Cycle 1
Health 2024-10-09 · Fire 2024-10-09
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Waverly, OH
National Church Residences Bristol Village
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
444 Cherry St, Waverly, OH
(740) 947-2113
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
40
Certified beds
Average residents
34
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-06-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.81
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.49
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.36
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
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.14
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,808
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.96
Composite VBP score used to determine payment impact.
Payment multiplier
0.9887
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.72
Baseline 17.82% · Performance 19.71% · Measure score 3.72 · Achievement 3.72 · Improvement 0
Healthcare-associated infections
5.46
Baseline 5.25% · Performance 6.20% · Measure score 5.46 · Achievement 5.46 · Improvement 0
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1.46
Baseline 3.32 hours · Performance 3.49 hours · Measure score 1.46 · Achievement 1.46 · Improvement 0.20
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 9.28% · Lower 95% interval 6.96% |
| Discharge to community | 62.1% |
50.57%
11.5 pts better
|
Better than the National Rate · Eligible stays 85 · Observed rate 64.71% · Lower 95% interval 54.31% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 45 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 55.88% |
53.69%
2.2 pts better
|
Numerator 19 · Denominator 34 |
| Discharge mobility score | 44.12% |
50.94%
6.8 pts worse
|
Numerator 15 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 4.44% |
2.29%
2.2 pts worse
|
Numerator 2 · Denominator 45 · Adjusted rate 5.41% |
| Healthcare-associated infections requiring hospitalization | 6.2% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 2.13% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 42 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 61 |
| Discharge function score | 52.94% |
56.45%
3.5 pts worse
|
Numerator 18 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 39.13% |
25.2%
13.9 pts better
|
Numerator 9 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.0 · Expected 1.2 · 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 1.6 · 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 | 96.7% |
94.5%
2.2 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.3%
0.4 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 3.7% · Q4 4.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
26.1%
19 pts better
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 7.7% · Q4 16.7% · 4Q avg 7.1% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.2%
2.2 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 4.8% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
25.4%
14.9 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.0% · Q3 14.3% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.5% |
11.5%
10 pts better
|
16.7%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · 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 | 11.7% |
7.7%
4 pts worse
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
6.2%
1.7 pts worse
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 15.0% · Q3 4.8% · 4Q avg 7.9% · 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 | 1.0% |
0.5%
0.5 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.2% |
21.7%
10.5 pts worse
|
19.8%
12.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 55.1% · Q3 32.5% · Q4 22.1% · 4Q avg 32.2% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
3.7%
3.2 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 6.2% · Q3 14.6% · Q4 2.7% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
78.1%
21.9 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
12.5%
0.2 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 11.4% · Expected 10.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · 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 | 92.5% |
75.6%
16.9 pts better
|
79.7%
12.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.4% |
25.1%
1.7 pts better
|
23.9%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 20.5% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-17 · Fire 2022-11-17
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-01-23 · Fire 2020-01-23
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-09
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-11-01
E · Potential for more than minimal harm
2024-10-09
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-01
F · Potential for more than minimal harm
2022-11-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-01-05
F · Potential for more than minimal harm
2022-11-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-11-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-11-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-01-05
F · Potential for more than minimal harm
2020-01-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-03-13
F · Potential for more than minimal harm
2020-01-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-03-13
E · Potential for more than minimal harm
2020-01-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-11-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-08
F · Potential for more than minimal harm
2022-11-17
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 2023-01-05
D · Potential for more than minimal harm
2022-11-17
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 2023-01-05
D · Potential for more than minimal harm
2022-11-17
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-11-17
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2023-01-05
E · Potential for more than minimal harm
2020-01-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-03-13
Penalties and ownership
What sits behind the stars
Ownership
National Church Residences
5% Or Greater Direct Ownership Interest · Organization
Alexander, Sean
Corporate Director · Individual
Anderson, Denise
Corporate Director · Individual
Brown, Sonya
Corporate Director · Individual
Clemmons, Amy
Operational/Managerial Control · Individual
Dehring, Lindsey
Corporate Officer · Individual
Kessler, David
Corporate Director · Individual
Mettler, Brianna
Corporate Officer · Individual
Meyung, Kelli
Corporate Director · Individual
National Church Residences Health Care
Operational/Managerial Control · Organization
Rule, Matthew
Corporate Director · Individual
Stitzer, Parker
Corporate Director · Individual
Woolley, Julie
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Piketon Nursing Center
Piketon, OH
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
The Pavilion At Piketon
Piketon, OH
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Chillicothe Post Acute
Chillicothe, OH
4-star overall rating with 3-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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