9 health deficiencies
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Edgerton, OH
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
328 West Vine Street, Edgerton, OH
(419) 298-2321
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
74
Certified beds
Average residents
58
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Exceptional Living Centers
Operator or chain grouping
Approved since
1981-10-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 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
RN hours / resident day
0.41
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.25
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
4,658
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9921
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0.51
Baseline 18.96% · Performance 21.20% · Measure score 0.51 · Achievement 0.51 · Improvement 0
Healthcare-associated infections
7.01
Baseline 6.42% · Performance 5.74% · Measure score 7.01 · Achievement 7.01 · Improvement 4.26
Total nurse turnover
5.97
Baseline 55.00% · Performance 39.29% · Measure score 5.97 · Achievement 5.97 · Improvement 4.71
Adjusted total nurse staffing
2.14
Baseline 3.12 hours · Performance 3.69 hours · Measure score 2.14 · Achievement 2.14 · Improvement 1.63
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.73% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 4.65% · Lower 95% interval 6.21% |
| Discharge to community | 45.82% |
50.57%
4.8 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 36.67% · Lower 95% interval 32.17% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 75.86% |
95.27%
19.4 pts worse
|
Numerator 22 · Denominator 29 |
| Falls with major injury | 3.45% |
0.77%
2.7 pts worse
|
Numerator 1 · Denominator 29 |
| Discharge self-care score | 65% |
53.69%
11.3 pts better
|
Numerator 13 · Denominator 20 |
| Discharge mobility score | 65% |
50.94%
14.1 pts better
|
Numerator 13 · Denominator 20 |
| Pressure ulcers or injuries, new or worsened | 10.34% |
2.29%
8.1 pts worse
|
Numerator 3 · Denominator 29 · Adjusted rate 12.45% |
| Healthcare-associated infections requiring hospitalization | 5.74% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 0% · Lower 95% interval 2.75% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 73 |
| Staff flu vaccination coverage | 27.63% |
42%
14.4 pts worse
|
Numerator 21 · Denominator 76 |
| Discharge function score | 65% |
56.45%
8.5 pts better
|
Numerator 13 · Denominator 20 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · 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 15 · Too few residents or stays to report publicly. |
Quality measures
| 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 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
92.4%
1.1 pts better
|
93.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.4% · Q2 92.6% · Q3 92.5% · Q4 94.4% · 4Q avg 93.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.5%
3.8 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.3%
0.9 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.7% · Q3 3.8% · Q4 5.6% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.4% |
26.1%
6.7 pts better
|
11.4%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 15.4% · Q3 19.5% · Q4 30.0% · 4Q avg 19.4% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.2%
0.3 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 8.0% · Q3 3.9% · Q4 9.8% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
25.4%
0.6 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 21.2% · Q3 29.4% · Q4 23.1% · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.0% |
11.5%
6.5 pts better
|
16.7%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.6% · Q3 6.7% · Q4 3.2% · 4Q avg 5.0% · 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 | 8.0% |
7.7%
0.3 pts worse
|
16.3%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 12.5% · Q3 3.1% · Q4 5.9% · 4Q avg 8.0% · 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 1.9% · Q2 6.0% · Q3 7.8% · Q4 9.6% · 4Q avg 6.3% · 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 | 24.3% |
21.7%
2.6 pts worse
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 29.8% · Q3 22.1% · Q4 26.8% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 0.6% |
3.7%
3.1 pts better
|
5.1%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.8% |
78.1%
11.7 pts better
|
81.7%
8.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.3% · Q2 84.2% · Q3 94.3% · Q4 95.0% · 4Q avg 89.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.7% |
12.5%
8.8 pts better
|
12.0%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.7% · Observed 4.2% · Expected 12.6% · 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 · 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 | 58.3% |
75.6%
17.3 pts worse
|
79.7%
21.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.9% |
25.1%
13.2 pts better
|
23.9%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.9% · Observed 12.5% · Expected 25.1% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Environmental (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Use approved construction type or materials.
Corrected 2023-06-23
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 2023-06-23
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-23
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-06-23
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-06-23
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-23
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-06-23
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-23
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 2020-01-20
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 2020-01-20
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-01-20
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-01-20
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-07
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 2026-01-07
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-08-09
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-09
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-06-23
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-23
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-06-23
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 2023-06-23
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-23
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-06-23
Health
Implement a program that monitors antibiotic use.
Corrected 2023-06-23
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 2023-04-03
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-01-20
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 2020-01-20
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2018-12-26
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2018-12-26
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
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