laboratory tests were not conducted until three months after the recommendation, despite a lab draw occurring in the interim. The Director of Nursing confirmed that the physician had signed off on the recommendation, but the necessary tests were not ordered until much later. This delay in executing the pharmacy's recommendations affected the resident's care and highlighted a lapse in the facility's medication management process.
Unnecessary Medication Use for UTI Prevention
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication use. This deficiency was identified in the case of a resident who had been diagnosed with a urinary tract infection (UTI) on multiple occasions. The resident, who had a medical history of renal cancer and an acquired absence of a kidney, was prescribed Macrodantin indefinitely for prophylactic purposes. Despite the resident experiencing only nocturnal urination without other symptoms of a UTI, the medication was continued as per the recommendation of an outside urologist. Interviews with the resident's physician and a urology nurse practitioner confirmed the indefinite use of Macrodantin to prevent further UTIs and protect the remaining kidney, despite the resident having experienced four UTIs in the past year without specific dates provided.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to adhere to proper medication administration procedures, resulting in a significant medication error involving a resident with diabetes mellitus. The resident, who was cognitively intact and required insulin, was prescribed Humalog Kwikpen to be administered subcutaneously before meals. During an observation, an LPN prepared the insulin pen for administration but did not prime the pen as per the manufacturer's instructions. The LPN attached the needle, set the dose to 10 units, and administered the insulin without performing the necessary air shot to ensure the correct dose. The facility's policy on medication administration, as well as guidance from Medscape and the Kwikpen reference guide, clearly state the importance of priming the insulin pen with a two-unit air shot before each use to avoid air and ensure the proper dose. The LPN confirmed in an interview that she did not perform this step prior to administering the insulin. This oversight was identified as a significant medication error, affecting the resident's care and highlighting a deviation from established medication administration protocols.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that medications were consumed at the time of administration and not left unsupervised at the resident's bedside. This deficiency was identified during an observation and interview with a resident, who had a medication cup with several medications left on their bedside table. The resident reported that the nurse left the medications there while she went to get supplies for an intravenous medication, and no nurse was present in the room or hallway at the time. The resident involved was alert and oriented, with a medical history that included aftercare following joint replacement, acquired absence of the right hip joint, anemia, anxiety, and hypertension. The medications due for administration included celecoxib, cholecalciferol, Cymbalta, folic acid, leflunomide, metoprolol, a multivitamin, aspirin, rifampin, ferrous sulfate, gabapentin, and pantoprazole. The facility's policy on administering medications, revised in April 2019, requires that medications be administered safely, timely, and as prescribed, with observation of consumption, which was not adhered to in this instance.
Failure to Follow Isolation Protocols for Resident with Open Wounds
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding isolation protocols for a resident with open wounds. Resident #47, who was at risk for infection due to conditions such as cerebral infarction, diabetes type two mellitus, and heart disease, was placed under Enhanced Barrier Precautions (EBP) as per the facility's policy. The care plan for Resident #47 included interventions to follow isolation protocols to prevent infection spread. However, during an observation, it was noted that a State tested Nursing Aide (STNA) entered the resident's room without donning the required personal protective equipment (PPE), such as gloves and a gown, while performing personal care tasks including incontinence care and transferring the resident from bed to wheelchair. The STNA confirmed in an interview that she did not follow the EBP protocols, acknowledging the absence of gloves and a gown during the care process. The Infection Control Preventionist (ICP) also confirmed that Resident #47 was under isolation protocols due to open wounds and that the facility's policy mandated the use of appropriate PPE for all staff providing personal care to residents under EBP. The facility's policy, dated 07/15/22, clearly stated that all residents with wounds should be placed under EBP, requiring staff to wear gowns and gloves during care activities to prevent infection spread.
Failure to Provide Required Beneficiary Notices
Penalty
Summary
The facility failed to provide two residents with the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Provider Non-Coverage (NOMNC). For Resident #58, the medical record indicated that the last covered day of Part A service was 03/11/24, and the NOMNC stated that services would end on the same date. A handwritten note by Quality Assurance (QA) #328 mentioned that the resident's daughter was informed of the last covered day and the right to appeal through Livanta. However, the form was not signed by the resident or their family, and there was no verification that the notification letter had been sent, despite QA #328's claim of sending it via certified mail. Similarly, for Resident #91, the SNF ABN indicated that the last covered day of Part A service was 03/08/24, with the NOMNC also stating that services would end on that date. QA #328 documented that the resident's daughter was notified of the last covered day and the right to appeal, but again, the form lacked signatures from the resident or family. QA #328 stated that the letter was sent via certified mail, yet the facility had no proof of this action. These deficiencies affected two of the three residents reviewed for beneficiary notices, with the facility census being 99.
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Troy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Troy Rehabilitation And Healthcare Center | 3.8 mi | ★★★★★ | 18 | 0 |
| Ayden Healthcare Of Piqua | 4 mi | ★★★★★ | 0 | 0 |
| Piqua Manor | 4.8 mi | ★★★★★ | 14 | 0 |
| Stillwater Skilled Nursing And Rehabilitation | 6.9 mi | ★★★★★ | 11 | 0 |
| Springmeade Healthcenter | 8.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.