Cycle 1
Health 2024-01-18 · Fire 2024-01-18
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Hicksville, OH
Vancrest Of Hicksville
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
601 Defiance Avenue, Hicksville, OH
(419) 542-7795
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
61
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vancrest Health Care Centers
Operator or chain grouping
Approved since
1986-05-19
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
0.59
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,857
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.09
Performance 20.46% · Measure score 2.09 · Achievement 2.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
5.39
Performance 6.22% · Measure score 5.39 · Achievement 5.39 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
7.57
Baseline 36.84% · Performance 32.73% · Measure score 7.57 · Achievement 7.57 · Improvement 2.93
Adjusted total nurse staffing
1.90
Baseline 3.20 hours · Performance 3.62 hours · Measure score 1.90 · Achievement 1.90 · Improvement 1.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.9% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 6.45% · Lower 95% interval 6.03% |
| Discharge to community | 42.87% |
50.57%
7.7 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 34.78% · Lower 95% interval 28.96% |
| 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 66 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 39.13% |
53.69%
14.6 pts worse
|
Numerator 18 · Denominator 46 |
| Discharge mobility score | 56.52% |
50.94%
5.6 pts better
|
Numerator 26 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 2 · Denominator 66 · Adjusted rate 2.82% |
| Healthcare-associated infections requiring hospitalization | 6.22% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 2.38% · Lower 95% interval 2.91% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 93 |
| Staff flu vaccination coverage | 36.56% |
42%
5.4 pts worse
|
Numerator 34 · Denominator 93 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 24 · Denominator 46 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.8
0.3 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.8 · 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 | 97.9% |
94.5%
3.4 pts better
|
95.5%
2.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.3%
2.9 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 6.8% · Q3 5.9% · Q4 4.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 97.2% |
26.1%
71.1 pts worse
|
11.4%
85.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 97.6% · Q3 97.9% · Q4 97.8% · 4Q avg 97.2% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
6.2%
0.1 pts better
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 4.7% · Q3 6.2% · Q4 2.2% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
25.4%
13.1 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 14.0% · Q3 13.7% · Q4 16.7% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.8% |
11.5%
6.7 pts better
|
16.7%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 3.4% · Q3 6.1% · Q4 0.0% · 4Q avg 4.8% · 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 | 4.9% |
7.7%
2.8 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 0.0% · Q3 3.6% · Q4 3.6% · 4Q avg 4.9% · 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 7.1% · Q2 2.4% · Q3 2.0% · Q4 2.2% · 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 | 0.5% |
0.5%
About the same
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
21.7%
7.5 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 36.9% · Q3 21.5% · Q4 30.3% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
3.7%
1.5 pts worse
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.9% · Q3 9.9% · Q4 2.2% · 4Q avg 5.2% · Used in QM five-star |
| 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 | 7.4% |
12.5%
5.1 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.1% · Expected 10.7% · 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 | 81.4% |
75.6%
5.8 pts better
|
79.7%
1.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.2% |
25.1%
13.1 pts worse
|
23.9%
14.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.2% · Observed 37.5% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-06 · Fire 2021-05-06
6 health deficiencies
Top issue: Administration (2 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-09-05 · Fire 2019-09-05
2 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-27
F · Potential for more than minimal harm
2024-01-18
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 2024-02-27
F · Potential for more than minimal harm
2024-01-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-18
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-27
F · Potential for more than minimal harm
2021-05-06
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-06
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-06
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-06
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-06
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-06-20
F · Potential for more than minimal harm
2021-05-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-20
E · Potential for more than minimal harm
2021-05-06
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 2021-06-20
E · Potential for more than minimal harm
2021-05-06
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-06-20
E · Potential for more than minimal harm
2021-05-06
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-06-20
E · Potential for more than minimal harm
2021-05-06
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 2021-06-20
F · Potential for more than minimal harm
2019-09-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-21
F · Potential for more than minimal harm
2019-09-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-01
E · Potential for more than minimal harm
2019-09-05
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 2019-09-21
E · Potential for more than minimal harm
2019-09-05
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 2019-09-21
E · Potential for more than minimal harm
2019-09-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-09-21
E · Potential for more than minimal harm
2019-09-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-09-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-02
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-05-13
F · Potential for more than minimal harm
2024-01-18
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 2024-02-27
D · Potential for more than minimal harm
2024-01-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-27
E · Potential for more than minimal harm
2021-05-06
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2021-06-20
D · Potential for more than minimal harm
2021-05-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-06-20
D · Potential for more than minimal harm
2021-05-06
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 2021-06-20
D · Potential for more than minimal harm
2021-05-06
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-06-20
D · Potential for more than minimal harm
2021-05-06
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2021-06-20
C · Minimal harm
2021-05-06
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2021-06-11
D · Potential for more than minimal harm
2019-09-05
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2019-09-21
D · Potential for more than minimal harm
2019-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-21
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
Myers, Mark
5% Or Greater Direct Ownership Interest · Individual
White, Nicolaus
5% Or Greater Direct Ownership Interest · Individual
Gehl, Jacob
5% Or Greater Direct Ownership Interest · Individual
Mccleery, Mark
5% Or Greater Direct Ownership Interest · Individual
White, Carol
5% Or Greater Direct Ownership Interest · Individual
Bagley, Jon
Corporate Officer · Individual
Bradford, Martha
W-2 Managing Employee · Individual
Gehl, Jacob
Corporate Officer · Individual
Mccleery, Mark
Corporate Officer · Individual
Myers, Mark
Corporate Officer · Individual
Vancrest Management Corp.
Operational/Managerial Control · Organization
White, Carol
Corporate Officer · Individual
White, Claire
5% Or Greater Direct Ownership Interest · Individual
White, Claire
Corporate Officer · Individual
White, Mark
Corporate Officer · Individual
White, Nicolaus
Corporate Officer · Individual
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