Cycle 1
Health 2023-08-24 · Fire 2023-08-24
7 health deficiencies
Top issue: Environmental (3 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Marion, OH
Embassy Of Marion
2-star overall rating with 2-star inspections with $40,053 in total fines with 7 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
175 Community Drive, Marion, OH
(740) 387-7537
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Embassy Healthcare
Operator or chain grouping
Approved since
1979-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 health / 2 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
0.53
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,599
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.85
Performance 43.86% · Measure score 4.85 · Achievement 4.85 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.61
Baseline 2.67 hours · Performance 3.32 hours · Measure score 1.61 · Achievement 0.86 · Improvement 1.61
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.06% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 14.29% · Lower 95% interval 6.92% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.24% |
95.27%
About the same
|
Numerator 20 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 110 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 78.3% |
92.4%
14.1 pts worse
|
93.4%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.1% · Q2 72.3% · Q3 81.8% · Q4 89.2% · 4Q avg 78.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.5% |
94.5%
7 pts worse
|
95.5%
8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 52.8% |
26.1%
26.7 pts worse
|
11.4%
41.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 34.5% · Q3 87.3% · Q4 87.9% · 4Q avg 52.8% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
6.2%
0.3 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 7.4% · Q3 5.7% · Q4 3.8% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.9% |
25.4%
10.5 pts worse
|
19.6%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 38.9% · Q3 39.6% · Q4 37.7% · 4Q avg 35.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.1% |
11.5%
4.6 pts worse
|
16.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 11.4% · Q3 19.5% · Q4 22.0% · 4Q avg 16.1% · 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 | 3.6% |
7.7%
4.1 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.3% |
6.2%
3.9 pts better
|
14.9%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.8% · Q3 1.9% · Q4 0.0% · 4Q avg 2.3% · 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 | 24.0% |
21.7%
2.3 pts worse
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 36.2% · Q3 15.1% · Q4 21.1% · 4Q avg 24.0% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
3.7%
1.9 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 40.2% |
78.1%
37.9 pts worse
|
81.7%
41.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 38.1% · Q3 47.2% · Q4 46.3% · 4Q avg 40.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.7% |
12.5%
10.2 pts worse
|
12.0%
10.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 25.9% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.9% |
1.2%
3.7 pts worse
|
1.6%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q3 9.5% · Q4 4.2% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 31.0% |
75.6%
44.6 pts worse
|
79.7%
48.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 31.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
25.1%
4.1 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 29.6% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-24 · Fire 2021-06-24
8 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-02-07 · Fire 2019-02-07
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-24
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-24
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-09-29
F · Potential for more than minimal harm
2023-08-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-24
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 2023-09-29
E · Potential for more than minimal harm
2023-08-24
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-24
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 2023-09-29
E · Potential for more than minimal harm
2023-08-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-24
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-29
E · Potential for more than minimal harm
2023-08-24
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-09-29
F · Potential for more than minimal harm
2021-06-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-16
F · Potential for more than minimal harm
2021-06-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-07-16
F · Potential for more than minimal harm
2021-06-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-07-16
E · Potential for more than minimal harm
2021-06-24
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 2021-07-16
E · Potential for more than minimal harm
2021-06-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-07-16
E · Potential for more than minimal harm
2021-06-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-07-16
E · Potential for more than minimal harm
2021-06-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-07-16
E · Potential for more than minimal harm
2019-02-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-03-01
E · Potential for more than minimal harm
2019-02-07
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2019-03-01
E · Potential for more than minimal harm
2019-02-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-03-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-21
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-04-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-05-16
F · Potential for more than minimal harm
2024-09-26
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-21
E · Potential for more than minimal harm
2024-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-09-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-04-02
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 2024-04-05
L · Immediate jeopardy
2023-12-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-12-18
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 2024-01-10
E · Potential for more than minimal harm
2023-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-12-18
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 2024-01-10
F · Potential for more than minimal harm
2023-08-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-24
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 2023-09-29
D · Potential for more than minimal harm
2023-08-24
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-24
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 2023-09-29
D · Potential for more than minimal harm
2023-08-24
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 2023-09-29
E · Potential for more than minimal harm
2023-07-27
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-14
D · Potential for more than minimal harm
2023-04-27
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-05-04
F · Potential for more than minimal harm
2021-06-24
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2021-08-19
E · Potential for more than minimal harm
2021-06-24
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2021-08-19
E · Potential for more than minimal harm
2021-06-24
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 2021-08-19
D · Potential for more than minimal harm
2021-06-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-08-19
F · Potential for more than minimal harm
2019-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-02-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-02-07
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-02-07
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2019-03-01
D · Potential for more than minimal harm
2019-02-07
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 2019-03-01
Penalties and ownership
What sits behind the stars
$40,053
2023-12-18
Fine
Fine · fine $40,053
Fine
Ownership
Nearby options
Other facilities in reach
#1
Marion Valley Post Acute
Marion, OH
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Meadows Of Marion Health And Rehabilitation The
Marion, OH
0-star overall rating with 0-star inspections
#3
Marion Pointe
Marion, OH
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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