Cycle 1
Health 2024-04-18 · Fire 2024-04-18
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Delaware, OH
Ohio Living Sarah Moore
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
26 North Union Street, Delaware, OH
(740) 362-9641
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
47
Certified beds
Average residents
43
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ohio Living Communities
Operator or chain grouping
Approved since
2005-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 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
0.94
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.49
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.04
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.08
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.67
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
0.91
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
378
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
71.32
Composite VBP score used to determine payment impact.
Payment multiplier
1.0230
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.91
Baseline 20.03% · Performance 17.30% · Measure score 8.91 · Achievement 8.91 · Improvement 8.59
Healthcare-associated infections
8.05
Baseline 8.21% · Performance 5.46% · Measure score 8.05 · Achievement 7.94 · Improvement 8.05
Total nurse turnover
8.44
Baseline 37.50% · Performance 29.17% · Measure score 8.44 · Achievement 8.44 · Improvement 6.09
Adjusted total nurse staffing
3.12
Baseline 4.72 hours · Performance 3.96 hours · Measure score 3.12 · Achievement 3.12 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.21% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 9.43% · Lower 95% interval 7.11% |
| Discharge to community | 63.71% |
50.57%
13.1 pts better
|
Better than the National Rate · Eligible stays 109 · Observed rate 60.55% · Lower 95% interval 55.19% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 75 · Denominator 75 |
| Falls with major injury | 2.67% |
0.77%
1.9 pts worse
|
Numerator 2 · Denominator 75 |
| Discharge self-care score | 70.15% |
53.69%
16.5 pts better
|
Numerator 47 · Denominator 67 |
| Discharge mobility score | 55.22% |
50.94%
4.3 pts better
|
Numerator 37 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 75 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.46% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 1.37% · Lower 95% interval 2.9% |
| Staff COVID-19 vaccination coverage | 0.9% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 111 |
| Staff flu vaccination coverage | 22.5% |
42%
19.5 pts worse
|
Numerator 27 · Denominator 120 |
| Discharge function score | 70.15% |
56.45%
13.7 pts better
|
Numerator 47 · Denominator 67 |
| Transfer of health information to provider | 97.5% |
95.95%
1.5 pts better
|
Numerator 39 · Denominator 40 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 40.54% |
25.2%
15.3 pts better
|
Numerator 15 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.9% |
92.4%
6.5 pts worse
|
93.4%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 52.9% · Q2 97.1% · Q3 100.0% · Q4 94.1% · 4Q avg 85.9% |
| 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 | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 3.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.4% |
26.1%
17.7 pts better
|
11.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 9.1% · Q3 9.4% · Q4 0.0% · 4Q avg 8.4% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
6.2%
0.8 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 8.3% · Q4 8.3% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.9% |
25.4%
6.5 pts better
|
19.6%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 22.7% · Q3 20.8% · Q4 12.0% · 4Q avg 18.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.1% |
11.5%
10.4 pts better
|
16.7%
15.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · 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 | 14.1% |
7.7%
6.4 pts worse
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
6.2%
0.1 pts worse
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 8.3% · Q4 12.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.2%
0.5 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · 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 | 14.9% |
21.7%
6.8 pts better
|
19.8%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 6.6% · Q3 19.4% · Q4 12.9% · 4Q avg 14.9% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
3.7%
3.2 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.9% |
78.1%
11.2 pts worse
|
81.7%
14.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 78.3% · Q2 62.0% · Q3 58.8% · Q4 69.1% · 4Q avg 66.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.6% |
12.5%
1.9 pts better
|
12.0%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.6% · Observed 8.8% · Expected 9.2% · 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 1.8% · Q2 0.0% · 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 | 94.7% |
75.6%
19.1 pts better
|
79.7%
15 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.8% |
25.1%
13.3 pts better
|
23.9%
12.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 8.8% · Expected 17.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-22 · Fire 2023-06-22
4 health deficiencies
Top issue: Environmental (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-05-27 · Fire 2021-05-27
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-04-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-05-16
F · Potential for more than minimal harm
2023-06-22
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 2023-07-21
F · Potential for more than minimal harm
2023-06-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-21
F · Potential for more than minimal harm
2023-06-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-21
E · Potential for more than minimal harm
2021-05-27
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2021-06-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-04-18
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 2024-05-09
E · Potential for more than minimal harm
2024-04-18
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-05-09
E · Potential for more than minimal harm
2024-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-09
D · Potential for more than minimal harm
2024-04-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-05-09
D · Potential for more than minimal harm
2023-06-22
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 2023-07-21
D · Potential for more than minimal harm
2023-06-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-22
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 2023-07-21
D · Potential for more than minimal harm
2023-06-22
F917 · Environmental Deficiencies
Health
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space.
Corrected 2023-07-21
Penalties and ownership
What sits behind the stars
Ownership
Adam, Sandra
Corporate Director · Individual
Arnett, Aric
Operational/Managerial Control · Individual
Belfance, Leslie
Corporate Director · Individual
Gumina, Laurence
Corporate Officer · Individual
Hucek, Peter
Operational/Managerial Control · Individual
Ingwersen, Melissa
Corporate Director · Individual
Joyce, James
Corporate Director · Individual
Stillman, Robert
Corporate Officer · Individual
White, Terry
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Country Club Center V, Inc
Delaware, OH
5-star overall rating with 4-star inspections with 7 recent health deficiencies
#2
Delaware Court Health Care Center
Delaware, OH
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Cherith Care Center At Willow Brook
Delaware, OH
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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