Upper Sandusky, OH

Vancrest Of Upper Sandusky

4-star overall rating with 3-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

850 Marseilles Avenue, Upper Sandusky, OH

(419) 294-4973

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

99

Certified beds

Average residents

92

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Vancrest Health Care Centers

Operator or chain grouping

Approved since

1980-04-03

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

0.75

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

2.30

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.86

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

3.49

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.37

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

0.74

CMS adjusted RN staffing hours

Adjusted total hours

3.82

CMS adjusted total nurse staffing hours

Case-mix index

1.38

Higher values indicate more complex resident acuity

RN turnover

29%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

56%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

1,973

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

Performance score

52.53

Composite VBP score used to determine payment impact.

Payment multiplier

1.0071

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6

Baseline 23.10% · Performance 19.15% · Measure score 6 · Achievement 4.92 · Improvement 6

Healthcare-associated infections

5

Baseline 8.23% · Performance 6.45% · Measure score 5 · Achievement 4.63 · Improvement 5

Total nurse turnover

7.21

Baseline 49.30% · Performance 34.21% · Measure score 7.21 · Achievement 7.21 · Improvement 5.67

Adjusted total nurse staffing

2.81

Baseline 2.57 hours · Performance 3.63 hours · Measure score 2.81 · Achievement 1.94 · Improvement 2.81

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.51%	10.72% 0.2 pts better	No Different than the National Rate · Eligible stays 85 · Observed rate 9.41% · Lower 95% interval 6.97%
Discharge to community	55.15%	50.57% 4.6 pts better	No Different than the National Rate · Eligible stays 70 · Observed rate 51.43% · Lower 95% interval 42.59%
Medicare spending per beneficiary	1.2	1.02 0.2 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 50 · Denominator 50
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 50
Discharge self-care score	38.71%	53.69% 15 pts worse	Numerator 12 · Denominator 31
Discharge mobility score	61.29%	50.94% 10.4 pts better	Numerator 19 · Denominator 31
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 50 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.45%	7.12% 0.7 pts better	No Different than the National Rate · Eligible stays 46 · Observed rate 4.35% · Lower 95% interval 3.16%
Staff COVID-19 vaccination coverage	1.65%	8.2% 6.5 pts worse	Numerator 2 · Denominator 121
Staff flu vaccination coverage	47.53%	42% 5.5 pts better	Numerator 77 · Denominator 162
Discharge function score	61.29%	56.45% 4.8 pts better	Numerator 19 · Denominator 31
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	12%	25.2% 13.2 pts worse	Numerator 3 · Denominator 25

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.0	1.8 0.2 pts worse	1.9 0.1 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.0	1.8 2.2 pts worse	1.8 2.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 3.3 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.7%	92.4% 7.3 pts better	93.4% 6.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7%
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	1.9%	3.3% 1.4 pts better	3.3% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.3% · Q3 2.6% · Q4 1.2% · 4Q avg 1.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	5.0%	26.1% 21.1 pts better	11.4% 6.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.0% · Q3 6.9% · Q4 4.0% · 4Q avg 5.0%
Percentage of long-stay residents who lose too much weight	6.2%	6.2% About the same	5.4% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 10.3% · Q3 4.3% · Q4 5.6% · 4Q avg 6.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	34.3%	25.4% 8.9 pts worse	19.6% 14.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.2% · Q2 35.3% · Q3 35.7% · Q4 30.1% · 4Q avg 34.3%
Percentage of long-stay residents who received an antipsychotic medication	10.3%	11.5% 1.2 pts better	16.7% 6.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 14.0% · Q3 9.4% · Q4 7.7% · 4Q avg 10.3% · 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	12.4%	7.7% 4.7 pts worse	16.3% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 28.3% · Q3 5.3% · Q4 6.7% · 4Q avg 12.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	9.2%	6.2% 3 pts worse	14.9% 5.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 14.5% · Q3 1.6% · Q4 7.1% · 4Q avg 9.2% · 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	1.0%	0.5% 0.5 pts worse	1.7% 0.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.8%	21.7% 7.9 pts better	19.8% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 20.2% · Q3 7.6% · Q4 3.7% · 4Q avg 13.8%
Percentage of long-stay residents with pressure ulcers	3.3%	3.7% 0.4 pts better	5.1% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 2.4% · Q3 4.0% · Q4 2.2% · 4Q avg 3.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.6%	78.1% 19.5 pts better	81.7% 15.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 93.8% · Q3 98.6% · Q4 100.0% · 4Q avg 97.6%
Percentage of short-stay residents who had an outpatient emergency department visit	6.9%	12.5% 5.6 pts better	12.0% 5.1 pts better	Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 6.8% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.3%	1.2% 0.1 pts worse	1.6% 0.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 2.1% · 4Q avg 1.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	87.7%	75.6% 12.1 pts better	79.7% 8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 87.7%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	18.5%	25.1% 6.6 pts better	23.9% 5.4 pts better	Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 18.2% · Expected 23.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-10-26 · Fire 2023-10-26

8 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

7 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 2 Health 2021-07-06 · Fire 2021-07-06

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2019-03-21 · Fire 2019-03-21

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-10-26

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-11-17

F · Potential for more than minimal harm 2023-10-26

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-11-17

F · Potential for more than minimal harm 2023-10-26

K521 · Services Deficiencies

Fire Safety

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

Corrected 2023-11-17

F · Potential for more than minimal harm 2023-10-26

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-10-26

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 2023-11-17

E · Potential for more than minimal harm 2023-10-26

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-10-26

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2023-11-17

E · Potential for more than minimal harm 2021-07-06

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 2021-08-23

E · Potential for more than minimal harm 2021-07-06

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2021-08-23

E · Potential for more than minimal harm 2021-07-06

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-08-23

E · Potential for more than minimal harm 2021-07-06

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-08-23

F · Potential for more than minimal harm 2019-03-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-04-26

Inspection history

Recent health citations

F · Potential for more than minimal harm 2023-10-26

F851 · Administration Deficiencies

Health

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Corrected 2023-06-01

E · Potential for more than minimal harm 2023-10-26

F569 · Resident Rights Deficiencies

Health

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-10-26

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-26

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-26

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-26

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 2023-11-17

D · Potential for more than minimal harm 2023-10-26

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-10-26

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 2023-11-17

E · Potential for more than minimal harm 2021-07-06

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2021-08-23

D · Potential for more than minimal harm 2021-07-06

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2021-08-23

G · Actual harm 2019-03-21

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2019-04-26

D · Potential for more than minimal harm 2019-03-21

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2019-04-26

D · Potential for more than minimal harm 2019-03-21

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2019-04-26

D · Potential for more than minimal harm 2019-03-21

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2019-04-26

D · Potential for more than minimal harm 2019-03-21

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2019-04-26

D · Potential for more than minimal harm 2019-03-21

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2019-04-26

Penalties and ownership