Cycle 1
Health 2024-12-05 · Fire 2024-12-05
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Upper Sandusky, OH
Wyandot County Skilled Nursing And Rehabilitation
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
7830 N St Hwy 199 Rr2, Upper Sandusky, OH
(419) 294-1714
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
82
Certified beds
Average residents
72
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2003-04-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.40
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.24
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
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,875
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9953
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.07
Baseline 18.18% · Performance 20.94% · Measure score 1.07 · Achievement 1.07 · Improvement 0
Healthcare-associated infections
4.73
Baseline 5.75% · Performance 6.42% · Measure score 4.73 · Achievement 4.73 · Improvement 0
Total nurse turnover
8.44
Baseline 37.68% · Performance 29.17% · Measure score 8.44 · Achievement 8.44 · Improvement 6.14
Adjusted total nurse staffing
2.68
Baseline 3.97 hours · Performance 3.84 hours · Measure score 2.68 · Achievement 2.68 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.7% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 106 · Observed rate 11.32% · Lower 95% interval 7.92% |
| Discharge to community | 47.42% |
50.57%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 41.18% · Lower 95% interval 36.54% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 60 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 57.78% |
53.69%
4.1 pts better
|
Numerator 26 · Denominator 45 |
| Discharge mobility score | 51.11% |
50.94%
0.2 pts better
|
Numerator 23 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 6.67% |
2.29%
4.4 pts worse
|
Numerator 4 · Denominator 60 · Adjusted rate 5.67% |
| Healthcare-associated infections requiring hospitalization | 6.42% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 4.29% · Lower 95% interval 3.58% |
| Staff COVID-19 vaccination coverage | 2.02% |
8.2%
6.2 pts worse
|
Numerator 2 · Denominator 99 |
| Staff flu vaccination coverage | 8.33% |
42%
33.7 pts worse
|
Numerator 9 · Denominator 108 |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 25 · Denominator 45 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.24% |
25.2%
8 pts worse
|
Numerator 5 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.8% |
94.5%
2.3 pts better
|
95.5%
1.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.3%
2 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.7% · Q3 5.4% · Q4 5.2% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.7% |
26.1%
22.4 pts better
|
11.4%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 3.5% · Q3 5.5% · Q4 1.9% · 4Q avg 3.7% |
| Percentage of long-stay residents who lose too much weight | 11.7% |
6.2%
5.5 pts worse
|
5.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 12.0% · Q3 17.8% · Q4 12.5% · 4Q avg 11.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.9% |
25.4%
7.5 pts better
|
19.6%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 19.2% · Q3 17.0% · Q4 16.3% · 4Q avg 17.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.2% |
11.5%
2.3 pts better
|
16.7%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.8% · Q3 11.4% · Q4 14.9% · 4Q avg 9.2% · 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 | 5.9% |
7.7%
1.8 pts better
|
16.3%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 4.1% · Q3 0.0% · Q4 15.0% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.6% |
6.2%
1.4 pts worse
|
14.9%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 10.0% · Q3 6.8% · Q4 6.4% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.2%
1.2 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 3.5% · Q4 0.0% · 4Q avg 1.4% · 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 1.9% · Q2 0.0% · Q3 0.0% · 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 | 25.3% |
21.7%
3.6 pts worse
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 27.6% · Q3 29.2% · Q4 16.7% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 0.4% |
3.7%
3.3 pts better
|
5.1%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
78.1%
20.4 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 98.6% · Q4 97.2% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.3% |
12.5%
2.2 pts better
|
12.0%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 10.0% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
75.6%
22.8 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.3% |
25.1%
4.2 pts worse
|
23.9%
5.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.3% · Observed 26.7% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-28 · Fire 2023-12-28
10 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2021-09-10 · Fire 2021-09-10
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-05
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2024-12-19
E · Potential for more than minimal harm
2024-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-19
E · Potential for more than minimal harm
2024-12-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-19
F · Potential for more than minimal harm
2023-12-28
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-03-18
F · Potential for more than minimal harm
2023-12-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-22
F · Potential for more than minimal harm
2023-12-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-22
F · Potential for more than minimal harm
2021-09-10
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-10-28
F · Potential for more than minimal harm
2021-09-10
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-10-28
F · Potential for more than minimal harm
2021-09-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-28
F · Potential for more than minimal harm
2021-09-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-10-28
E · Potential for more than minimal harm
2021-09-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-10-28
E · Potential for more than minimal harm
2021-09-10
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-10-28
E · Potential for more than minimal harm
2021-09-10
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2021-10-28
E · Potential for more than minimal harm
2021-09-10
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-10-28
E · Potential for more than minimal harm
2021-09-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-10-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-05
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 2024-12-19
D · Potential for more than minimal harm
2024-12-05
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 2024-12-19
D · Potential for more than minimal harm
2024-12-05
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 2024-12-19
D · Potential for more than minimal harm
2024-12-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-19
G · Actual harm
2023-12-28
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 2024-01-22
F · Potential for more than minimal harm
2023-12-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-22
D · Potential for more than minimal harm
2023-12-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-01-22
D · Potential for more than minimal harm
2023-12-28
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 2024-01-22
D · Potential for more than minimal harm
2023-12-28
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 2024-01-22
D · Potential for more than minimal harm
2023-12-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-22
D · Potential for more than minimal harm
2023-12-28
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 2024-01-22
D · Potential for more than minimal harm
2023-12-28
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-22
D · Potential for more than minimal harm
2023-12-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-22
D · Potential for more than minimal harm
2023-12-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-22
D · Potential for more than minimal harm
2021-09-10
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2021-10-28
D · Potential for more than minimal harm
2021-09-10
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 2021-10-28
Penalties and ownership
What sits behind the stars
Ownership
Roynon, Elaine
Operational/Managerial Control · Individual
Nearby options
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4-star overall rating with 3-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
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Bucyrus, OH
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
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3-star overall rating with 3-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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