Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Vancrest-Upper Valley
TROY, OH · 127 certified beds · Last Life Safety survey July 25, 2024
CMS Certification Number 365735 · first certified May 1989
Ownership
Operated by VANCREST HEALTH CARE CENTERS · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within OH
24 citations — more than 75% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 14 citations; the earlier surveys in the window averaged 5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: March 2026 to March 2027. This facility’s last Life Safety survey was July 2024. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 24 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
How that compares
Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 24 |
| Median facility in OH | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 22, 2019 | 6 |
| November 23, 2021 | 4 |
| July 25, 2024 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2024-07-25 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 2 | 2021-11-23 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-07-25 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2024-07-25 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2019-08-22 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2024-07-25 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2021-11-23 |
| K-0311 | Have an enclosure around a vertical opening shaft. | 1 | 2019-08-22 |
What the citations cover
- Smoke Deficiencies 8
- Egress Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Services Deficiencies 3
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Egress Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Services Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 25, 2024 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Waiver has been granted (January 23, 2025) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Waiver has been granted (January 23, 2025) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Waiver has been granted (January 23, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 23, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 23, 2024) |
November 23, 2021 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (December 13, 2021) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (December 13, 2021) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (December 13, 2021) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 13, 2021) |
August 22, 2019 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (September 16, 2019) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (September 16, 2019) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (September 16, 2019) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 16, 2019) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (September 16, 2019) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (September 16, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.