Cycle 1
Health 2022-10-27 · Fire 2022-10-27
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Dayton, OH
Bethany Village
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
6451 Far Hills Avenue, Dayton, OH
(937) 436-6841
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
252
Certified beds
Average residents
239
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.51
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.67
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
436
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
69.97
Composite VBP score used to determine payment impact.
Payment multiplier
1.0224
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.80
Baseline 21.88% · Performance 17.37% · Measure score 8.80 · Achievement 8.77 · Improvement 8.80
Healthcare-associated infections
10
Baseline 5.42% · Performance 4.96% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
5.69
Baseline 46.23% · Performance 40.42% · Measure score 5.69 · Achievement 5.69 · Improvement 2.22
Adjusted total nurse staffing
3.49
Baseline 3.75 hours · Performance 4.07 hours · Measure score 3.49 · Achievement 3.49 · Improvement 1.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.66% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 479 · Observed rate 7.93% · Lower 95% interval 7.71% |
| Discharge to community | 60.12% |
50.57%
9.5 pts better
|
Better than the National Rate · Eligible stays 446 · Observed rate 56.95% · Lower 95% interval 55.57% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.68% |
95.27%
1.4 pts better
|
Numerator 291 · Denominator 301 |
| Falls with major injury | 0.33% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 301 |
| Discharge self-care score | 71.21% |
53.69%
17.5 pts better
|
Numerator 183 · Denominator 257 |
| Discharge mobility score | 65.76% |
50.94%
14.8 pts better
|
Numerator 169 · Denominator 257 |
| Pressure ulcers or injuries, new or worsened | 2.33% |
2.29%
About the same
|
Numerator 7 · Denominator 301 · Adjusted rate 1.89% |
| Healthcare-associated infections requiring hospitalization | 4.96% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 267 · Observed rate 2.62% · Lower 95% interval 3.14% |
| Staff COVID-19 vaccination coverage | 6.23% |
8.2%
2 pts worse
|
Numerator 32 · Denominator 514 |
| Staff flu vaccination coverage | 26.79% |
42%
15.2 pts worse
|
Numerator 146 · Denominator 545 |
| Discharge function score | 73.15% |
56.45%
16.7 pts better
|
Numerator 188 · Denominator 257 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 228 · Denominator 228 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 56.96% |
25.2%
31.8 pts better
|
Numerator 90 · Denominator 158 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
92.4%
6.5 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.3%
0.4 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.0% · Q3 3.0% · Q4 3.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
26.1%
25.4 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 0.5% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
6.2%
1.5 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.1% · Q3 4.8% · Q4 6.1% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
25.4%
12 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 11.8% · Q3 14.7% · Q4 16.3% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.5% |
11.5%
5 pts better
|
16.7%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.7% · Q3 7.9% · Q4 7.1% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.7% |
7.7%
8 pts worse
|
16.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 17.4% · Q3 15.9% · Q4 10.1% · 4Q avg 15.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
6.2%
10.9 pts worse
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 13.6% · Q3 14.6% · Q4 19.5% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.5%
0.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 1.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.8% |
21.7%
0.9 pts better
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 23.4% · Q3 19.5% · Q4 17.7% · 4Q avg 20.8% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
3.7%
1.4 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 3.7% · Q3 1.6% · Q4 1.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
78.1%
21.8 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
12.5%
3.6 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 6.9% · Expected 8.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.0% · Q3 0.5% · Q4 1.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.5% |
75.6%
21.9 pts better
|
79.7%
17.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.8% |
25.1%
6.3 pts better
|
23.9%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 15.4% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-31 · Fire 2019-10-31
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2018-09-13 · Fire 2018-09-13
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-10-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-11-30
C · Minimal harm
2022-10-27
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-11-30
E · Potential for more than minimal harm
2019-10-31
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-12-20
E · Potential for more than minimal harm
2019-10-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-20
E · Potential for more than minimal harm
2019-10-31
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2019-12-20
E · Potential for more than minimal harm
2019-10-31
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2019-12-20
E · Potential for more than minimal harm
2019-10-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-02
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-03-14
D · Potential for more than minimal harm
2022-10-27
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-11-30
G · Actual harm
2018-09-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-10-08
Penalties and ownership
What sits behind the stars
Ownership
Adams, Mary
Corporate Director · Individual
Ashworth, Linda
Corporate Director · Individual
Baines, Ann
Corporate Director · Individual
Bair, Rita
Corporate Director · Individual
Barhorst, Dawn
Corporate Officer · Individual
Budi, Judy
Corporate Officer · Individual
Chilson, Mark
Corporate Director · Individual
Cox-Vance, Lora
Corporate Director · Individual
Coyle, Lauren
Operational/Managerial Control · Individual
D'aurora, Jackie
Corporate Officer · Individual
Driskell, Dan
Corporate Director · Individual
Feuer, Mark
Corporate Director · Individual
Graceworks Lutheran Services
Operational/Managerial Control · Organization
Houghtling, Amy
Corporate Director · Individual
Jones, Twana
Corporate Director · Individual
Jordan, Jessica
Corporate Director · Individual
Long, Eugene
Corporate Director · Individual
Mittermaier, John
Corporate Director · Individual
Nels, Kevin
Corporate Director · Individual
Patel, Meenakshi
Operational/Managerial Control · Individual
Quick, Teresa
Corporate Director · Individual
Reichard, Robert
Corporate Officer · Individual
Richardson, Mose
Corporate Director · Individual
Schemmel, Ann
Corporate Director · Individual
Townsend, Mari
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Centerville Post Acute
Centerville, OH
3-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Oak Creek Terrace Inc
Kettering, OH
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Centerville Health And Rehab
Dayton, OH
1-star overall rating with 2-star inspections with 18 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
Jump out