3 health deficiencies
Top issue: Environmental (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Sandusky, OH
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
3800 Boardwalk Blvd, Sandusky, OH
(419) 621-1900
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
84
Certified beds
Average residents
72
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
United Church Homes
Operator or chain grouping
Approved since
1995-04-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 3 overall / 3 health / 3 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
RN hours / resident day
0.80
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.80
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.42
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.88
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.51
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
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.51
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
37%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
4,494
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.76
Composite VBP score used to determine payment impact.
Payment multiplier
0.9927
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.38
Baseline 17.76% · Performance 20.33% · Measure score 2.38 · Achievement 2.38 · Improvement 0
Healthcare-associated infections
7.04
Baseline 6.16% · Performance 5.73% · Measure score 7.04 · Achievement 7.04 · Improvement 3.19
Total nurse turnover
2.56
Baseline 29.89% · Performance 53.21% · Measure score 2.56 · Achievement 2.56 · Improvement 0
Adjusted total nurse staffing
3.92
Baseline 4.07 hours · Performance 4.19 hours · Measure score 3.92 · Achievement 3.92 · Improvement 0.24
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 134 · Observed rate 10.45% · Lower 95% interval 7.68% |
| Discharge to community | 57.09% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 137 · Observed rate 53.28% · Lower 95% interval 49.69% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.67% |
95.27%
2.4 pts better
|
Numerator 84 · Denominator 86 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 86 |
| Discharge self-care score | 56.52% |
53.69%
2.8 pts better
|
Numerator 39 · Denominator 69 |
| Discharge mobility score | 56.52% |
50.94%
5.6 pts better
|
Numerator 39 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 1.16% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 86 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 5.73% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 2% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 1.38% |
8.2%
6.8 pts worse
|
Numerator 3 · Denominator 218 |
| Staff flu vaccination coverage | 47.22% |
42%
5.2 pts better
|
Numerator 102 · Denominator 216 |
| Discharge function score | 62.32% |
56.45%
5.9 pts better
|
Numerator 43 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 50 · Denominator 50 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 18.6% |
25.2%
6.6 pts worse
|
Numerator 8 · Denominator 43 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
92.4%
7.2 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 5.6% |
3.3%
2.3 pts worse
|
3.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 8.5% · Q3 5.4% · Q4 5.3% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.1% |
26.1%
25 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.4% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
6.2%
2.5 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 7.7% · Q3 8.0% · Q4 10.0% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.6% |
25.4%
6.8 pts better
|
19.6%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 22.6% · Q3 12.0% · Q4 10.0% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
11.5%
0.9 pts worse
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 16.3% · Q3 12.2% · Q4 9.1% · 4Q avg 12.4% · 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 | 7.4% |
7.7%
0.3 pts better
|
16.3%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 14.0% · Q3 8.5% · Q4 3.7% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.5% |
6.2%
0.7 pts better
|
14.9%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 9.8% · Q3 8.7% · Q4 2.2% · 4Q avg 5.5% · 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 | 0.4% |
0.5%
0.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.3% |
21.7%
11.6 pts worse
|
19.8%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.3% · Q2 38.8% · Q3 38.6% · Q4 16.2% · 4Q avg 33.3% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
3.7%
0.4 pts worse
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.5% · Q3 2.8% · Q4 6.3% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
78.1%
21.7 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.2% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.8% |
12.5%
6.7 pts better
|
12.0%
6.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.8% · Observed 6.0% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
75.6%
22.8 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.6% |
25.1%
6.5 pts better
|
23.9%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 20.2% · Expected 26.0% · Used in QM five-star |
Survey summary
Top issue: Environmental (2 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Infection Control (2 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-20
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-20
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-20
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-20
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-11-20
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-20
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-20
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 2022-05-06
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-06
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-05-06
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-05-06
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-05-06
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-05-06
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-05-06
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-05-06
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-05-06
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-05-06
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-05-06
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-05-14
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 2019-05-14
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-05-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-05-14
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-05-14
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-20
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-11-20
Health
Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
Corrected 2024-11-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-19
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-01
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-05-06
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-05-06
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 2022-05-06
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-05-06
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-05-06
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 2022-05-06
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-05-06
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-05-06
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-05-06
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-14
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2019-05-14
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-05-14
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 2019-05-14
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-05-14
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 2019-05-14
Penalties and ownership
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
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Sandusky, OH
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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