Cycle 1
Health 2023-09-28 · Fire 2023-09-28
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Delphos, OH
Vancrest Of Delphos
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1425 East Fifth Street, Delphos, OH
(419) 695-2871
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vancrest Health Care Centers
Operator or chain grouping
Approved since
2000-02-04
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
0.41
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.97
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.18
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.21
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.53
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.02
CMS adjusted total nurse staffing hours
Case-mix index
1.44
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
1,415
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
56.84
Composite VBP score used to determine payment impact.
Payment multiplier
1.0120
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.14
Baseline 18.94% · Performance 18.12% · Measure score 7.14 · Achievement 7.14 · Improvement 3.78
Healthcare-associated infections
5.63
Baseline 6.84% · Performance 6.15% · Measure score 5.63 · Achievement 5.63 · Improvement 3.24
Total nurse turnover
8.10
Baseline 36.36% · Performance 30.59% · Measure score 8.10 · Achievement 8.10 · Improvement 4.52
Adjusted total nurse staffing
1.86
Baseline 3.46 hours · Performance 3.61 hours · Measure score 1.86 · Achievement 1.86 · Improvement 0.14
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.67% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 5.43% · Lower 95% interval 6.28% |
| Discharge to community | 68.02% |
50.57%
17.4 pts better
|
Better than the National Rate · Eligible stays 120 · Observed rate 61.67% · Lower 95% interval 57.06% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 98 · Denominator 98 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 98 |
| Discharge self-care score | 70.51% |
53.69%
16.8 pts better
|
Numerator 55 · Denominator 78 |
| Discharge mobility score | 51.28% |
50.94%
0.3 pts better
|
Numerator 40 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 2.04% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 98 · Adjusted rate 2.3% |
| Healthcare-associated infections requiring hospitalization | 6.15% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 3.7% · Lower 95% interval 3.61% |
| Staff COVID-19 vaccination coverage | 2.61% |
8.2%
5.6 pts worse
|
Numerator 4 · Denominator 153 |
| Staff flu vaccination coverage | 29.3% |
42%
12.7 pts worse
|
Numerator 46 · Denominator 157 |
| Discharge function score | 76.92% |
56.45%
20.5 pts better
|
Numerator 60 · Denominator 78 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 61 · Denominator 61 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24.53% |
25.2%
0.7 pts worse
|
Numerator 13 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 2.9% |
3.3%
0.4 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.3% · Q3 1.5% · Q4 2.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 23.0% |
26.1%
3.1 pts better
|
11.4%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 16.1% · Q3 29.5% · Q4 30.6% · 4Q avg 23.0% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
6.2%
0.5 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 3.3% · Q3 5.4% · Q4 6.7% · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.6% |
25.4%
3.2 pts worse
|
19.6%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 32.8% · Q3 28.6% · Q4 21.3% · 4Q avg 28.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.6% |
11.5%
0.1 pts worse
|
16.7%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 15.2% · Q3 10.6% · Q4 8.3% · 4Q avg 11.6% · 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 | 5.1% |
7.7%
2.6 pts better
|
16.3%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.5% · Q3 7.1% · Q4 7.2% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
6.2%
1.1 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 7.5% · Q3 2.0% · Q4 7.1% · 4Q avg 5.1% · 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 | 0.0% |
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 | 25.1% |
21.7%
3.4 pts worse
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 20.6% · Q3 22.9% · Q4 32.9% · 4Q avg 25.1% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
3.7%
2.6 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 2.3% · Q4 1.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
78.1%
20.2 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 96.4% · Q3 98.9% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.6% |
12.5%
6.1 pts worse
|
12.0%
6.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.6% · Observed 18.1% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.2%
0.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 1.8% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.3% |
75.6%
19.7 pts better
|
79.7%
15.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
25.1%
6.8 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 18.1% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-18 · Fire 2021-11-18
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-05-16 · Fire 2019-05-16
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-09-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-02
F · Potential for more than minimal harm
2023-09-28
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-11-02
F · Potential for more than minimal harm
2023-09-28
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 2023-11-02
E · Potential for more than minimal harm
2023-09-28
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 2023-11-02
E · Potential for more than minimal harm
2023-09-28
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 2023-11-02
E · Potential for more than minimal harm
2023-09-28
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 2023-11-02
E · Potential for more than minimal harm
2023-09-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-02
F · Potential for more than minimal harm
2021-11-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-12-13
E · Potential for more than minimal harm
2021-11-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-13
E · Potential for more than minimal harm
2019-05-16
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2019-06-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-09-28
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 2023-11-02
D · Potential for more than minimal harm
2023-09-28
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-11-02
D · Potential for more than minimal harm
2023-09-28
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-11-02
E · Potential for more than minimal harm
2021-11-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-12-13
D · Potential for more than minimal harm
2021-11-18
F657 · Resident Assessment and Care Planning Deficiencies
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 2021-12-13
D · Potential for more than minimal harm
2021-11-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-12-13
E · Potential for more than minimal harm
2019-05-16
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 2019-06-03
D · Potential for more than minimal harm
2019-05-16
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-06-03
D · Potential for more than minimal harm
2019-05-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-03
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
Bagley, Jon
Corporate Officer · Individual
Hershey, Nicole
W-2 Managing Employee · Individual
Murphy, Mickey
W-2 Managing Employee · Individual
Vancrest Management Corp.
Operational/Managerial Control · Organization
White, Mark
Corporate Director · Individual
White, Mark
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Meadows Of Delphos The
Delphos, OH
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Roselawn Manor
Spencerville, OH
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Liberty Retirement Community Of Lima Inc
Lima, OH
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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