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Vancrest-Upper Valley

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Vancrest-Upper Valley is a non profit - corporation facility in TROY, OH with 127 certified beds and a 4-star overall CMS rating. The facility has 32 deficiency records on file. Total penalties: $4K.

3232 NORTH COUNTY ROAD 25A, TROY, OH 45373

Phone: 9374407663

Overall Rating

4/5

Health Inspection

3/5

Staffing

3/5

Quality Measures

5/5

Long-Stay Quality

5/5

Facility Information

Provider Number
365735
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
Beds
127
Residents
118
In Hospital
No
County
Miami
Last Inspection
Jul 25, 2024

Staffing Data

RN Hours
0.41 (nat'l avg: 0.68)
LPN Hours
1.12
CNA Hours
2.33
Total Nursing Hours
3.87 (nat'l avg: 3.89)
PT Hours
0.05
Nursing Turnover
34.6%
RN Turnover
30.0%

What the CMS Record Reveals About Vancrest-Upper Valley

Vancrest-Upper Valley operates 127 certified beds in TROY, OH with approximately 118 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (3★), staffing levels (3★), and quality measures (5★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 32 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $4K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.87 total nursing hours per resident day (national average 3.89), with RN coverage at 0.41 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "Non profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Vancrest-Upper Valley falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 34.6%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (32 most recent)

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0760

Ensure that residents are free from significant medication errors.

Category: Pharmacy Service Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Category: Pharmacy Service Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0756

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Category: Pharmacy Service Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0700

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.

Category: Quality of Life and Care Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0690

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Category: Quality of Life and Care Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Category: Quality of Life and Care Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0637

Assess the resident when there is a significant change in condition

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0585

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.

Category: Resident Rights Deficiencies

Corrected: Aug 23, 2024

B — Pattern - No harm Jul 25, 2024 Tag: 0582

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Category: Resident Rights Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Jul 25, 2024 Tag: 0552

Ensure that residents are fully informed and understand their health status, care and treatments.

Category: Resident Rights Deficiencies

Corrected: Aug 23, 2024

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0921

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Category: Environmental Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0770

Provide timely, quality laboratory services/tests to meet the needs of residents.

Category: Administration Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0761

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.

Category: Pharmacy Service Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0758

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.

Category: Pharmacy Service Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0688

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.

Category: Quality of Life and Care Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0657

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0580

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Category: Resident Rights Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0578

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.

Category: Resident Rights Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0569

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Category: Resident Rights Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Nov 23, 2021 Tag: 0558

Reasonably accommodate the needs and preferences of each resident.

Category: Resident Rights Deficiencies

Corrected: Dec 13, 2021

D — Isolated - Minimal harm Aug 22, 2019 Tag: 0883

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Category: Infection Control Deficiencies

Corrected: Sep 16, 2019

E — Pattern - Minimal harm Aug 22, 2019 Tag: 0770

Provide timely, quality laboratory services/tests to meet the needs of residents.

Category: Administration Deficiencies

Corrected: Sep 16, 2019

G — Isolated - Actual harm Aug 22, 2019 Tag: 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 16, 2019

D — Isolated - Minimal harm Aug 22, 2019 Tag: 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Category: Quality of Life and Care Deficiencies

Corrected: Sep 16, 2019

C — Widespread - No harm Aug 22, 2019 Tag: 0607

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected: Sep 16, 2019

D — Isolated - Minimal harm Aug 22, 2019 Tag: 0578

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.

Category: Resident Rights Deficiencies

Corrected: Sep 16, 2019

D — Isolated - Minimal harm Aug 22, 2019 Tag: 0569

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Category: Resident Rights Deficiencies

Corrected: Sep 16, 2019

D — Isolated - Minimal harm Aug 22, 2019 Tag: 0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Category: Resident Rights Deficiencies

Corrected: Sep 16, 2019

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 2.3% Yes
Percentage of long-stay residents who lose too much weight Long Stay 4.2% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 0.0% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 0.5% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 11.6% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 5.9% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 99.2% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 95.3% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 1.2% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 2.6% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 26.8% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 99.0% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 88.8% No
Percentage of long-stay residents with pressure ulcers Long Stay 1.1% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 5.0% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 8.1% Yes

Penalty History 1 penalties totaling $4K

Date Type Amount
Aug 14, 2023 Fine $4K

Frequently Asked Questions

What is the overall CMS rating for Vancrest-Upper Valley?
Vancrest-Upper Valley has an overall CMS rating of 4 out of 5 stars. This rating combines health inspection results (3★), staffing levels (3★), and quality measures (5★).
What are the staffing levels at Vancrest-Upper Valley?
Vancrest-Upper Valley reports 3.87 total nursing hours per resident day (national average: 3.89). RN hours are 0.41 per resident day (national average: 0.68). Nursing staff turnover is 34.6%.
How many beds does Vancrest-Upper Valley have?
Vancrest-Upper Valley has 127 certified beds with approximately 118 residents. The facility is located at 3232 NORTH COUNTY ROAD 25A, TROY, OH 45373.
Does Vancrest-Upper Valley have any deficiencies on record?
Yes, Vancrest-Upper Valley has 32 deficiencies on record from recent inspections. Of these, 1 are classified as causing actual harm or jeopardy.
Has Vancrest-Upper Valley received any fines or penalties?
Yes, Vancrest-Upper Valley has received 1 penalties totaling $4K.
Who owns Vancrest-Upper Valley?
Vancrest-Upper Valley is classified as "Non profit - Corporation" ownership. The facility type is "Medicare and Medicaid".
When was Vancrest-Upper Valley last inspected?
The most recent health inspection for Vancrest-Upper Valley was on Jul 25, 2024. The facility received a health inspection rating of 3 out of 5 stars.
What quality measures are tracked for Vancrest-Upper Valley?
Vancrest-Upper Valley is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial