Cycle 1
Health 2025-02-27 · Fire 2025-02-27
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
St Marys, OH
Grande Lake Healthcare Center
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1209 Indiana Avenue, St Marys, OH
(419) 394-7611
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
45
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Communicare Health
Operator or chain grouping
Approved since
1990-10-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
122 facilities
Chain averages 3 overall / 2 health / 2 staffing / 4 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
0.55
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.77
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.87
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
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,606
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
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
1.60
Baseline 63.64% · Performance 57.14% · Measure score 1.60 · Achievement 1.60 · Improvement 1.17
Adjusted total nurse staffing
2.36
Baseline 3.56 hours · Performance 3.75 hours · Measure score 2.36 · Achievement 2.36 · Improvement 0.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.48% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 9.09% · Lower 95% interval 6.81% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · 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 19 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 19 · 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 11 · 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 80 |
| Staff flu vaccination coverage | 89.36% |
42%
47.4 pts better
|
Numerator 42 · Denominator 47 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · 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 | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.6 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 4.7% |
3.3%
1.4 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 8.6% · Q4 8.6% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.2% |
26.1%
11.9 pts better
|
11.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 7.1% · Q3 16.1% · Q4 16.7% · 4Q avg 14.2% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
6.2%
2.6 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 8.3% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.8% |
25.4%
3.4 pts worse
|
19.6%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 30.6% · Q3 27.3% · Q4 29.0% · 4Q avg 28.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.8% |
11.5%
8.7 pts better
|
16.7%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 2.8% · 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 | 7.1% |
7.7%
0.6 pts better
|
16.3%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 4.7% · Q3 9.4% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
6.2%
1.1 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.7% · Q3 6.1% · Q4 3.2% · 4Q avg 5.1% · 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 | 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 | 22.1% |
21.7%
0.4 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 33.0% · Q3 19.9% · Q4 23.1% · 4Q avg 22.1% |
| 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 0.0% · Q2 3.6% · 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 | 97.5% |
78.1%
19.4 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 97.4% · Q3 97.9% · Q4 100.0% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.8% |
12.5%
1.7 pts better
|
12.0%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.8% · Observed 13.6% · Expected 14.0% · 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 · 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 | 95.1% |
75.6%
19.5 pts better
|
79.7%
15.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
25.1%
1.4 pts better
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 27.3% · Expected 27.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-13 · Fire 2023-02-13
11 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2020-01-04 · Fire 2020-01-04
15 health deficiencies
Top issue: Infection Control (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-21
E · Potential for more than minimal harm
2025-02-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-21
F · Potential for more than minimal harm
2023-02-13
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 2023-03-06
F · Potential for more than minimal harm
2023-02-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-06
E · Potential for more than minimal harm
2023-02-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-06
E · Potential for more than minimal harm
2020-01-04
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 2020-02-04
E · Potential for more than minimal harm
2020-01-04
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-02-04
Inspection history
Recent health citations
G · Actual harm
2025-02-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-21
F · Potential for more than minimal harm
2025-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-27
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-27
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-02-27
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-03-21
D · Potential for more than minimal harm
2024-06-27
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 2024-07-03
F · Potential for more than minimal harm
2023-02-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-03-06
F · Potential for more than minimal harm
2023-02-13
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-03-06
E · Potential for more than minimal harm
2023-02-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-02-13
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 2023-03-06
D · Potential for more than minimal harm
2023-02-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-02-13
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 2023-03-06
D · Potential for more than minimal harm
2023-02-13
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-02-13
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 2023-03-06
D · Potential for more than minimal harm
2023-02-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-06
D · Potential for more than minimal harm
2023-02-13
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-03-06
F · Potential for more than minimal harm
2020-01-04
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2020-02-04
F · Potential for more than minimal harm
2020-01-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-04
E · Potential for more than minimal harm
2020-01-04
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2020-02-04
E · Potential for more than minimal harm
2020-01-04
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2020-02-04
D · Potential for more than minimal harm
2020-01-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-02-04
D · Potential for more than minimal harm
2020-01-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2020-02-04
D · Potential for more than minimal harm
2020-01-04
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-02-04
D · Potential for more than minimal harm
2020-01-04
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2020-02-04
D · Potential for more than minimal harm
2020-01-04
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 2020-02-04
D · Potential for more than minimal harm
2020-01-04
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 2020-02-04
D · Potential for more than minimal harm
2020-01-04
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-02-04
D · Potential for more than minimal harm
2020-01-04
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 2020-02-04
D · Potential for more than minimal harm
2020-01-04
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 2020-02-04
D · Potential for more than minimal harm
2020-01-04
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2020-02-04
D · Potential for more than minimal harm
2020-01-04
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2020-02-04
Penalties and ownership
What sits behind the stars
Ownership
Sxcy Mstr Lsco, LLC
5% Or Greater Direct Ownership Interest · Organization
C.r. Stoltz Family Investment Company Inc
5% Or Greater Indirect Ownership Interest · Organization
C.r. Stoltz Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Groves, Donna
Operational/Managerial Control · Individual
Health Care Lease Facilities, LLC
5% Or Greater Indirect Ownership Interest · Organization
I. Rosedale Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Indiana Mgt Co., LLC
Operational/Managerial Control · Organization
Peyton, Joseph
Operational/Managerial Control · Individual
R.s. Wilheim Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Romeo, Dominic
Operational/Managerial Control · Individual
Romeo, Dominic
Corporate Officer · Individual
Ronald S Wilheim 2012 Spousal Trust
5% Or Greater Indirect Ownership Interest · Organization
Rosedale Family Investment Company, Inc
5% Or Greater Indirect Ownership Interest · Organization
Rrw, LLC
5% Or Greater Indirect Ownership Interest · Organization
S.l. Rosedale Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Skilled Hc Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Stoltz, Charles
Corporate Officer · Individual
Sxcy Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Taylor, Jane
Operational/Managerial Control · Individual
Wilheim Family Investment Company, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Wilheim, Ronald
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Vancrest Of St Mary's
St Marys, OH
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Transitional Care Unit
Saint Marys, OH
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Otterbein St Marys Retirement Community
St Marys, OH
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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