Vancrest-Upper Valley

CMS star ratings

Overall★★★★★ 4/5

State avg 3.2

Health inspections★★★★★ 3/5

State avg 2.8

Staffing★★★★★ 2/5

State avg 2.4

Quality measures★★★★★ 5/5

State avg 4.4

Long-stay quality★★★★★ 5/5

Short-stay quality★★★★★ 5/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing: 3.87 (state 3.69 · U.S. 3.86)
Registered nurses (RN): 0.53 (state 0.64 · U.S. 0.69)
Licensed practical nurses: 1.00 (state 0.95 · U.S. 0.86)
Nurse aides: 2.34 (state 2.09 · U.S. 2.32)
Weekend total: 3.38 (state 3.28 · U.S. 3.42)
Nursing staff turnover: 40.9 (state 48.7 · U.S. 45.8)%
RN turnover: 30.0 (state 43.9 · U.S. 42.9)%
Administrators who left: 0 in the last year

Inspections

Last standard inspection: July 25, 2024
Health deficiencies (last cycle): 13.0 (state 10.7 · U.S. 9.3)
From complaints: 0
Citations on record (3 years): 32 health · 24 fire safety · includes actual harm

Date	Citation	Severity	Status
2024-07-25	Ensure that residents are fully informed and understand their health status, care and treatments. F0552 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	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. F0585 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	Assess the resident when there is a significant change in condition F0637 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	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. F0700 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. F0756 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	Ensure that residents are free from significant medication errors. F0760 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	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. F0761 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2024-08-23
2024-07-25	Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. F0582 · Resident Rights Deficiencies	B No actual harm, potential for minimal harm	Corrected 2024-08-23
2021-11-23	Reasonably accommodate the needs and preferences of each resident. F0558 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2021-11-23	Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. F0569 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2021-11-23	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. F0578 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2021-11-23	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. F0580 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2021-11-23	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. F0657 · Resident Assessment and Care Planning Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2021-11-23	Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2021-11-23	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. F0688 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2021-11-23	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. F0758 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2021-11-23	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. F0761 · Pharmacy Service Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2021-11-23	Provide timely, quality laboratory services/tests to meet the needs of residents. F0770 · Administration Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2021-11-23	Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. F0921 · Environmental Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2021-12-13
2019-08-22	Provide appropriate pressure ulcer care and prevent new ulcers from developing. F0686 · Quality of Life and Care Deficiencies	G Actual harm	Corrected 2019-09-16
2019-08-22	Provide timely, quality laboratory services/tests to meet the needs of residents. F0770 · Administration Deficiencies	E No actual harm, potential for more than minimal harm	Corrected 2019-09-16
2019-08-22	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. F0550 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2019-09-16
2019-08-22	Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. F0569 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2019-09-16
2019-08-22	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. F0578 · Resident Rights Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2019-09-16
2019-08-22	Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2019-09-16
2019-08-22	Develop and implement policies and procedures for flu and pneumonia vaccinations. F0883 · Infection Control Deficiencies	D No actual harm, potential for more than minimal harm	Corrected 2019-09-16
2019-08-22	Develop and implement policies and procedures to prevent abuse, neglect, and theft. F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies	C No actual harm, potential for minimal harm	Corrected 2019-09-16

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

No federal fines or payment denials in the last three years.

Ownership & management

Name	Role	Since
Bagley, Jon (individual)	5%+ Direct Ownership Interest
McCleery, Mark (individual)	5%+ Direct Ownership Interest
Myers, Mark (individual)	5%+ Direct Ownership Interest
White, Claire (individual)	5%+ Direct Ownership Interest
White, Mark (individual)	5%+ Direct Ownership Interest
White, Nicolaus (individual)	5%+ Direct Ownership Interest
White, Scott (individual)	5%+ Direct Ownership Interest
Allen, Betty (individual)	Administrator · NOT APPLICABLE
Aquila Initiative INC (organization)	Administrator · NOT APPLICABLE
Bashore Reineck Stoller & Waterman INC (organization)	Administrator · NOT APPLICABLE
Contento, Robert (individual)	Administrator · NOT APPLICABLE
Fuelling, Elizabeth (individual)	Administrator · NOT APPLICABLE
Howard, Wershbale & Co (organization)	Administrator · NOT APPLICABLE
Madireddy, Naga (individual)	Administrator · NOT APPLICABLE
Parker, Kathy (individual)	Administrator · NOT APPLICABLE
Pottenger, Julia (individual)	Administrator · NOT APPLICABLE
Rudasill, Mark (individual)	Administrator · NOT APPLICABLE
Silalahi, Edgar (individual)	Administrator · NOT APPLICABLE
Stewart, Shane (individual)	Administrator · NOT APPLICABLE
Sutherland, Cierra (individual)	Administrator · NOT APPLICABLE
Therapy Solutions (organization)	Administrator · NOT APPLICABLE
Troy Health Facilities, LLC (organization)	Administrator · NOT APPLICABLE
Twomagnets LLC (organization)	Administrator · NOT APPLICABLE
Uvmc Nursing Care, INC (organization)	Administrator · NOT APPLICABLE
Vancrest Management Corp. (organization)	Administrator · NOT APPLICABLE
Veracity Resourcing and Services LLC (organization)	Administrator · NOT APPLICABLE
Bagley, Jon (individual)	Corporate Officer · NOT APPLICABLE
White, Mark (individual)	Corporate Officer · NOT APPLICABLE
Silalahi, Edgar (individual)	Managing Control - Governing Body · NOT APPLICABLE
Stewart, Shane (individual)	Managing Control - Governing Body · NOT APPLICABLE
Allen, Betty (individual)	Operational/managerial Control · NOT APPLICABLE
Contento, Robert (individual)	Operational/managerial Control · NOT APPLICABLE
Fuelling, Elizabeth (individual)	Operational/managerial Control · NOT APPLICABLE
Madireddy, Naga (individual)	Operational/managerial Control · NOT APPLICABLE
Parker, Kathy (individual)	Operational/managerial Control · NOT APPLICABLE
Pottenger, Julia (individual)	Operational/managerial Control · NOT APPLICABLE
Rudasill, Mark (individual)	Operational/managerial Control · NOT APPLICABLE
Silalahi, Edgar (individual)	Operational/managerial Control · NOT APPLICABLE
Stewart, Shane (individual)	Operational/managerial Control · NOT APPLICABLE
Sutherland, Cierra (individual)	Operational/managerial Control · NOT APPLICABLE
Troy Health Facilities, LLC (organization)	Operational/managerial Control · NOT APPLICABLE
Vancrest Management Corp. (organization)	Operational/managerial Control · NOT APPLICABLE
White, Mark (individual)	Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Vancrest-Upper Valley?

Vancrest-Upper Valley has a 4-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.2-star average in Ohio.

How many beds does Vancrest-Upper Valley have?

It has 127 certified beds and cares for about 115 residents per day.

Has Vancrest-Upper Valley been fined?

CMS lists no federal fines or payment denials in the last three years.

Who owns Vancrest-Upper Valley?

It is part of Vancrest Health Care Centers and is classified as non profit - corporation. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Vancrest-Upper Valley?

(937) 440-7663. The facility is located at 3232 North County Road 25A, Troy, OH 45373.

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Contact & location

Facility details