Cycle 1
Health 2024-07-11 · Fire 2024-07-11
4 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Wilmington, OH
Wilmington Nursing & Rehab
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
75 Hale Street, Wilmington, OH
(937) 382-1621
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
76
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
1974-04-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
126 facilities
Chain averages 3 overall / 3 health / 3 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
0.77
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.09
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,168
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.75
Baseline 45.65% · Performance 52.46% · Measure score 2.75 · Achievement 2.75 · Improvement 0
Adjusted total nurse staffing
0.82
Baseline 2.94 hours · Performance 3.31 hours · Measure score 0.82 · Achievement 0.82 · Improvement 0.80
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.34% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 21.05% · Lower 95% interval 7.68% |
| Discharge to community | 34% |
50.57%
16.6 pts worse
|
Worse than the National Rate · Eligible stays 26 · Observed rate 19.23% · Lower 95% interval 23.16% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.37% |
8.2%
6.8 pts worse
|
Numerator 1 · Denominator 73 |
| Staff flu vaccination coverage | 34.25% |
42%
7.8 pts worse
|
Numerator 25 · Denominator 73 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.9% |
92.4%
0.5 pts better
|
93.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 92.5% · Q3 88.5% · Q4 94.1% · 4Q avg 92.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
94.5%
1.9 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.3%
1.9 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 1.9% · Q4 2.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 25.8% |
26.1%
0.3 pts better
|
11.4%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 34.6% · Q3 28.9% · Q4 20.8% · 4Q avg 25.8% |
| Percentage of long-stay residents who lose too much weight | 10.4% |
6.2%
4.2 pts worse
|
5.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.3% · Q3 12.5% · Q4 11.4% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.9% |
25.4%
2.5 pts better
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 15.4% · Q3 20.0% · Q4 34.1% · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
11.5%
0.8 pts worse
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.8% · Q3 20.0% · Q4 11.1% · 4Q avg 12.3% · 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 | 2.1% |
7.7%
5.6 pts better
|
16.3%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.3% |
6.2%
2.9 pts better
|
14.9%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 5.3% · Q4 5.1% · 4Q avg 3.3% · 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 | 0.5% |
0.5%
About the same
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
21.7%
4.1 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 13.2% · Q3 10.4% · Q4 29.8% · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
3.7%
2.5 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 1.6% · Q4 1.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.1% |
78.1%
18 pts worse
|
81.7%
21.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 61.1% · Q2 61.8% · Q3 65.1% · Q4 51.9% · 4Q avg 60.1% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.2%
0.6 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 3.2% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.1% |
75.6%
9.5 pts worse
|
79.7%
13.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.1% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-15 · Fire 2022-03-15
9 health deficiencies
Top issue: Administration (2 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2019-06-06 · Fire 2019-06-06
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-07-11
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 2024-08-06
E · Potential for more than minimal harm
2024-07-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-06
F · Potential for more than minimal harm
2022-03-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-04-19
F · Potential for more than minimal harm
2022-03-15
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-04-19
F · Potential for more than minimal harm
2022-03-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-07
F · Potential for more than minimal harm
2022-03-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-07
F · Potential for more than minimal harm
2022-03-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-04-19
F · Potential for more than minimal harm
2022-03-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-04-19
F · Potential for more than minimal harm
2022-03-15
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 2022-04-19
F · Potential for more than minimal harm
2022-03-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-19
E · Potential for more than minimal harm
2022-03-15
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2022-04-19
E · Potential for more than minimal harm
2022-03-15
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-04-19
E · Potential for more than minimal harm
2022-03-15
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2022-04-19
E · Potential for more than minimal harm
2022-03-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-04-19
E · Potential for more than minimal harm
2022-03-15
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 2022-04-19
E · Potential for more than minimal harm
2022-03-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-04-19
E · Potential for more than minimal harm
2022-03-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-10-07
E · Potential for more than minimal harm
2022-03-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-04-19
F · Potential for more than minimal harm
2019-06-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-15
F · Potential for more than minimal harm
2019-06-06
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2019-07-15
F · Potential for more than minimal harm
2019-06-06
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 2019-07-15
E · Potential for more than minimal harm
2019-06-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-07-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-26
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-23
E · Potential for more than minimal harm
2024-07-11
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 2024-08-06
D · Potential for more than minimal harm
2024-07-11
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-06
C · Minimal harm
2024-07-11
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-08-06
F · Potential for more than minimal harm
2023-11-08
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-29
D · Potential for more than minimal harm
2023-11-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-29
D · Potential for more than minimal harm
2023-09-21
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 2023-11-29
D · Potential for more than minimal harm
2023-09-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-29
F · Potential for more than minimal harm
2022-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-15
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 2022-04-19
D · Potential for more than minimal harm
2022-03-15
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 2022-04-19
D · Potential for more than minimal harm
2022-03-15
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 2022-04-19
D · Potential for more than minimal harm
2022-03-15
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-15
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-04-19
D · Potential for more than minimal harm
2022-03-15
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2022-04-19
F · Potential for more than minimal harm
2019-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-15
D · Potential for more than minimal harm
2019-06-06
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2019-07-15
D · Potential for more than minimal harm
2019-06-06
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2019-07-15
D · Potential for more than minimal harm
2019-06-06
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 2019-07-15
Penalties and ownership
What sits behind the stars
Ownership
Saber Healthcare Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Benjamin N. Volpe Family Dynasty Trust (Dated December 29, 2020)
5% Or Greater Indirect Ownership Interest · Organization
Bnv Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Decanted William I. Weisberg Family Dynasty Trust (Dated Sept 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Hohlefelder, Jason
Operational/Managerial Control · Individual
Luken, Beth
Operational/Managerial Control · Individual
Nicoluzakis, Gregory
Corporate Officer · Individual
Saber Governance LLC
Operational/Managerial Control · Organization
Shg Management LLC
Operational/Managerial Control · Organization
Volpe, Benjamin
Corporate Director · Individual
Volpe, Benjamin
Corporate Officer · Individual
Weisberg, William
Corporate Director · Individual
Weisberg, William
Corporate Officer · Individual
Wiw Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
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#2
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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Laurels Of Blanchester, The
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5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
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