Cycle 1
Health 2025-04-10 · Fire 2025-04-10
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Marysville, OH
Milcrest Nursing Center
3-star overall rating with 2-star inspections with $68,006 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
730 Milcrest Drive, Marysville, OH
(937) 642-1026
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
50
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Country Club Rehabilitation Campus
Operator or chain grouping
Approved since
1984-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 3 overall / 3 health / 3 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
0.91
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.51
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.95
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,465
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.68
Baseline 25.16% · Performance 20.13% · Measure score 5.68 · Achievement 2.81 · Improvement 5.68
Healthcare-associated infections
1.60
Baseline 8.23% · Performance 7.55% · Measure score 1.60 · Achievement 0.94 · Improvement 1.60
Total nurse turnover
3.73
Baseline 68.42% · Performance 50.00% · Measure score 3.73 · Achievement 3.35 · Improvement 3.73
Adjusted total nurse staffing
2.10
Baseline 3.03 hours · Performance 3.67 hours · Measure score 2.10 · Achievement 2.10 · Improvement 1.86
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.41% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 55 · Observed rate 10.91% · Lower 95% interval 7.47% |
| Discharge to community | 57.71% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 49.02% · Lower 95% interval 44.58% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 25 · Denominator 25 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 25 |
| 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 | 12% |
2.29%
9.7 pts worse
|
Numerator 3 · Denominator 25 · Adjusted rate 11.47% |
| Healthcare-associated infections requiring hospitalization | 7.55% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 29 · Observed rate 10.34% · Lower 95% interval 3.71% |
| Staff COVID-19 vaccination coverage | 4.48% |
8.2%
3.7 pts worse
|
Numerator 3 · Denominator 67 |
| Staff flu vaccination coverage | 43.01% |
42%
1 pts better
|
Numerator 40 · Denominator 93 |
| 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 15 · 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 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 80.0% |
92.4%
12.4 pts worse
|
93.4%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.7% · Q2 76.7% · Q3 88.6% · Q4 80.0% · 4Q avg 80.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 78.7% |
94.5%
15.8 pts worse
|
95.5%
16.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 78.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.5% |
3.3%
3.2 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 9.3% · Q3 5.7% · Q4 5.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.6% |
26.1%
12.5 pts better
|
11.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 16.2% · Q3 12.5% · Q4 16.7% · 4Q avg 13.6% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
6.2%
3.9 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.9% · Q3 3.3% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.2% |
25.4%
13.8 pts worse
|
19.6%
19.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 40.0% · Q3 41.9% · Q4 44.1% · 4Q avg 39.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.9% |
11.5%
8.6 pts better
|
16.7%
13.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.6% · Q3 3.8% · Q4 3.8% · 4Q avg 2.9% · 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 | 6.1% |
7.7%
1.6 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.1% |
6.2%
3.1 pts better
|
14.9%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 0.0% · Q4 5.9% · 4Q avg 3.1% · 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 | 0.7% |
0.5%
0.2 pts worse
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.2% |
21.7%
2.5 pts worse
|
19.8%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 21.9% · Q3 20.7% · Q4 28.7% · 4Q avg 24.2% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
3.7%
1.5 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 41.2% |
78.1%
36.9 pts worse
|
81.7%
40.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 43.9% · Q3 62.3% · Q4 40.0% · 4Q avg 41.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
12.5%
0.5 pts better
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 11.5% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.1% |
75.6%
33.5 pts worse
|
79.7%
37.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.1% |
25.1%
13 pts better
|
23.9%
11.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 11.5% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-26 · Fire 2022-05-26
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-05-22 · Fire 2019-05-22
10 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-29
F · Potential for more than minimal harm
2022-05-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-10
F · Potential for more than minimal harm
2022-05-26
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-06-10
E · Potential for more than minimal harm
2022-05-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-10
E · Potential for more than minimal harm
2022-05-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-10
F · Potential for more than minimal harm
2019-05-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-06-18
E · Potential for more than minimal harm
2019-05-22
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 2019-06-18
E · Potential for more than minimal harm
2019-05-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-06-18
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-10
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 2025-04-29
D · Potential for more than minimal harm
2025-04-10
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 2025-04-29
D · Potential for more than minimal harm
2025-04-10
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 2025-04-29
D · Potential for more than minimal harm
2025-04-10
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 2025-04-29
D · Potential for more than minimal harm
2025-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-04-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-04-10
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-04-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-04-10
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 2025-04-29
D · Potential for more than minimal harm
2025-04-10
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-29
C · Minimal harm
2025-04-10
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2025-04-29
J · Immediate jeopardy
2024-06-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-14
J · Immediate jeopardy
2024-06-13
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-06-14
D · Potential for more than minimal harm
2024-06-13
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 2024-06-14
D · Potential for more than minimal harm
2023-08-23
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 2023-09-11
D · Potential for more than minimal harm
2023-08-23
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 2023-09-11
D · Potential for more than minimal harm
2023-08-23
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 2023-09-11
D · Potential for more than minimal harm
2022-05-26
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 2022-06-10
D · Potential for more than minimal harm
2022-05-26
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 2022-06-10
D · Potential for more than minimal harm
2022-05-26
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 2022-06-10
D · Potential for more than minimal harm
2022-05-26
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 2022-06-10
D · Potential for more than minimal harm
2022-05-26
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-06-10
D · Potential for more than minimal harm
2022-05-26
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-06-10
F · Potential for more than minimal harm
2019-05-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-06-18
F · Potential for more than minimal harm
2019-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-18
E · Potential for more than minimal harm
2019-05-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-06-18
D · Potential for more than minimal harm
2019-05-22
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 2019-06-18
D · Potential for more than minimal harm
2019-05-22
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 2019-06-18
D · Potential for more than minimal harm
2019-05-22
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 2019-06-18
D · Potential for more than minimal harm
2019-05-22
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 2019-06-18
Penalties and ownership
What sits behind the stars
$68,006
2024-06-13
Fine
Fine · fine $68,006
Fine
Ownership
Harris, Janet
5% Or Greater Direct Ownership Interest · Individual
Harris, Janet
Operational/Managerial Control · Individual
Harris, Janet
Corporate Director · Individual
Harris, Janet
Corporate Officer · Individual
Harris, Janet
W-2 Managing Employee · Individual
Helmandollar, Charles
W-2 Managing Employee · Individual
Olson, Lyle
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Prestige Gardens Rehabilitation And Nursing Center
Marysville, OH
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Gables Of Marysville Health And Rehabilitation
Marysville, OH
2-star overall rating with 3-star inspections with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Als Woodstock Inc
Woodstock, OH
1-star overall rating with 2-star inspections with $42,094 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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