Cycle 1
Health 2023-06-22 · Fire 2023-06-22
2 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Yellow Springs, OH
Friends Extended Care Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
150 East Herman Street, Yellow Springs, OH
(937) 767-7363
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
42
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-10-29
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
0.44
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.43
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.70
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.87
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.11
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.26
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
0.40
CMS adjusted RN staffing hours
Adjusted total hours
4.23
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
50%
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
13,419
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.40% · Performance 24.04% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.94% · Performance 9.13% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 100.00% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.19
Baseline 3.90 hours · Performance 3.70 hours · Measure score 2.19 · Achievement 2.19 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.65% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 10.96% · Lower 95% interval 7.4% |
| Discharge to community | 53.04% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 45.45% · Lower 95% interval 43.38% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 56 · Denominator 56 |
| Falls with major injury | 1.79% |
0.77%
1 pts worse
|
Numerator 1 · Denominator 56 |
| Discharge self-care score | 64.29% |
53.69%
10.6 pts better
|
Numerator 27 · Denominator 42 |
| Discharge mobility score | 45.24% |
50.94%
5.7 pts worse
|
Numerator 19 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 56 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.13% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 15.09% · Lower 95% interval 5.8% |
| Staff COVID-19 vaccination coverage | 52.58% |
8.2%
44.4 pts better
|
Numerator 51 · Denominator 97 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 52.38% |
56.45%
4.1 pts worse
|
Numerator 22 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 27 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 3.45% |
25.2%
21.8 pts worse
|
Numerator 1 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.8
1.2 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.7 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
92.4%
5.3 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 100.0% · Q3 97.1% · Q4 97.1% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
94.5%
2.6 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.3%
0.3 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 5.7% · Q4 5.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 36.1% |
26.1%
10 pts worse
|
11.4%
24.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 31.0% · Q3 46.7% · Q4 37.5% · 4Q avg 36.1% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
6.2%
2.1 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.7% |
25.4%
0.3 pts worse
|
19.6%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 30.0% · 4Q avg 25.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.0% |
11.5%
7.5 pts worse
|
16.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.0% · 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 | 2.7% |
7.7%
5 pts better
|
16.3%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
6.2%
About the same
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.2% · 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 | 28.8% |
21.7%
7.1 pts worse
|
19.8%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 28.7% · Q3 14.0% · Q4 35.4% · 4Q avg 28.8% |
| 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 1.7% · Q2 2.0% · Q3 1.4% · Q4 1.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.8% |
78.1%
0.3 pts worse
|
81.7%
3.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.0% · Q2 73.0% · Q3 80.0% · Q4 81.0% · 4Q avg 77.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.9% |
12.5%
5.4 pts worse
|
12.0%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.9% · Observed 16.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.2%
1.9 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 9.5% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.0% |
75.6%
1.4 pts better
|
79.7%
2.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
25.1%
2.7 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 27.8% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-27 · Fire 2021-08-27
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2019-04-04 · Fire 2019-04-04
2 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-06-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-11
F · Potential for more than minimal harm
2023-06-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-11
E · Potential for more than minimal harm
2023-06-22
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-08-11
E · Potential for more than minimal harm
2023-06-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-31
E · Potential for more than minimal harm
2021-08-27
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 2021-10-12
E · Potential for more than minimal harm
2021-08-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-10-12
E · Potential for more than minimal harm
2021-08-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-10-12
E · Potential for more than minimal harm
2021-08-27
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-10-12
F · Potential for more than minimal harm
2019-04-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-04-28
F · Potential for more than minimal harm
2019-04-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-04-28
E · Potential for more than minimal harm
2019-04-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-04-28
D · Potential for more than minimal harm
2019-04-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-06-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-06-22
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 2023-08-11
F · Potential for more than minimal harm
2021-08-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-12
D · Potential for more than minimal harm
2021-08-27
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2021-10-12
D · Potential for more than minimal harm
2019-04-04
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2019-04-28
D · Potential for more than minimal harm
2019-04-04
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 2019-04-28
Penalties and ownership
What sits behind the stars
Ownership
Bean, Rodney
Corporate Director · Individual
Bowers, Alma
Corporate Officer · Individual
Bradtmiller, Bruce
Corporate Officer · Individual
Cooper, Ann
Corporate Director · Individual
Jackson, Kevin
Corporate Director · Individual
Porter, Elizabeth
Corporate Director · Individual
Reed, Kathrine
Corporate Director · Individual
Rubin, Beth
Corporate Officer · Individual
Silvert, Donna
Corporate Director · Individual
Wright, Sterling
Corporate Director · Individual
Zalar, Karl
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Trinity Community At Fairborn
Fairborn, OH
4-star overall rating with 3-star inspections with 14 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Dayspring Of Miami Valley Hlth Care Center & Rehab
Fairborn, OH
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Wright Rehabilitation And Healthcare Center
Fairborn, OH
2-star overall rating with 3-star inspections with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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