Cycle 1
Health 2023-11-03 · Fire 2023-11-03
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Mason, OH
Mcv Health Care Facilities, Inc
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
411 Western Row Road, Mason, OH
(513) 398-1486
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
73
Certified beds
Average residents
65
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-11-25
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
0.75
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.58
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.96
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.28
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.33
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.69
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
5.44
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
23%
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
1,290
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
57.95
Composite VBP score used to determine payment impact.
Payment multiplier
1.0131
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.99
Baseline 19.64% · Performance 19.12% · Measure score 4.99 · Achievement 4.99 · Improvement 1.50
Healthcare-associated infections
4.41
Baseline 6.00% · Performance 6.52% · Measure score 4.41 · Achievement 4.41 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
7.99
Baseline 5.16 hours · Performance 5.35 hours · Measure score 7.99 · Achievement 7.99 · Improvement 2.56
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.87% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 225 · Observed rate 8.44% · Lower 95% interval 8.16% |
| Discharge to community | 57.47% |
50.57%
6.9 pts better
|
Better than the National Rate · Eligible stays 201 · Observed rate 57.71% · Lower 95% interval 51.69% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.5% |
95.27%
2.2 pts better
|
Numerator 117 · Denominator 120 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 120 |
| Discharge self-care score | 52.63% |
53.69%
1.1 pts worse
|
Numerator 50 · Denominator 95 |
| Discharge mobility score | 53.68% |
50.94%
2.7 pts better
|
Numerator 51 · Denominator 95 |
| Pressure ulcers or injuries, new or worsened | 3.33% |
2.29%
1 pts worse
|
Numerator 4 · Denominator 120 · Adjusted rate 3.13% |
| Healthcare-associated infections requiring hospitalization | 6.52% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 4.03% · Lower 95% interval 3.49% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 220 |
| Staff flu vaccination coverage | 19.69% |
42%
22.3 pts worse
|
Numerator 64 · Denominator 325 |
| Discharge function score | 63.16% |
56.45%
6.7 pts better
|
Numerator 60 · Denominator 95 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 74 · Denominator 74 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 19 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.2 · 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 | 98.2% |
94.5%
3.7 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| 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 5.4% · Q2 5.7% · Q3 3.8% · Q4 4.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.7% |
26.1%
16.4 pts better
|
11.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 8.2% · Q3 11.8% · Q4 8.3% · 4Q avg 9.7% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
6.2%
0.5 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 17.2% · Q3 0.0% · Q4 3.0% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
25.4%
5.1 pts better
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 17.2% · Q3 22.9% · Q4 27.3% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
11.5%
5.6 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 14.3% · Q3 0.0% · Q4 0.0% · 4Q avg 5.9% · 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 | 17.6% |
7.7%
9.9 pts worse
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.1% |
6.2%
6.9 pts worse
|
14.9%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 9.1% · Q3 13.8% · Q4 12.5% · 4Q avg 13.1% · 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 | 1.4% |
0.5%
0.9 pts worse
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 2.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
21.7%
8 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.2% · Q2 31.8% · Q3 36.1% · Q4 27.3% · 4Q avg 29.7% |
| Percentage of long-stay residents with pressure ulcers | 0.8% |
3.7%
2.9 pts better
|
5.1%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
78.1%
20.9 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
12.5%
0.4 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 11.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.3% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
75.6%
22.6 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.8% |
25.1%
4.3 pts better
|
23.9%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 17.1% · Expected 19.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-20 · Fire 2020-02-20
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-12-19 · Fire 2018-12-19
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-11-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-01
F · Potential for more than minimal harm
2023-11-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-12-01
E · Potential for more than minimal harm
2023-11-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-01
F · Potential for more than minimal harm
2020-02-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-04-24
E · Potential for more than minimal harm
2020-02-20
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-04-24
E · Potential for more than minimal harm
2020-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-24
E · Potential for more than minimal harm
2020-02-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-04-24
E · Potential for more than minimal harm
2020-02-20
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2020-04-24
F · Potential for more than minimal harm
2018-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-03-08
E · Potential for more than minimal harm
2018-12-19
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 2019-03-08
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-21
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 2026-02-13
E · Potential for more than minimal harm
2023-11-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-01
D · Potential for more than minimal harm
2018-12-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-03-08
D · Potential for more than minimal harm
2018-12-19
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-03-08
D · Potential for more than minimal harm
2018-12-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-03-08
D · Potential for more than minimal harm
2018-12-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-03-08
D · Potential for more than minimal harm
2018-12-19
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 2019-03-08
Penalties and ownership
What sits behind the stars
Ownership
The Christian Benevolent Association Of Greater Cincinnati, Inc
5% Or Greater Direct Ownership Interest · Organization
Brashear, Vickie
Corporate Officer · Individual
Coates, Dale
Corporate Director · Individual
Eger, Charles
Corporate Director · Individual
Engel, David
Corporate Director · Individual
Garner, Kitty
Corporate Director · Individual
Lippert, Dave
Corporate Director · Individual
Mccann, Jon
Corporate Director · Individual
Monroe, Larry
Corporate Officer · Individual
Nelson, Naveena
Contracted Managing Employee · Individual
Rehmel, Jason
Corporate Director · Individual
Sims, Scott
Corporate Director · Individual
Slade, Robert
W-2 Managing Employee · Individual
Snyder, Harry
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Majestic Care Of Cedar Village.
Mason, OH
3-star overall rating with 2-star inspections with $73,281 in total fines with 13 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#2
Chesterwood Village
West Chester, OH
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Mason Health Care Center
Mason, OH
2-star overall rating with 2-star inspections with 16 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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