Cycle 1
Health 2024-07-25 · Fire 2024-07-25
13 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Troy, OH
Vancrest-Upper Valley
4-star overall rating with 3-star inspections with $4,233 in total fines with 13 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
3232 North County Road 25a, Troy, OH
(937) 440-7663
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
127
Certified beds
Average residents
118
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Vancrest Health Care Centers
Operator or chain grouping
Approved since
1989-05-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.41
Registered nurse staffing
LPN hours / resident day
1.12
Licensed practical nurse staffing
Aide hours / resident day
2.33
Nurse aide staffing
Weekend hours
3.46
Weekend nurse staffing
RN turnover
30%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
92.4%
6.8 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
94.5%
4.5 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.3%
2.6 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 11.6% |
26.1%
14.5 pts better
|
11.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.2% |
6.2%
2 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.8% |
25.4%
1.4 pts worse
|
19.6%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
11.5%
3.4 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 2.6% |
7.7%
5.1 pts better
|
16.3%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.3% |
6.2%
3.9 pts better
|
14.9%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.0% |
21.7%
16.7 pts better
|
19.8%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
78.1%
17.2 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.7% |
12.5%
2.2 pts worse
|
12.0%
2.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.8% |
75.6%
13.2 pts better
|
79.7%
9.1 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.7% |
25.1%
8.4 pts better
|
23.9%
7.2 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-23 · Fire 2021-11-23
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2019-08-22 · Fire 2019-08-22
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-25
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 2025-01-23
F · Potential for more than minimal harm
2024-07-25
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-23
F · Potential for more than minimal harm
2024-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
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 2024-08-23
E · Potential for more than minimal harm
2024-07-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-23
E · Potential for more than minimal harm
2024-07-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-07-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-23
E · Potential for more than minimal harm
2024-07-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-23
E · Potential for more than minimal harm
2021-11-23
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 2021-12-13
E · Potential for more than minimal harm
2021-11-23
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
2021-11-23
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-12-13
E · Potential for more than minimal harm
2021-11-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-13
F · Potential for more than minimal harm
2019-08-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-09-16
E · Potential for more than minimal harm
2019-08-22
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 2019-09-16
E · Potential for more than minimal harm
2019-08-22
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-09-16
E · Potential for more than minimal harm
2019-08-22
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-09-16
E · Potential for more than minimal harm
2019-08-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-09-16
E · Potential for more than minimal harm
2019-08-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-09-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-25
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
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 2024-08-23
D · Potential for more than minimal harm
2024-07-25
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 2024-08-23
D · Potential for more than minimal harm
2024-07-25
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 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
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 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-23
D · Potential for more than minimal harm
2024-07-25
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 2024-08-23
D · Potential for more than minimal harm
2024-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-23
B · Minimal harm
2024-07-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-23
D · Potential for more than minimal harm
2021-11-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-12-13
D · Potential for more than minimal harm
2021-11-23
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2021-12-13
D · Potential for more than minimal harm
2021-11-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-12-13
D · Potential for more than minimal harm
2021-11-23
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 2021-12-13
D · Potential for more than minimal harm
2021-11-23
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
2021-11-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-12-13
D · Potential for more than minimal harm
2021-11-23
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 2021-12-13
D · Potential for more than minimal harm
2021-11-23
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 2021-12-13
D · Potential for more than minimal harm
2021-11-23
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 2021-12-13
D · Potential for more than minimal harm
2021-11-23
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2021-12-13
D · Potential for more than minimal harm
2021-11-23
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-12-13
G · Actual harm
2019-08-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-09-16
E · Potential for more than minimal harm
2019-08-22
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-22
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 2019-09-16
D · Potential for more than minimal harm
2019-08-22
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-09-16
D · Potential for more than minimal harm
2019-08-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-09-16
C · Minimal harm
2019-08-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-09-16
Penalties and ownership
What sits behind the stars
$4,233
2023-08-14
Fine
Fine · fine $4,233
Fine
Ownership
Allen, Betty
Operational/Managerial Control · Individual
Bagley, Jon
5% Or Greater Direct Ownership Interest · Individual
Bagley, Jon
Corporate Officer · Individual
Contento, Robert
Operational/Managerial Control · Individual
Fuelling, Elizabeth
Operational/Managerial Control · Individual
Madireddy, Naga
Operational/Managerial Control · Individual
Mccleery, Mark
5% Or Greater Direct Ownership Interest · Individual
Myers, Mark
5% Or Greater Direct Ownership Interest · Individual
Parker, Kathy
Operational/Managerial Control · Individual
Pottenger, Julia
Operational/Managerial Control · Individual
Rudasill, Mark
Operational/Managerial Control · Individual
Silalahi, Edgar
Operational/Managerial Control · Individual
Stewart, Shane
Operational/Managerial Control · Individual
Sutherland, Cierra
Operational/Managerial Control · Individual
Troy Health Facilities, LLC
Operational/Managerial Control · Organization
Vancrest Management Corp.
Operational/Managerial Control · Organization
White, Claire
5% Or Greater Direct Ownership Interest · Individual
White, Mark
5% Or Greater Direct Ownership Interest · Individual
White, Mark
Operational/Managerial Control · Individual
White, Mark
Corporate Officer · Individual
White, Nicolaus
5% Or Greater Direct Ownership Interest · Individual
White, Scott
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Troy Rehabilitation And Healthcare Center
Troy, OH
2-star overall rating with 2-star inspections with $35,968 in total fines with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Ayden Healthcare Of Piqua
Piqua, OH
2-star overall rating with 2-star inspections with $19,890 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Piqua Manor
Piqua, OH
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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