Galion, OH

Mill Creek Nursing & Rehabilitation

4-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

900 Wedgewood Circle, Galion, OH

(419) 462-0173

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 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

79

Certified beds

Average residents

75

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Foundations Health Solutions

Operator or chain grouping

Approved since

2009-01-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

63 facilities

Chain averages 4 overall / 4 health / 2 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

No

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.61

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.09

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.13

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.83

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.70

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.29

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.32

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

0.51

CMS adjusted RN staffing hours

Adjusted total hours

3.22

CMS adjusted total nurse staffing hours

Case-mix index

1.63

Higher values indicate more complex resident acuity

RN turnover

0%

Annual RN turnover

Total nurse turnover

23%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,104

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

59.89

Composite VBP score used to determine payment impact.

Payment multiplier

1.0151

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

7.32

Baseline 17.21% · Performance 18.04% · Measure score 7.32 · Achievement 7.32 · Improvement 0

Healthcare-associated infections

8.62

Baseline 6.57% · Performance 5.26% · Measure score 8.62 · Achievement 8.62 · Improvement 7.83

Total nurse turnover

6.14

Performance 38.60% · Measure score 6.14 · Achievement 6.14 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

1.88

Baseline 1.91 hours · Performance 2.83 hours · Measure score 1.88 · Achievement 0 · Improvement 1.88

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.2%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 153 · Observed rate 11.76% · Lower 95% interval 8.48%
Discharge to community	51.33%	50.57% 0.8 pts better	No Different than the National Rate · Eligible stays 131 · Observed rate 48.85% · Lower 95% interval 44.44%
Medicare spending per beneficiary	1.15	1.02 0.1 pts worse
Drug regimen review with follow-up	78.9%	95.27% 16.4 pts worse	Numerator 86 · Denominator 109
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 109
Discharge self-care score	45.35%	53.69% 8.3 pts worse	Numerator 39 · Denominator 86
Discharge mobility score	24.42%	50.94% 26.5 pts worse	Numerator 21 · Denominator 86
Pressure ulcers or injuries, new or worsened	2.75%	2.29% 0.5 pts worse	Numerator 3 · Denominator 109 · Adjusted rate 2.33%
Healthcare-associated infections requiring hospitalization	5.26%	7.12% 1.9 pts better	No Different than the National Rate · Eligible stays 98 · Observed rate 1.02% · Lower 95% interval 3.16%
Staff COVID-19 vaccination coverage	2.26%	8.2% 5.9 pts worse	Numerator 3 · Denominator 133
Staff flu vaccination coverage	5.88%	42% 36.1 pts worse	Numerator 8 · Denominator 136
Discharge function score	29.07%	56.45% 27.4 pts worse	Numerator 25 · Denominator 86
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 22 · Denominator 22
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 53 · Denominator 53
Resident COVID-19 vaccinations up to date	34.78%	25.2% 9.6 pts better	Numerator 24 · Denominator 69

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.6	1.8 0.2 pts better	1.9 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 2.1 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.2	1.8 0.4 pts worse	1.8 0.4 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.9 · Expected 1.5 · 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	0.0%	3.3% 3.3 pts better	3.3% 3.3 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 who have depressive symptoms	68.9%	26.1% 42.8 pts worse	11.4% 57.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 64.2% · Q2 65.4% · Q3 74.5% · Q4 71.0% · 4Q avg 68.9%
Percentage of long-stay residents who lose too much weight	2.6%	6.2% 3.6 pts better	5.4% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 4.1% · Q4 2.0% · 4Q avg 2.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	29.3%	25.4% 3.9 pts worse	19.6% 9.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 32.6% · Q2 28.0% · Q3 31.4% · Q4 25.9% · 4Q avg 29.3%
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 5.3% · Q2 7.1% · Q3 4.4% · Q4 6.7% · 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	2.9%	7.7% 4.8 pts better	16.3% 13.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	2.9%	6.2% 3.3 pts better	14.9% 12 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.4% · Q3 0.0% · Q4 2.1% · 4Q avg 2.9% · 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	20.7%	21.7% 1 pts better	19.8% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 30.8% · Q3 11.7% · Q4 9.7% · 4Q avg 20.7%
Percentage of long-stay residents with pressure ulcers	5.8%	3.7% 2.1 pts worse	5.1% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.3% · Q3 5.7% · Q4 9.1% · 4Q avg 5.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	95.2%	78.1% 17.1 pts better	81.7% 13.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 96.6% · Q3 95.5% · Q4 90.9% · 4Q avg 95.2%
Percentage of short-stay residents who had an outpatient emergency department visit	18.9%	12.5% 6.4 pts worse	12.0% 6.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 18.9% · Observed 18.8% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.4%	1.2% 0.8 pts better	1.6% 1.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	95.7%	75.6% 20.1 pts better	79.7% 16 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.2%	25.1% 1.9 pts better	23.9% 0.7 pts better	Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 25.0% · Expected 25.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-12 · Fire 2025-02-12

4 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-08-03 · Fire 2023-08-03

0 health deficiencies

No concentrated health issue counts in this cycle.

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2019-12-28 · Fire 2019-12-28

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-12

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-03-14

F · Potential for more than minimal harm 2025-02-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-14

F · Potential for more than minimal harm 2025-02-12

K915 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper power supply for life support equipment.

Corrected 2025-03-14

E · Potential for more than minimal harm 2025-02-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-03-14

F · Potential for more than minimal harm 2023-08-03

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-08-04

F · Potential for more than minimal harm 2023-08-03

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-08-04

F · Potential for more than minimal harm 2019-12-28

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2020-01-14

E · Potential for more than minimal harm 2019-12-28

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2020-01-14

E · Potential for more than minimal harm 2019-12-28

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2020-01-14

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-02-12

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 2025-03-14

D · Potential for more than minimal harm 2025-02-12

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-12

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-03-14

D · Potential for more than minimal harm 2025-02-12

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2025-03-14