Cycle 1
Health 2023-01-12 · Fire 2023-01-12
2 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Eaton, OH
Vancrest Health Care Center Of Eaton
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
1600 Park Avenue, Eaton, OH
(937) 456-3010
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
81
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vancrest Health Care Centers
Operator or chain grouping
Approved since
1996-08-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 4 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
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.69
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.14
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,042
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.73% · Performance 21.81% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 4.95% · Performance 7.92% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.80
Baseline 50.00% · Performance 52.24% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Adjusted total nurse staffing
0.74
Baseline 2.67 hours · Performance 3.06 hours · Measure score 0.74 · Achievement 0 · Improvement 0.74
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.49% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 136 · Observed rate 9.56% · Lower 95% interval 7.41% |
| Discharge to community | 47.97% |
50.57%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 43.44% · Lower 95% interval 39.85% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 102 · Denominator 102 |
| Falls with major injury | 2.94% |
0.77%
2.2 pts worse
|
Numerator 3 · Denominator 102 |
| Discharge self-care score | 56.58% |
53.69%
2.9 pts better
|
Numerator 43 · Denominator 76 |
| Discharge mobility score | 57.89% |
50.94%
7 pts better
|
Numerator 44 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 102 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.92% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 8.24% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 4.31% |
8.2%
3.9 pts worse
|
Numerator 5 · Denominator 116 |
| Staff flu vaccination coverage | 41.38% |
42%
0.6 pts worse
|
Numerator 48 · Denominator 116 |
| Discharge function score | 68.42% |
56.45%
12 pts better
|
Numerator 52 · Denominator 76 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 90.48% |
96.28%
5.8 pts worse
|
Numerator 19 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 29.41% |
25.2%
4.2 pts better
|
Numerator 15 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.2 |
1.8
2.4 pts worse
|
1.8
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 3.7 · Expected 1.5 · 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 100.0% · Q2 98.2% · 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 | 4.9% |
3.3%
1.6 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 5.5% · Q3 3.4% · Q4 5.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 96.1% |
26.1%
70 pts worse
|
11.4%
84.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.7% · Q2 98.1% · Q3 98.0% · Q4 100.0% · 4Q avg 96.1% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.2%
0.5 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 6.8% · Q4 11.1% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.8% |
25.4%
12.6 pts better
|
19.6%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 10.8% · Q3 11.4% · Q4 13.2% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.5% |
11.5%
9 pts better
|
16.7%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.3% · Q3 0.0% · Q4 3.3% · 4Q avg 2.5% · 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 | 2.1% |
7.7%
5.6 pts better
|
16.3%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 8.2% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.4% |
6.2%
2.8 pts better
|
14.9%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.4% · Q3 0.0% · Q4 5.3% · 4Q avg 3.4% · 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 | 22.1% |
21.7%
0.4 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.6% · Q2 17.6% · Q3 20.1% · Q4 24.3% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
78.1%
15.8 pts better
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 94.2% · Q3 92.9% · Q4 92.6% · 4Q avg 93.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.0% |
12.5%
0.5 pts worse
|
12.0%
1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.0% · Observed 12.1% · Expected 10.4% · 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 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.4% |
75.6%
17.8 pts better
|
79.7%
13.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.9% |
25.1%
6.8 pts worse
|
23.9%
8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.9% · Observed 26.4% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-03 · Fire 2019-10-03
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2018-08-23 · Fire 2018-08-23
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-01-12
K223 · Egress Deficiencies
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 2023-03-20
F · Potential for more than minimal harm
2023-01-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-01-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-01-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-01-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-01-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-20
F · Potential for more than minimal harm
2023-01-12
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-20
E · Potential for more than minimal harm
2023-01-12
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 2023-03-20
E · Potential for more than minimal harm
2023-01-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-03-20
E · Potential for more than minimal harm
2023-01-12
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-03-20
E · Potential for more than minimal harm
2023-01-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-20
E · Potential for more than minimal harm
2023-01-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-20
E · Potential for more than minimal harm
2023-01-12
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 2023-03-20
E · Potential for more than minimal harm
2023-01-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-20
E · Potential for more than minimal harm
2023-01-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-20
F · Potential for more than minimal harm
2019-10-03
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2020-01-03
E · Potential for more than minimal harm
2019-10-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-01-03
E · Potential for more than minimal harm
2019-10-03
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2020-01-03
E · Potential for more than minimal harm
2019-10-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-01-03
E · Potential for more than minimal harm
2019-10-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-01-03
F · Potential for more than minimal harm
2018-08-23
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2018-09-15
F · Potential for more than minimal harm
2018-08-23
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2018-09-15
F · Potential for more than minimal harm
2018-08-23
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2018-09-15
F · Potential for more than minimal harm
2018-08-23
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2018-09-15
E · Potential for more than minimal harm
2018-08-23
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 2018-09-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
D · Potential for more than minimal harm
2023-01-12
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 2023-03-20
D · Potential for more than minimal harm
2023-01-12
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 2023-03-20
E · Potential for more than minimal harm
2019-10-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2020-01-03
D · Potential for more than minimal harm
2019-10-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2020-01-03
D · Potential for more than minimal harm
2018-08-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-09-15
Penalties and ownership
What sits behind the stars
Ownership
White, Mark
5% Or Greater Direct Ownership Interest · Individual
Bagley, Jon
5% Or Greater Direct Ownership Interest · Individual
Bagley, Jon
Corporate Director · Individual
Dennis, Rosemary
W-2 Managing Employee · Individual
Mccleery, Mark
Corporate Director · Individual
Vancrest Management Corp.
Operational/Managerial Control · Organization
White, Mark
Corporate Director · Individual
Nearby options
Other facilities in reach
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Greenbriar Nursing Center
Eaton, OH
4-star overall rating with 4-star inspections with $28,626 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Maple Gardens Rehabilitiation And Nursing Center
Eaton, OH
2-star overall rating with 3-star inspections with $101,411 in total fines with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Arbor Trace Health & Living Community
Richmond, IN
5-star overall rating with 4-star inspections with 1 fire-safety deficiencies in the latest cycle
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