21 health deficiencies
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Vandalia, OH
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
208 North Cassel Road, Vandalia, OH
(937) 898-4202
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
118
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-11-10
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
RN hours / resident day
0.25
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
2.99
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.67
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.20
CMS adjusted RN staffing hours
Adjusted total hours
2.44
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
8,103
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
4.55
Baseline 33.77% · Performance 45.10% · Measure score 4.55 · Achievement 4.55 · Improvement 0
Adjusted total nurse staffing
1.01
Baseline 2.59 hours · Performance 3.07 hours · Measure score 1.01 · Achievement 0 · Improvement 1.01
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.3% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 15.38% · Lower 95% interval 6.83% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 10 · 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 111 |
| Staff flu vaccination coverage | 2.46% |
42%
39.5 pts worse
|
Numerator 3 · Denominator 122 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.2% |
92.4%
8.2 pts worse
|
93.4%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.8% · Q2 90.5% · Q3 82.5% · Q4 80.0% · 4Q avg 84.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.9% |
94.5%
3.6 pts worse
|
95.5%
4.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.1% · Q3 5.2% · Q4 3.2% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 91.0% |
26.1%
64.9 pts worse
|
11.4%
79.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 74.4% · Q2 92.9% · Q3 98.9% · Q4 97.8% · 4Q avg 91.0% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
6.2%
1.6 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.8% · Q3 2.3% · Q4 4.7% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.8% |
25.4%
7.4 pts worse
|
19.6%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 33.0% · Q3 30.2% · Q4 33.3% · 4Q avg 32.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.5% |
11.5%
9 pts worse
|
16.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 10.0% · Q3 20.5% · Q4 28.9% · 4Q avg 20.5% · 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 | 4.9% |
7.7%
2.8 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 9.3% · Q3 5.7% · Q4 0.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
6.2%
2.4 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.7% · Q3 2.3% · Q4 1.1% · 4Q avg 3.8% · 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 | 17.9% |
21.7%
3.8 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 23.5% · Q3 17.5% · Q4 13.1% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
3.7%
0.8 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.1% · Q3 2.8% · Q4 3.1% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 43.5% |
78.1%
34.6 pts worse
|
81.7%
38.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 40.0% · Q2 44.1% · Q3 48.1% · Q4 40.9% · 4Q avg 43.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.7% |
12.5%
4.2 pts worse
|
12.0%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 20.0% · Expected 13.4% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 50.0% |
75.6%
25.6 pts worse
|
79.7%
29.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 50.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.8% |
25.1%
0.7 pts worse
|
23.9%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 30.0% · Expected 27.7% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
26 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Top issue: Resident Rights (4 deficiencies)
16 fire-safety deficiencies
Top issue: Emergency Preparedness (6 deficiencies)
Fire safety
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-14
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-14
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-14
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-14
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-14
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-14
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-14
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-14
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-14
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-11-14
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-11-14
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 2024-11-14
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-11-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-14
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-14
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-11-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-14
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-14
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-06-20
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 2023-06-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-20
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-20
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-20
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-20
Fire Safety
Establish emergency prep training and testing.
Corrected 2019-12-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-13
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-12-13
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 2019-12-13
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-12-13
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-12-13
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-12-13
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2018-10-31
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2018-10-31
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2018-10-31
Fire Safety
Establish methods for sharing information.
Corrected 2018-10-31
Fire Safety
Establish emergency prep training and testing.
Corrected 2018-10-31
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2018-10-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-10-31
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2018-10-31
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2018-10-31
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2018-10-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-10-31
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2018-10-31
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 2018-10-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-10-31
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-10-31
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-10-31
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-18
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 2024-11-14
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-14
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 2024-11-14
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2024-07-22
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 2024-06-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-18
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-04-02
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-07-28
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-06-20
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-20
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-06-20
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 2023-06-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-06-20
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 2023-06-20
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-06-20
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-20
Health
Keep all essential equipment working safely.
Corrected 2023-06-20
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-06-20
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-06-20
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-06-20
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-20
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-20
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-06-20
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 2023-06-20
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-20
Health
Provide or obtain dental services for each resident.
Corrected 2023-06-20
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-06-20
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-06-20
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 2023-06-20
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 2023-03-24
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-12-13
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-12-13
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 2019-12-13
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-12-13
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 2019-12-13
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-12-13
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-12-13
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2018-10-31
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 2018-10-31
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-10-31
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2018-10-31
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2018-10-31
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2018-10-31
Penalties and ownership
Payment Denial · denial start 2023-06-03 · 17 days
17 day denial
5% Or Greater Direct Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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