Cycle 1
Health 2025-01-09 · Fire 2025-01-09
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Findlay, OH
Birchaven Retirement Village
5-star overall rating with 3-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
15100 Birchaven Lane, Findlay, OH
(419) 424-3000
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-09-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.37
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.63
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.65
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
5.29
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
1.01
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.28
CMS adjusted RN staffing hours
Adjusted total hours
5.27
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
232
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
76.65
Composite VBP score used to determine payment impact.
Payment multiplier
1.0250
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.81
Baseline 16.89% · Performance 17.35% · Measure score 8.81 · Achievement 8.81 · Improvement 0
Healthcare-associated infections
7.37
Baseline 4.83% · Performance 5.63% · Measure score 7.37 · Achievement 7.37 · Improvement 0
Total nurse turnover
6.53
Baseline 35.37% · Performance 36.97% · Measure score 6.53 · Achievement 6.53 · Improvement 0
Adjusted total nurse staffing
7.94
Baseline 5.33 hours · Performance 5.34 hours · Measure score 7.94 · Achievement 7.94 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.43% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 349 · Observed rate 6.88% · Lower 95% interval 6.74% |
| Discharge to community | 61.58% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 327 · Observed rate 63% · Lower 95% interval 55.65% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 180 · Denominator 180 |
| Falls with major injury | 1.11% |
0.77%
0.3 pts worse
|
Numerator 2 · Denominator 180 |
| Discharge self-care score | 74.45% |
53.69%
20.8 pts better
|
Numerator 102 · Denominator 137 |
| Discharge mobility score | 62.04% |
50.94%
11.1 pts better
|
Numerator 85 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 3.89% |
2.29%
1.6 pts worse
|
Numerator 7 · Denominator 180 · Adjusted rate 3.81% |
| Healthcare-associated infections requiring hospitalization | 5.63% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 207 · Observed rate 3.38% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 315 |
| Staff flu vaccination coverage | 51.86% |
42%
9.9 pts better
|
Numerator 209 · Denominator 403 |
| Discharge function score | 68.61% |
56.45%
12.2 pts better
|
Numerator 94 · Denominator 137 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 114 · Denominator 114 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 14.58% |
25.2%
10.6 pts worse
|
Numerator 14 · Denominator 96 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.6 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.1 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 1.7% · Q4 3.3% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.8% |
26.1%
19.3 pts better
|
11.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.4% · Q3 9.3% · Q4 5.6% · 4Q avg 6.8% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
6.2%
0.9 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 7.0% · Q3 3.6% · Q4 8.6% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.6% |
25.4%
8.8 pts better
|
19.6%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 13.8% · Q3 17.9% · Q4 19.0% · 4Q avg 16.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.5% |
11.5%
3 pts better
|
16.7%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.3% · Q3 11.6% · Q4 11.1% · 4Q avg 8.5% · 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 | 3.8% |
7.7%
3.9 pts better
|
16.3%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 3.4% · Q4 7.1% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
6.2%
3 pts worse
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 7.4% · Q3 9.8% · Q4 5.7% · 4Q avg 9.2% · 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 | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 26.4% |
21.7%
4.7 pts worse
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 31.1% · Q3 26.7% · Q4 29.4% · 4Q avg 26.4% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
3.7%
1.1 pts worse
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.2% · Q3 4.3% · Q4 2.8% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
78.1%
20.5 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 98.9% · Q3 99.5% · Q4 98.4% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
12.5%
2.2 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 9.9% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.3% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.8% |
75.6%
16.2 pts better
|
79.7%
12.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
25.1%
3.4 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 20.5% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-07 · Fire 2022-11-07
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-12-18 · Fire 2019-12-18
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-09
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-09
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-10
F · Potential for more than minimal harm
2022-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-09
F · Potential for more than minimal harm
2022-11-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-09
F · Potential for more than minimal harm
2022-11-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-11-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-02-17
E · Potential for more than minimal harm
2022-11-07
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-12-09
E · Potential for more than minimal harm
2022-11-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-09
E · Potential for more than minimal harm
2019-12-18
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2020-02-03
E · Potential for more than minimal harm
2019-12-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-02-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-09
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-09
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-09
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-02-10
D · Potential for more than minimal harm
2022-11-07
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-12-09
D · Potential for more than minimal harm
2022-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-09
C · Minimal harm
2022-11-07
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-12-09
E · Potential for more than minimal harm
2019-12-18
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2020-02-03
E · Potential for more than minimal harm
2019-12-18
F920 · Environmental Deficiencies
Health
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Corrected 2020-02-03
D · Potential for more than minimal harm
2019-12-18
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 2020-02-03
D · Potential for more than minimal harm
2019-12-18
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2020-02-03
D · Potential for more than minimal harm
2019-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-03
Penalties and ownership
What sits behind the stars
Ownership
Blanchard Valley Health System
5% Or Greater Direct Ownership Interest · Organization
Bishop-Pierce, Judith
Operational/Managerial Control · Individual
Brough, Michael
Corporate Director · Individual
Cosiano, Frank
Corporate Director · Individual
Cytlak, David
Operational/Managerial Control · Individual
Dowling, James
Corporate Director · Individual
Edgington, Annette
Corporate Director · Individual
Hopkins, William
Corporate Director · Individual
Jones, Ginger
Corporate Director · Individual
Kennard, Dan
Corporate Director · Individual
Kroetz, Elizabeth
Corporate Director · Individual
Lause, Thomas
Corporate Director · Individual
Lewis, Myron
Corporate Director · Individual
Longo, Joseph
Corporate Director · Individual
Malarky, Donald
Corporate Director · Individual
Manuel, Michael
Operational/Managerial Control · Individual
Overton, Kirby
Corporate Director · Individual
Polder, Richard
Corporate Director · Individual
Reineke, John
Corporate Director · Individual
Shrader, Jeffery
Corporate Director · Individual
Webb, Adele
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Fox Run Manor
Findlay, OH
2-star overall rating with 2-star inspections with 18 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
The Manor At Greendale
Findlay, OH
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Heritage The
Findlay, OH
2-star overall rating with 2-star inspections with 20 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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