Cycle 1
Health 2024-06-27 · Fire 2024-06-27
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Georgetown, OH
Villa Georgetown Rehabilitation And Healthcare Cen
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
8065 Dr Faul Road, Georgetown, OH
(937) 378-4178
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Crown Healthcare Group
Operator or chain grouping
Approved since
1990-04-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 2 overall / 2 health / 1 staffing / 4 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
0.51
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.82
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.14
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.83
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.26
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
2.61
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,468
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.55
Baseline 19.37% · Performance 19.79% · Measure score 3.55 · Achievement 3.55 · Improvement 0
Healthcare-associated infections
0
Baseline 7.69% · Performance 8.84% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.03
Baseline 65.18% · Performance 47.22% · Measure score 4.03 · Achievement 4.03 · Improvement 3.95
Adjusted total nurse staffing
0.53
Baseline 2.28 hours · Performance 2.64 hours · Measure score 0.53 · Achievement 0 · Improvement 0.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.27% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 126 · Observed rate 17.46% · Lower 95% interval 9.28% |
| Discharge to community | 57.22% |
50.57%
6.6 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 49.45% · Lower 95% interval 43.86% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 78 · Denominator 78 |
| Falls with major injury | 1.28% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 78 |
| Discharge self-care score | 47.22% |
53.69%
6.5 pts worse
|
Numerator 17 · Denominator 36 |
| Discharge mobility score | 47.22% |
50.94%
3.7 pts worse
|
Numerator 17 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 1.28% |
2.29%
1 pts better
|
Numerator 1 · Denominator 78 · Adjusted rate 1.52% |
| Healthcare-associated infections requiring hospitalization | 8.84% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 12% · Lower 95% interval 5.32% |
| Staff COVID-19 vaccination coverage | 1.27% |
8.2%
6.9 pts worse
|
Numerator 1 · Denominator 79 |
| Staff flu vaccination coverage | 23.31% |
42%
18.7 pts worse
|
Numerator 38 · Denominator 163 |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 20 · Denominator 36 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 11.9% |
25.2%
13.3 pts worse
|
Numerator 5 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
92.4%
2.5 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.6% · Q2 97.0% · Q3 94.5% · Q4 92.5% · 4Q avg 94.9% |
| 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 | 2.2% |
3.3%
1.1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 3.0% · Q3 1.4% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 63.3% |
26.1%
37.2 pts worse
|
11.4%
51.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 53.8% · Q2 65.6% · Q3 75.4% · Q4 57.9% · 4Q avg 63.3% |
| Percentage of long-stay residents who lose too much weight | 13.8% |
6.2%
7.6 pts worse
|
5.4%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 19.2% · Q3 12.3% · Q4 16.3% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.5% |
25.4%
12.9 pts better
|
19.6%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 11.3% · Q3 15.3% · Q4 11.8% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
11.5%
2.4 pts worse
|
16.7%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 15.4% · Q3 18.2% · Q4 11.1% · 4Q avg 13.9% · 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 | 2.3% |
7.7%
5.4 pts better
|
16.3%
14 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 3.1% · Q4 3.3% · 4Q avg 2.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 3.8% · Q3 5.2% · Q4 0.0% · 4Q avg 2.3% · 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 | 22.3% |
21.7%
0.6 pts worse
|
19.8%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 20.0% · Q3 13.2% · Q4 22.2% · 4Q avg 22.3% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
3.7%
1.7 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 5.9% · Q3 3.9% · Q4 3.9% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.7% |
78.1%
8.6 pts better
|
81.7%
5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 85.6% · Q3 85.6% · Q4 89.1% · 4Q avg 86.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
12.5%
3.8 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 17.3% · Expected 11.8% · 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 | 88.6% |
75.6%
13 pts better
|
79.7%
8.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
25.1%
1.4 pts better
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 26.7% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-22 · Fire 2021-07-22
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-03-12 · Fire 2020-03-12
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-06-27
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-06-27
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-06-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-19
F · Potential for more than minimal harm
2021-07-22
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2021-08-15
F · Potential for more than minimal harm
2021-07-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-08-15
E · Potential for more than minimal harm
2021-07-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-08-15
F · Potential for more than minimal harm
2020-03-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-07-31
Inspection history
Recent health citations
G · Actual harm
2025-02-25
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 2025-02-17
D · Potential for more than minimal harm
2024-06-27
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-27
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 2024-07-19
G · Actual harm
2023-03-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-22
F · Potential for more than minimal harm
2021-07-22
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-08-15
E · Potential for more than minimal harm
2021-07-22
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 2021-08-15
D · Potential for more than minimal harm
2021-07-22
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2021-08-15
D · Potential for more than minimal harm
2021-07-22
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 2021-08-15
D · Potential for more than minimal harm
2021-07-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-08-15
D · Potential for more than minimal harm
2021-07-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-15
C · Minimal harm
2021-07-22
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2021-08-15
G · Actual harm
2020-03-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-03-12
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-03-12
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 2020-03-20
D · Potential for more than minimal harm
2020-03-12
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 2020-03-20
D · Potential for more than minimal harm
2020-03-12
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 2020-03-20
Penalties and ownership
What sits behind the stars
Ownership
Crown Ohio Holdco Inc
5% Or Greater Direct Ownership Interest · Organization
Daubenmire, Kevin
5% Or Greater Indirect Ownership Interest · Individual
Mdatas Trust
5% Or Greater Indirect Ownership Interest · Organization
Fejcc Trust
5% Or Greater Indirect Ownership Interest · Organization
Mrs Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Shkop, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Weintraub, Moshe
5% Or Greater Indirect Ownership Interest · Individual
Capital Finance LLC
5% Or Greater Security Interest · Organization
Daubenmire, Kevin
Operational/Managerial Control · Individual
Donohoo, Jeffrey
Operational/Managerial Control · Individual
Singer, Meir
Corporate Officer · Individual
Stout, Gregory
Operational/Managerial Control · Individual
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#3
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