New Carlisle, OH

Vancrest Of New Carlisle

5-star overall rating with 4-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

1885 N Dayton Lakeview Rd, New Carlisle, OH

(937) 845-8219

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 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

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Vancrest Health Care Centers

Operator or chain grouping

Approved since

1997-01-09

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

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

0.39

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.17

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.43

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.99

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.56

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.66

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.20

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

0.33

CMS adjusted RN staffing hours

Adjusted total hours

3.39

CMS adjusted total nurse staffing hours

Case-mix index

1.61

Higher values indicate more complex resident acuity

RN turnover

50%

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

12,567

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

11.66

Composite VBP score used to determine payment impact.

Payment multiplier

0.9810

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 20.78% · Performance 22.29% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.90

Baseline 5.32% · Performance 7.27% · Measure score 1.90 · Achievement 1.90 · Improvement 0

Total nurse turnover

2.21

Baseline 44.00% · Performance 54.65% · Measure score 2.21 · Achievement 2.21 · Improvement 0

Adjusted total nurse staffing

0.55

Baseline 3.12 hours · Performance 3.24 hours · Measure score 0.55 · Achievement 0.55 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.13%	10.72% 0.6 pts better	No Different than the National Rate · Eligible stays 137 · Observed rate 9.49% · Lower 95% interval 7.65%
Discharge to community	59.48%	50.57% 8.9 pts better	No Different than the National Rate · Eligible stays 122 · Observed rate 56.56% · Lower 95% interval 49.53%
Medicare spending per beneficiary	0.85	1.02 0.2 pts better
Drug regimen review with follow-up	98.72%	95.27% 3.5 pts better	Numerator 77 · Denominator 78
Falls with major injury	1.28%	0.77% 0.5 pts worse	Numerator 1 · Denominator 78
Discharge self-care score	63.46%	53.69% 9.8 pts better	Numerator 33 · Denominator 52
Discharge mobility score	61.54%	50.94% 10.6 pts better	Numerator 32 · Denominator 52
Pressure ulcers or injuries, new or worsened	3.85%	2.29% 1.6 pts worse	Numerator 3 · Denominator 78 · Adjusted rate 4.71%
Healthcare-associated infections requiring hospitalization	7.27%	7.12% 0.1 pts worse	No Different than the National Rate · Eligible stays 81 · Observed rate 7.41% · Lower 95% interval 4.51%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 143
Staff flu vaccination coverage	10.78%	42% 31.2 pts worse	Numerator 18 · Denominator 167
Discharge function score	51.92%	56.45% 4.5 pts worse	Numerator 27 · Denominator 52
Transfer of health information to provider	87.23%	95.95% 8.7 pts worse	Numerator 41 · Denominator 47
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 18 · 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 34

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
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 98.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	96.9%	94.5% 2.4 pts better	95.5% 1.4 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9%
Percentage of long-stay residents experiencing one or more falls with major injury	2.2%	3.3% 1.1 pts better	3.3% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 1.7% · Q3 1.9% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	69.0%	26.1% 42.9 pts worse	11.4% 57.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 80.9% · Q3 33.3% · Q4 59.3% · 4Q avg 69.0%
Percentage of long-stay residents who lose too much weight	8.7%	6.2% 2.5 pts worse	5.4% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 3.0% · Q3 5.6% · Q4 16.7% · 4Q avg 8.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	27.6%	25.4% 2.2 pts worse	19.6% 8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 37.1% · Q3 25.0% · Q4 18.6% · 4Q avg 27.6%
Percentage of long-stay residents who received an antipsychotic medication	9.1%	11.5% 2.4 pts better	16.7% 7.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 7.4% · Q3 10.0% · Q4 6.5% · 4Q avg 9.1% · 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	14.9%	7.7% 7.2 pts worse	16.3% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 14.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	7.0%	6.2% 0.8 pts worse	14.9% 7.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 9.1% · Q3 2.9% · Q4 2.6% · 4Q avg 7.0% · 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	0.4%	0.5% 0.1 pts better	1.7% 1.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	26.1%	21.7% 4.4 pts worse	19.8% 6.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 18.3% · Q3 26.6% · Q4 25.3% · 4Q avg 26.1%
Percentage of long-stay residents with pressure ulcers	3.5%	3.7% 0.2 pts better	5.1% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 4.2% · Q4 5.2% · 4Q avg 3.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.2%	78.1% 18.1 pts better	81.7% 14.5 pts better	Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 94.4% · Q3 94.3% · Q4 97.1% · 4Q avg 96.2%
Percentage of short-stay residents who had an outpatient emergency department visit	5.4%	12.5% 7.1 pts better	12.0% 6.6 pts better	Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 5.2% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	3.4%	1.2% 2.2 pts worse	1.6% 1.8 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.2% · Q3 3.0% · Q4 2.7% · 4Q avg 3.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	90.9%	75.6% 15.3 pts better	79.7% 11.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	29.5%	25.1% 4.4 pts worse	23.9% 5.6 pts worse	Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 29.3% · Expected 23.7% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-02-16 · Fire 2023-02-16

6 health deficiencies

Top issue: Resident Rights (3 deficiencies)

6 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Cycle 2 Health 2021-05-10 · Fire 2021-05-10

3 health deficiencies

Top issue: Resident Rights (2 deficiencies)

15 fire-safety deficiencies

Top issue: Smoke (7 deficiencies)

Cycle 3 Health 2019-06-13 · Fire 2019-06-13

7 health deficiencies

Top issue: Resident Rights (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-02-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-03-31

E · Potential for more than minimal harm 2023-02-16

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 2023-03-31

E · Potential for more than minimal harm 2023-02-16

K226 · Egress Deficiencies

Fire Safety

Have horizontal exits used in accordance with safety requirements.

Corrected 2023-03-31

E · Potential for more than minimal harm 2023-02-16

K281 · Egress Deficiencies

Fire Safety

Install proper backup exit lighting.

Corrected 2023-03-31

E · Potential for more than minimal harm 2023-02-16

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-03-31

E · Potential for more than minimal harm 2023-02-16

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2023-03-31

F · Potential for more than minimal harm 2021-05-10

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2021-08-06

F · Potential for more than minimal harm 2021-05-10

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2021-08-06

F · Potential for more than minimal harm 2021-05-10

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-08-06

F · Potential for more than minimal harm 2021-05-10

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2021-08-06

F · Potential for more than minimal harm 2021-05-10

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2021-08-06

F · Potential for more than minimal harm 2021-05-10

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2021-08-06

F · Potential for more than minimal harm 2021-05-10

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2021-08-06

E · Potential for more than minimal harm 2021-05-10

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2021-08-06

E · Potential for more than minimal harm 2021-05-10

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2021-08-06

E · Potential for more than minimal harm 2021-05-10

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 2021-08-06

E · Potential for more than minimal harm 2021-05-10

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2021-08-06

E · Potential for more than minimal harm 2021-05-10

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2021-08-06

E · Potential for more than minimal harm 2021-05-10

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 2021-08-06

D · Potential for more than minimal harm 2021-05-10

K928 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.

Corrected 2021-08-06

B · Minimal harm 2021-05-10

K753 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of highly flammable decorations.

Corrected 2021-08-06

F · Potential for more than minimal harm 2019-06-13

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2019-07-26

F · Potential for more than minimal harm 2019-06-13

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2019-07-26

F · Potential for more than minimal harm 2019-06-13

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2019-07-26

E · Potential for more than minimal harm 2019-06-13

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 2019-07-26

E · Potential for more than minimal harm 2019-06-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-07-26

Inspection history

Recent health citations

D · Potential for more than minimal harm 2024-06-03

F559 · Resident Rights Deficiencies

Health

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Corrected 2024-07-10

D · Potential for more than minimal harm 2024-06-03

F624 · Resident Rights Deficiencies

Health

Prepare residents for a safe transfer or discharge from the nursing home.

Corrected 2024-07-10

D · Potential for more than minimal harm 2024-06-03

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-07-10

E · Potential for more than minimal harm 2023-02-16

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 2023-03-31

D · Potential for more than minimal harm 2023-02-16

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-03-31

D · Potential for more than minimal harm 2023-02-16

F564 · Resident Rights Deficiencies

Health

Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges.

Corrected 2023-03-31

D · Potential for more than minimal harm 2023-02-16

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2023-03-31

D · Potential for more than minimal harm 2023-02-16

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2023-03-31

D · Potential for more than minimal harm 2023-02-16

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2023-03-31

E · Potential for more than minimal harm 2019-06-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-07-26

D · Potential for more than minimal harm 2019-06-13

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 2019-07-26

D · Potential for more than minimal harm 2019-06-13

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2019-07-26

D · Potential for more than minimal harm 2019-06-13

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2019-07-26

D · Potential for more than minimal harm 2019-06-13

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 2019-07-26

D · Potential for more than minimal harm 2019-06-13

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2019-07-26

D · Potential for more than minimal harm 2019-06-13

F825 · Quality of Life and Care Deficiencies

Health

Provide or get specialized rehabilitative services as required for a resident.

Corrected 2019-07-26

Penalties and ownership