Cycle 1
Health 2025-09-18 · Fire 2025-09-18
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Englewood, OH
Cypress Pointe Health Campus
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
600 West National Road, Englewood, OH
(937) 836-3149
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
67
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2010-02-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
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
0.65
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.25
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.80
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.71
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
0.11
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,468
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.74
Baseline 18.08% · Performance 20.63% · Measure score 1.74 · Achievement 1.74 · Improvement 0
Healthcare-associated infections
0.64
Baseline 6.26% · Performance 7.64% · Measure score 0.64 · Achievement 0.64 · Improvement 0
Total nurse turnover
4.41
Baseline 65.33% · Performance 45.65% · Measure score 4.41 · Achievement 4.41 · Improvement 4.36
Adjusted total nurse staffing
2.65
Baseline 3.38 hours · Performance 3.83 hours · Measure score 2.65 · Achievement 2.65 · Improvement 1.39
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.4% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 219 · Observed rate 7.76% · Lower 95% interval 7.06% |
| Discharge to community | 65.87% |
50.57%
15.3 pts better
|
Better than the National Rate · Eligible stays 231 · Observed rate 58.44% · Lower 95% interval 59.99% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 138 · Denominator 138 |
| Falls with major injury | 2.9% |
0.77%
2.1 pts worse
|
Numerator 4 · Denominator 138 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 78 · Denominator 104 |
| Discharge mobility score | 71.15% |
50.94%
20.2 pts better
|
Numerator 74 · Denominator 104 |
| Pressure ulcers or injuries, new or worsened | 0.72% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 138 · Adjusted rate 0.56% |
| Healthcare-associated infections requiring hospitalization | 7.64% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 144 · Observed rate 9.03% · Lower 95% interval 5.26% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 147 |
| Staff flu vaccination coverage | 29.7% |
42%
12.3 pts worse
|
Numerator 60 · Denominator 202 |
| Discharge function score | 84.62% |
56.45%
28.2 pts better
|
Numerator 88 · Denominator 104 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 85 · Denominator 85 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 35 · Denominator 35 |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 12 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
92.4%
3.8 pts worse
|
93.4%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 93.0% · Q3 91.1% · Q4 78.7% · 4Q avg 88.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.3% |
94.5%
8.2 pts worse
|
95.5%
9.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.3%
2.1 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 7.0% · Q3 4.4% · Q4 8.5% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
26.1%
22.4 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.2%
1.4 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 0.0% · Q3 5.4% · Q4 5.4% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.6% |
25.4%
1.8 pts better
|
19.6%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 23.5% · Q3 21.6% · Q4 26.3% · 4Q avg 23.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
11.5%
11.5 pts better
|
16.7%
16.7 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 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 | 2.4% |
7.7%
5.3 pts better
|
16.3%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.5% |
6.2%
4.7 pts better
|
14.9%
13.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 3.0% · Q4 0.0% · 4Q avg 1.5% · 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 | 19.2% |
21.7%
2.5 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 16.5% · Q3 23.1% · Q4 20.1% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 1.0% |
3.7%
2.7 pts better
|
5.1%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.5% |
78.1%
8.4 pts better
|
81.7%
4.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.6% · Q2 87.7% · Q3 84.4% · Q4 84.0% · 4Q avg 86.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
12.5%
0.3 pts better
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 12.9% · Expected 11.8% · 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 | 81.3% |
75.6%
5.7 pts better
|
79.7%
1.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.2% |
25.1%
3.9 pts better
|
23.9%
2.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.2% · Observed 25.0% · Expected 28.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-13 · Fire 2022-10-13
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-10-17 · Fire 2019-10-17
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-09-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-06
F · Potential for more than minimal harm
2022-10-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-10-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-10-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-16
E · Potential for more than minimal harm
2022-10-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-16
F · Potential for more than minimal harm
2019-10-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-12-05
E · Potential for more than minimal harm
2019-10-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-12-05
E · Potential for more than minimal harm
2019-10-17
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-12-05
E · Potential for more than minimal harm
2019-10-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-05
E · Potential for more than minimal harm
2019-10-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-12-05
E · Potential for more than minimal harm
2019-10-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-12-05
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 2019-12-05
D · Potential for more than minimal harm
2019-10-17
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2019-12-05
C · Minimal harm
2019-10-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-12-05
Inspection history
Recent health citations
G · Actual harm
2025-12-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-11-18
D · Potential for more than minimal harm
2025-12-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-12-30
D · Potential for more than minimal harm
2024-07-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-06
D · Potential for more than minimal harm
2023-10-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-01
E · Potential for more than minimal harm
2022-10-13
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 2022-12-16
E · Potential for more than minimal harm
2022-10-13
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 2022-12-16
D · Potential for more than minimal harm
2022-10-13
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-10-13
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 2022-12-16
D · Potential for more than minimal harm
2022-10-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-12-16
D · Potential for more than minimal harm
2019-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-05
Penalties and ownership
What sits behind the stars
Ownership
Trilogy Opco LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Reit Inc
5% Or Greater Indirect Ownership Interest · Organization
Barney, Leigh
Corporate Officer · Individual
Bryant, William
Corporate Officer · Individual
Bufford, Randall
Corporate Officer · Individual
Conner, Gregory
Corporate Officer · Individual
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
W-2 Managing Employee · Individual
Davis, David
Corporate Officer · Individual
Fightmaster, Lisa
W-2 Managing Employee · Individual
Gahc3 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Gahc4 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Keybank National Association
5% Or Greater Mortgage Interest · Organization
Mehaffey, Todd
Corporate Officer · Individual
Northstar Healthcare Income Inc
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Operating Partnership LP
5% Or Greater Indirect Ownership Interest · Organization
Pietrowski, Cristina
Corporate Officer · Individual
Prosky, Danny
Corporate Officer · Individual
Streiff, Mathieu
Corporate Officer · Individual
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Holdings Nt-Hci, LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Management Services LLC
Operational/Managerial Control · Organization
Trilogy Real Estate Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Reit Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Valentine, Anthony
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Grace Brethren Village
Englewood, OH
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Englewood Health And Rehab
Englewood, OH
2-star overall rating with 2-star inspections with 20 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Arc At Trotwood LLC
Dayton, OH
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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