Cycle 1
Health 2022-09-26 · Fire 2022-09-26
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Ashland, OH
Brethren Care Village Health Care Center
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2000 Center St, Ashland, OH
(419) 289-1585
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
79
Certified beds
Average residents
71
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-01-06
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
0.71
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
3.20
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.93
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.38
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.55
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.92
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,608
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9965
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.11
Baseline 19.18% · Performance 19.53% · Measure score 4.11 · Achievement 4.11 · Improvement 0
Healthcare-associated infections
7.70
Baseline 6.01% · Performance 5.54% · Measure score 7.70 · Achievement 7.70 · Improvement 4.17
Total nurse turnover
0
Baseline 46.85% · Performance 81.37% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
5.61
Baseline 3.95 hours · Performance 4.67 hours · Measure score 5.61 · Achievement 5.61 · Improvement 3.45
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.71% |
10.72%
3 pts better
|
Better than the National Rate · Eligible stays 213 · Observed rate 4.23% · Lower 95% interval 5.41% |
| Discharge to community | 62.32% |
50.57%
11.8 pts better
|
Better than the National Rate · Eligible stays 171 · Observed rate 60.23% · Lower 95% interval 52.57% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 121 · Denominator 121 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 121 |
| Discharge self-care score | 34.38% |
53.69%
19.3 pts worse
|
Numerator 33 · Denominator 96 |
| Discharge mobility score | 44.79% |
50.94%
6.1 pts worse
|
Numerator 43 · Denominator 96 |
| Pressure ulcers or injuries, new or worsened | 4.96% |
2.29%
2.7 pts worse
|
Numerator 6 · Denominator 121 · Adjusted rate 3.98% |
| Healthcare-associated infections requiring hospitalization | 5.54% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 114 · Observed rate 2.63% · Lower 95% interval 3.37% |
| Staff COVID-19 vaccination coverage | 0.54% |
8.2%
7.7 pts worse
|
Numerator 1 · Denominator 185 |
| Staff flu vaccination coverage | 18.52% |
42%
23.5 pts worse
|
Numerator 35 · Denominator 189 |
| Discharge function score | 38.54% |
56.45%
17.9 pts worse
|
Numerator 37 · Denominator 96 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 37 · Denominator 37 |
| Transfer of health information to patient | 97.67% |
96.28%
1.4 pts better
|
Numerator 42 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 22.73% |
25.2%
2.5 pts worse
|
Numerator 15 · Denominator 66 |
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 | 1.5 |
1.8
0.3 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
92.4%
7.1 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
94.5%
3.7 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.3%
2.4 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.7% · Q3 2.0% · Q4 3.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
26.1%
23.6 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 2.1% · Q4 6.1% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
6.2%
0.2 pts better
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.3% · Q3 0.0% · Q4 13.9% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.4% |
25.4%
6 pts worse
|
19.6%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 37.5% · Q3 30.6% · Q4 25.0% · 4Q avg 31.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
11.5%
1 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 10.7% · Q3 9.7% · Q4 10.0% · 4Q avg 10.5% · 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 | 18.1% |
7.7%
10.4 pts worse
|
16.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.1% |
6.2%
0.1 pts better
|
14.9%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 5.7% · Q3 3.3% · Q4 3.3% · 4Q avg 6.1% · 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 | 1.0% |
0.5%
0.5 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.8% |
21.7%
9.1 pts worse
|
19.8%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 42.3% · Q3 20.3% · Q4 29.9% · 4Q avg 30.8% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
3.7%
1.5 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 7.1% · Q3 3.7% · Q4 3.7% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
78.1%
21.5 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.4% · Q4 99.3% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.5% |
12.5%
8 pts worse
|
12.0%
8.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 19.8% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.2%
0.3 pts worse
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.2% · Q4 2.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.5% |
75.6%
17.9 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.8% |
25.1%
3.3 pts better
|
23.9%
2.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.8% · Observed 21.6% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-09-26 · Fire 2019-09-26
8 health deficiencies
Top issue: Infection Control (3 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2018-08-16 · Fire 2018-08-16
2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-09-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-11-06
F · Potential for more than minimal harm
2022-09-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-06
E · Potential for more than minimal harm
2022-09-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-11-06
E · Potential for more than minimal harm
2022-09-26
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2022-11-06
E · Potential for more than minimal harm
2019-09-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-10-18
F · Potential for more than minimal harm
2018-08-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-08-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2022-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-06
D · Potential for more than minimal harm
2022-09-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-06
D · Potential for more than minimal harm
2019-09-26
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-26
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-26
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 2019-10-18
D · Potential for more than minimal harm
2019-09-26
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-26
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-26
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-10-18
D · Potential for more than minimal harm
2019-09-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-10-18
D · Potential for more than minimal harm
2018-08-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2018-08-30
D · Potential for more than minimal harm
2018-08-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2018-08-30
Penalties and ownership
What sits behind the stars
Ownership
Brethren Care Inc
5% Or Greater Direct Ownership Interest · Organization
Bush, Andrew
Corporate Director · Individual
Harpster, Carrie
W-2 Managing Employee · Individual
Hickey, Linda
Corporate Director · Individual
Hinkel, Neil
Corporate Director · Individual
Huber, Michael
Corporate Director · Individual
Jones, Julia
Corporate Director · Individual
Lybarger, Crystal
Corporate Director · Individual
Martin, Gayle
Corporate Director · Individual
Mcfarland, Matthew
Corporate Officer · Individual
Mcfarland, Matthew
W-2 Managing Employee · Individual
Rowsey, Timothy
Corporate Director · Individual
Scurlock, Mindy
Corporate Officer · Individual
Scurlock, Mindy
W-2 Managing Employee · Individual
Snyder, Troy
Corporate Officer · Individual
Snyder, Troy
W-2 Managing Employee · Individual
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2-star overall rating with 2-star inspections with $26,685 in total fines with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
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4-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Kingston Of Ashland
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2-star overall rating with 2-star inspections with 13 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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