Cycle 1
Health 2023-07-27 · Fire 2023-07-27
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Spencerville, OH
Roselawn Manor
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
420 East Fourth Street, Spencerville, OH
(419) 647-4115
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
49
Certified beds
Average residents
44
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hcf Management
Operator or chain grouping
Approved since
1989-08-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 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
0.78
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,465
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9928
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.37
Baseline 19.50% · Performance 19.41% · Measure score 4.37 · Achievement 4.37 · Improvement 0
Healthcare-associated infections
3.72
Baseline 7.35% · Performance 6.72% · Measure score 3.72 · Achievement 3.72 · Improvement 2.16
Total nurse turnover
7.85
Baseline 47.73% · Performance 31.58% · Measure score 7.85 · Achievement 7.85 · Improvement 6.56
Adjusted total nurse staffing
0
Baseline 3.30 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.58% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 12.5% · Lower 95% interval 7.4% |
| Discharge to community | 44.32% |
50.57%
6.2 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 35.56% · Lower 95% interval 32.19% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 90.63% |
95.27%
4.6 pts worse
|
Numerator 29 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 11 · Denominator 22 |
| Discharge mobility score | 27.27% |
50.94%
23.7 pts worse
|
Numerator 6 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 6.25% |
2.29%
4 pts worse
|
Numerator 2 · Denominator 32 · Adjusted rate 5.61% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.29% |
| Staff COVID-19 vaccination coverage | 0.83% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 121 |
| Staff flu vaccination coverage | 44.63% |
42%
2.6 pts better
|
Numerator 54 · Denominator 121 |
| Discharge function score | 27.27% |
56.45%
29.2 pts worse
|
Numerator 6 · Denominator 22 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · 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
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 2.5 · Expected 3.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.6 · Expected 2.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
92.4%
6.9 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.3% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
94.5%
2.9 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.3%
2.6 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.8% |
26.1%
15.3 pts better
|
11.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 8.8% · Q3 13.9% · Q4 5.4% · 4Q avg 10.8% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
6.2%
0.6 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 6.2% · Q3 3.2% · Q4 3.2% · 4Q avg 5.6% |
| 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 28.1% · Q2 34.4% · Q3 25.0% · Q4 28.1% · 4Q avg 28.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
11.5%
5.4 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.7% · Q3 4.5% · Q4 3.6% · 4Q avg 6.1% · 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 | 10.4% |
7.7%
2.7 pts worse
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 15.5% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
6.2%
0.9 pts worse
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 10.7% · Q3 0.0% · Q4 6.9% · 4Q avg 7.1% · 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 | 0.7% |
0.5%
0.2 pts worse
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.7% |
21.7%
13 pts better
|
19.8%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 6.9% · Q3 6.7% · Q4 9.4% · 4Q avg 8.7% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
3.7%
2.2 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 5.9% · Q3 7.8% · Q4 0.0% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.9% |
78.1%
11.8 pts better
|
81.7%
8.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 92.5% · Q3 82.9% · Q4 86.1% · 4Q avg 89.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.9% |
12.5%
3.6 pts better
|
12.0%
3.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 8.7% · Expected 11.0% · 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 | 84.2% |
75.6%
8.6 pts better
|
79.7%
4.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.9% |
25.1%
9.2 pts better
|
23.9%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 17.4% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-03 · Fire 2021-06-03
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-02-21 · Fire 2019-02-21
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-07-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-07-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-07-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-07-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-07-27
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-09-27
F · Potential for more than minimal harm
2023-07-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-06
E · Potential for more than minimal harm
2023-07-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-27
E · Potential for more than minimal harm
2023-07-27
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-11-06
F · Potential for more than minimal harm
2021-06-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-07-30
E · Potential for more than minimal harm
2021-06-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-07-30
F · Potential for more than minimal harm
2019-02-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-03-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2023-07-27
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 2023-09-27
D · Potential for more than minimal harm
2023-07-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-07-27
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-07-27
F758 · Pharmacy Service Deficiencies
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 2023-09-27
D · Potential for more than minimal harm
2023-07-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-27
D · Potential for more than minimal harm
2019-02-21
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-03-22
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 2019-03-22
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 2019-03-22
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 2019-03-22
D · Potential for more than minimal harm
2019-02-21
F625 · Resident Rights Deficiencies
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 2019-03-22
D · Potential for more than minimal harm
2019-02-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-03-22
D · Potential for more than minimal harm
2019-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-22
Penalties and ownership
What sits behind the stars
Ownership
Hcf Operations, Inc
5% Or Greater Direct Ownership Interest · Organization
Chad M. Unverferth 12-14-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
David V. Unverferth 12-14-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
Hcf Management, Inc.
Operational/Managerial Control · Organization
Hcf, Inc
5% Or Greater Indirect Ownership Interest · Organization
Jeffrey L. Unverferth 12-14-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-29-04 Revocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kendra M. U
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kerri A. Ro
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kevan R. Un
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kristen S.
5% Or Greater Indirect Ownership Interest · Organization
Joann C. Unverferth 12-31-12 Irrevocable Grantor Trust Fbo Kyle J. Unv
5% Or Greater Indirect Ownership Interest · Organization
Joseph L. Unverferth 12-15-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
Klay, Celeste
Corporate Director · Individual
Klay, Celeste
Corporate Officer · Individual
Klay, Celeste
W-2 Managing Employee · Individual
Lawrence G. Unverferth 12-13-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
R. Steven Unverferth 12-14-11 Irrv Grantor Tr
5% Or Greater Indirect Ownership Interest · Organization
Romes, Kerri
Corporate Director · Individual
Romes, Kerri
Corporate Officer · Individual
Romes, Kerri
W-2 Managing Employee · Individual
Schwinnen, Samantha
Corporate Director · Individual
Schwinnen, Samantha
W-2 Managing Employee · Individual
Shaw, Anthony
Corporate Officer · Individual
Shaw, Anthony
W-2 Managing Employee · Individual
Unverferth, Chad
Corporate Officer · Individual
Unverferth, Chad
W-2 Managing Employee · Individual
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