Cycle 1
Health 2023-09-14 · Fire 2023-09-14
4 health deficiencies
Top issue: Administration (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
St Marys, OH
Otterbein St Marys Retirement Community
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
11230 State Route 364, St Marys, OH
(419) 394-6330
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
53
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Otterbein Seniorlife
Operator or chain grouping
Approved since
1994-02-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 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
0.65
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.75
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,059
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9996
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.90
Baseline 20.08% · Performance 19.62% · Measure score 3.90 · Achievement 3.90 · Improvement 1.01
Healthcare-associated infections
3.93
Baseline 6.67% · Performance 6.66% · Measure score 3.93 · Achievement 3.93 · Improvement 0
Total nurse turnover
10
Baseline 35.85% · Performance 20.93% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
0.65
Baseline 3.53 hours · Performance 3.26 hours · Measure score 0.65 · Achievement 0.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 160 · Observed rate 9.38% · Lower 95% interval 7.58% |
| Discharge to community | 57.83% |
50.57%
7.3 pts better
|
No Different than the National Rate · Eligible stays 157 · Observed rate 55.41% · Lower 95% interval 49.86% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 80% |
95.27%
15.3 pts worse
|
Numerator 76 · Denominator 95 |
| Falls with major injury | 3.16% |
0.77%
2.4 pts worse
|
Numerator 3 · Denominator 95 |
| Discharge self-care score | 29.23% |
53.69%
24.5 pts worse
|
Numerator 19 · Denominator 65 |
| Discharge mobility score | 29.23% |
50.94%
21.7 pts worse
|
Numerator 19 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 3.16% |
2.29%
0.9 pts worse
|
Numerator 3 · Denominator 95 · Adjusted rate 3.66% |
| Healthcare-associated infections requiring hospitalization | 6.66% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 5.15% · Lower 95% interval 3.73% |
| Staff COVID-19 vaccination coverage | 6.08% |
8.2%
2.1 pts worse
|
Numerator 9 · Denominator 148 |
| Staff flu vaccination coverage | 13.73% |
42%
28.3 pts worse
|
Numerator 35 · Denominator 255 |
| Discharge function score | 41.54% |
56.45%
14.9 pts worse
|
Numerator 27 · Denominator 65 |
| Transfer of health information to provider | 96.67% |
95.95%
0.7 pts better
|
Numerator 29 · Denominator 30 |
| Transfer of health information to patient | 97.73% |
96.28%
1.5 pts better
|
Numerator 43 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 6 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
92.4%
3.9 pts better
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 94.3% · Q3 96.9% · Q4 97.1% · 4Q avg 96.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.3% |
94.5%
2.2 pts worse
|
95.5%
3.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.3% |
| 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 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.2% |
26.1%
14.9 pts better
|
11.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 9.7% · Q3 13.3% · Q4 12.5% · 4Q avg 11.2% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
6.2%
2.7 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 14.3% · Q3 15.4% · Q4 6.9% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.9% |
25.4%
3.5 pts worse
|
19.6%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.0% · Q2 32.1% · Q3 30.8% · Q4 24.1% · 4Q avg 28.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.4% |
11.5%
5.9 pts worse
|
16.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 22.7% · Q3 29.2% · Q4 4.2% · 4Q avg 17.4% · 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 | 0.0% |
7.7%
7.7 pts better
|
16.3%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.9% |
6.2%
2.3 pts better
|
14.9%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 0.0% · Q3 4.3% · Q4 3.8% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.2%
0.7 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
0.5%
0.3 pts worse
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.2% |
21.7%
3.5 pts worse
|
19.8%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 33.6% · Q3 19.1% · Q4 15.7% · 4Q avg 25.2% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
3.7%
1.2 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 2.0% · Q3 5.8% · Q4 4.1% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
78.1%
15.4 pts better
|
81.7%
11.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 92.1% · Q3 91.8% · Q4 95.3% · 4Q avg 93.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
12.5%
1.7 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 14.9% · Expected 11.7% · 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 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.6% |
75.6%
10 pts better
|
79.7%
5.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.2% |
25.1%
4.1 pts worse
|
23.9%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.2% · Observed 29.9% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-10 · Fire 2021-06-10
7 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-02-21 · Fire 2019-02-21
13 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-09-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-09-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-09-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-09-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-20
F · Potential for more than minimal harm
2021-06-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-07-20
F · Potential for more than minimal harm
2021-06-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-07-20
E · Potential for more than minimal harm
2021-06-10
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 2021-07-20
F · Potential for more than minimal harm
2019-02-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-04-05
F · Potential for more than minimal harm
2019-02-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-04-05
E · Potential for more than minimal harm
2019-02-21
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-04-05
E · Potential for more than minimal harm
2019-02-21
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-04-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-04-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-04-18
D · Potential for more than minimal harm
2024-01-11
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 2024-01-26
G · Actual harm
2023-11-14
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 2023-12-08
D · Potential for more than minimal harm
2023-11-14
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 2023-12-08
E · Potential for more than minimal harm
2023-09-14
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-14
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-14
F849 · Administration Deficiencies
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 2023-10-20
D · Potential for more than minimal harm
2021-06-10
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 2021-07-20
D · Potential for more than minimal harm
2021-06-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-10
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 2021-07-20
D · Potential for more than minimal harm
2021-06-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-07-20
D · Potential for more than minimal harm
2021-06-10
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 2021-07-20
F · Potential for more than minimal harm
2019-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-05
E · Potential for more than minimal harm
2019-02-21
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 2019-04-05
D · Potential for more than minimal harm
2019-02-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-02-21
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 2019-04-05
D · Potential for more than minimal harm
2019-02-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-02-21
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 2019-04-05
D · Potential for more than minimal harm
2019-02-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-02-21
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 2019-04-05
D · Potential for more than minimal harm
2019-02-21
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2019-04-05
D · Potential for more than minimal harm
2019-02-21
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-04-05
Penalties and ownership
What sits behind the stars
Ownership
Otterbein Home
5% Or Greater Indirect Ownership Interest · Organization
Otterbein Lsc LLC
5% Or Greater Direct Ownership Interest · Organization
App, Lynn
Operational/Managerial Control · Individual
Bartlett, Victoria
Operational/Managerial Control · Individual
Bayliff, Becky
Operational/Managerial Control · Individual
Brownson, William
Operational/Managerial Control · Individual
Burke, Daniel
Operational/Managerial Control · Individual
Coleman, Robert
Operational/Managerial Control · Individual
Fraley, Ralph
Operational/Managerial Control · Individual
Functional Pathways Of Tennessee LLC
Operational/Managerial Control · Organization
Glosser, Heidi
Operational/Managerial Control · Individual
Green, James
Operational/Managerial Control · Individual
Green, James
Corporate Officer · Individual
Hawkins, Rita
Operational/Managerial Control · Individual
Hazelbaker, Tomas
Operational/Managerial Control · Individual
Hunter, Rachel
Operational/Managerial Control · Individual
Medaugh, John
Operational/Managerial Control · Individual
Medaugh, John
Corporate Director · Individual
Otterbein Home
Operational/Managerial Control · Organization
Sibert, Tara
Operational/Managerial Control · Individual
Slavik, Bruce
Operational/Managerial Control · Individual
Slavik, Bruce
Corporate Director · Individual
Vonderhaar, Steve
Operational/Managerial Control · Individual
Vonderhaar, Steve
Corporate Director · Individual
Wilson, Jill
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Grande Lake Healthcare Center
St Marys, OH
4-star overall rating with 3-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Vancrest Of St Mary's
St Marys, OH
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Transitional Care Unit
Saint Marys, OH
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out