Cycle 1
Health 2025-05-28 · Fire 2025-05-28
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Delaware, OH
Cherith Care Center At Willow Brook
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
100 Willow Brook Way, South, Delaware, OH
(740) 369-0048
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
34
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-08-01
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
0.83
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.00
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.68
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.25
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
4.91
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,806
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9866
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.64
Baseline 19.01% · Performance 20.21% · Measure score 2.64 · Achievement 2.64 · Improvement 0
Healthcare-associated infections
2.82
Baseline 6.72% · Performance 6.99% · Measure score 2.82 · Achievement 2.82 · Improvement 0
Total nurse turnover
2.74
Baseline 36.67% · Performance 52.50% · Measure score 2.74 · Achievement 2.74 · Improvement 0
Adjusted total nurse staffing
4.47
Baseline 3.81 hours · Performance 4.35 hours · Measure score 4.47 · Achievement 4.47 · Improvement 2.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.87% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 2.44% · Lower 95% interval 6.02% |
| Discharge to community | 50.24% |
50.57%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 50.65% · Lower 95% interval 39.35% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.88% |
95.27%
1.6 pts better
|
Numerator 62 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 50.94% |
53.69%
2.8 pts worse
|
Numerator 27 · Denominator 53 |
| Discharge mobility score | 43.4% |
50.94%
7.5 pts worse
|
Numerator 23 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 2 · Denominator 64 · Adjusted rate 2.98% |
| Healthcare-associated infections requiring hospitalization | 6.99% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 5.45% · Lower 95% interval 3.7% |
| Staff COVID-19 vaccination coverage | 2.34% |
8.2%
5.9 pts worse
|
Numerator 3 · Denominator 128 |
| Staff flu vaccination coverage | 6.84% |
42%
35.2 pts worse
|
Numerator 13 · Denominator 190 |
| Discharge function score | 52.83% |
56.45%
3.6 pts worse
|
Numerator 28 · Denominator 53 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 34.29% |
25.2%
9.1 pts better
|
Numerator 12 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
92.4%
5.5 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 100.0% · Q3 100.0% · Q4 96.2% · 4Q avg 97.9% |
| 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 | 3.1% |
3.3%
0.2 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.5% · Q3 4.0% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.5% |
26.1%
12.6 pts better
|
11.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 14.3% · Q3 9.1% · Q4 7.7% · 4Q avg 13.5% |
| Percentage of long-stay residents who lose too much weight | 12.9% |
6.2%
6.7 pts worse
|
5.4%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.4% |
25.4%
2 pts worse
|
19.6%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
11.5%
2.6 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.9% · 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 | 28.1% |
7.7%
20.4 pts worse
|
16.3%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
6.2%
2.4 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8% · 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 | 33.3% |
21.7%
11.6 pts worse
|
19.8%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 44.8% · Q3 34.5% · Q4 28.0% · 4Q avg 33.3% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
3.7%
2.1 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.2% · Q3 1.8% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
78.1%
17.6 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 93.9% · Q3 96.6% · Q4 95.2% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.5% |
12.5%
About the same
|
12.0%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.5% · Observed 10.9% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
75.6%
22.9 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
25.1%
6.8 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 14.5% · Expected 18.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-04 · Fire 2023-05-04
4 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-10-17 · Fire 2019-10-17
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-15
F · Potential for more than minimal harm
2025-05-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-15
F · Potential for more than minimal harm
2025-05-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-06-15
F · Potential for more than minimal harm
2023-05-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-25
E · Potential for more than minimal harm
2023-05-04
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 2023-05-25
F · Potential for more than minimal harm
2019-10-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-12-01
E · Potential for more than minimal harm
2019-10-17
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 2019-12-01
E · Potential for more than minimal harm
2019-10-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-28
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-28
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 2025-06-15
D · Potential for more than minimal harm
2025-05-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-06-15
D · Potential for more than minimal harm
2025-05-28
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 2025-06-15
D · Potential for more than minimal harm
2025-05-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-06-15
F · Potential for more than minimal harm
2023-05-04
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 2023-05-25
D · Potential for more than minimal harm
2023-05-04
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-05-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-25
D · Potential for more than minimal harm
2023-05-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-25
D · Potential for more than minimal harm
2019-10-17
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-12-01
D · Potential for more than minimal harm
2019-10-17
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-12-01
Penalties and ownership
What sits behind the stars
Ownership
Barth, Phil
Corporate Director · Individual
Davis, Brandi
Corporate Director · Individual
Dulgar, Jason
Corporate Director · Individual
Irwin, Terry
Corporate Director · Individual
Johnson, Kim
Corporate Director · Individual
Johnson, William
Corporate Director · Individual
Ketron, Nicole
Operational/Managerial Control · Individual
Longo, Scott
Corporate Director · Individual
March, Judy
Corporate Director · Individual
Mckenna, Blythe
Corporate Director · Individual
Mcknight, Matthew
Operational/Managerial Control · Individual
Mcknight, Matthew
Corporate Officer · Individual
Pickens, Roger
Corporate Director · Individual
Poulson, Thomas
Operational/Managerial Control · Individual
Poulson, Thomas
Corporate Officer · Individual
Sarkel, Ed
Corporate Director · Individual
Slingluff, Dana
Corporate Director · Individual
Susenna, Karen
Corporate Director · Individual
Tidwell, Peggy
Corporate Director · Individual
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5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Delaware Court Health Care Center
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2-star overall rating with 2-star inspections with 19 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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