Cycle 1
Health 2023-08-01 · Fire 2023-08-01
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Saint Marys, OH
Transitional Care Unit
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
200 St Clair Street, Saint Marys, OH
(419) 394-3335
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
15
Certified beds
Average residents
4
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-09-17
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
8,198
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 22.13% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.50
Baseline 7.22% · Performance 6.19% · Measure score 5.50 · Achievement 5.50 · Improvement 4.14
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 7.29% · Lower 95% interval 6.66% |
| Discharge to community | 73.18% |
50.57%
22.6 pts better
|
Better than the National Rate · Eligible stays 86 · Observed rate 81.4% · Lower 95% interval 65.91% |
| Medicare spending per beneficiary | 0.54 |
1.02
0.5 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 62 · Denominator 62 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 62 |
| Discharge self-care score | 25.42% |
53.69%
28.3 pts worse
|
Numerator 15 · Denominator 59 |
| Discharge mobility score | 8.47% |
50.94%
42.5 pts worse
|
Numerator 5 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 62 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.19% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 1.92% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 325 |
| Staff flu vaccination coverage | 67.24% |
42%
25.2 pts better
|
Numerator 275 · Denominator 409 |
| Discharge function score | 15.25% |
56.45%
41.2 pts worse
|
Numerator 9 · Denominator 59 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 38 · Denominator 38 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 17.95% |
25.2%
7.2 pts worse
|
Numerator 7 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
78.1%
21.9 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.5% |
12.5%
5 pts worse
|
12.0%
5.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 15.8% · Expected 10.1% · 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 | 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 | 23.1% |
25.1%
2 pts better
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 15.8% · Expected 16.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-12 · Fire 2020-02-12
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-12-27 · Fire 2018-12-27
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-08-01
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 2023-09-15
F · Potential for more than minimal harm
2023-08-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-15
F · Potential for more than minimal harm
2023-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-15
E · Potential for more than minimal harm
2023-08-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-08-01
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 2023-09-15
D · Potential for more than minimal harm
2020-02-12
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2020-02-28
F · Potential for more than minimal harm
2018-12-27
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 2019-02-15
C · Minimal harm
2018-12-27
F584 · Resident Rights Deficiencies
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 2019-02-15
Penalties and ownership
What sits behind the stars
Ownership
Hospital District Of Jackson, German, Noble, And St. Marys Townships
5% Or Greater Direct Ownership Interest · Organization
Berning, Cynthia
Operational/Managerial Control · Individual
Berning, Cynthia
Corporate Officer · Individual
Boley, Michael
Corporate Director · Individual
Chalasani, Venkata
Operational/Managerial Control · Individual
Coe, Claudia
Corporate Director · Individual
Fox, Kenneth
Corporate Director · Individual
Hinders, Lana
Operational/Managerial Control · Individual
Hoying, Isaac
Corporate Director · Individual
Jtd Hospital Foundation
Operational/Managerial Control · Organization
Jtdm Family Practice LLC
Operational/Managerial Control · Organization
Niekamp, Randall
Corporate Director · Individual
Pohl, Tricia
Operational/Managerial Control · Individual
Pohl, Tricia
Corporate Officer · Individual
Schlosser, Brian
Corporate Director · Individual
Squire, Jeffrey
Corporate Director · Individual
Stucke, Christopher
Corporate Director · Individual
Vordermark, Sara
Operational/Managerial Control · Individual
Wagner, Wally
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
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
#2
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
#3
Otterbein St Marys Retirement Community
St Marys, OH
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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