Cycle 1
Health 2023-12-21 · Fire 2023-12-21
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cuyahoga Falls, OH
Bath Creek Estates
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
186 West Bath Road, Cuyahoga Falls, OH
(330) 922-9911
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
2013-03-15
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
0.55
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.01
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,014
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.55% · Performance 21.52% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.63
Baseline 5.26% · Performance 6.75% · Measure score 3.63 · Achievement 3.63 · Improvement 0
Total nurse turnover
2.10
Baseline 57.69% · Performance 55.10% · Measure score 2.10 · Achievement 2.10 · Improvement 0.29
Adjusted total nurse staffing
0
Baseline 3.28 hours · Performance 3.22 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.66% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 9.8% · Lower 95% interval 8.18% |
| Discharge to community | 45.22% |
50.57%
5.4 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 40.38% · Lower 95% interval 36.99% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 78.35% |
95.27%
16.9 pts worse
|
Numerator 76 · Denominator 97 |
| Falls with major injury | 1.03% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 97 |
| Discharge self-care score | 41.27% |
53.69%
12.4 pts worse
|
Numerator 26 · Denominator 63 |
| Discharge mobility score | 39.68% |
50.94%
11.3 pts worse
|
Numerator 25 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 97 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.75% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 6.02% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 7.94% |
8.2%
0.3 pts worse
|
Numerator 10 · Denominator 126 |
| Staff flu vaccination coverage | 21.37% |
42%
20.6 pts worse
|
Numerator 28 · Denominator 131 |
| Discharge function score | 30.16% |
56.45%
26.3 pts worse
|
Numerator 19 · Denominator 63 |
| Transfer of health information to provider | 88.89% |
95.95%
7.1 pts worse
|
Numerator 24 · Denominator 27 |
| Transfer of health information to patient | 87.76% |
96.28%
8.5 pts worse
|
Numerator 43 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 47.17% |
25.2%
22 pts better
|
Numerator 25 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
92.4%
3.9 pts better
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.8% · Q3 100.0% · Q4 87.7% · 4Q avg 96.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.5%
4.1 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 5.2% · Q4 3.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.7% |
26.1%
6.4 pts better
|
11.4%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 10.0% · Q3 32.1% · Q4 35.2% · 4Q avg 19.7% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
6.2%
0.4 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.4% · Q3 8.3% · Q4 8.7% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.2% |
25.4%
20.2 pts better
|
19.6%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 7.1% · Q3 0.0% · Q4 0.0% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.8% |
11.5%
6.7 pts better
|
16.7%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 6.7% · Q3 6.8% · Q4 0.0% · 4Q avg 4.8% · 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 | 9.8% |
7.7%
2.1 pts worse
|
16.3%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 0.0% · 4Q avg 9.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
6.2%
0.4 pts worse
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 12.0% · Q3 0.0% · Q4 2.3% · 4Q avg 6.6% · 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 | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 19.7% |
21.7%
2 pts better
|
19.8%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 32.2% · Q3 16.5% · Q4 13.3% · 4Q avg 19.7% |
| Percentage of long-stay residents with pressure ulcers | 0.9% |
3.7%
2.8 pts better
|
5.1%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.7% |
78.1%
9.6 pts better
|
81.7%
6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.2% · Q2 91.7% · Q3 97.8% · Q4 76.3% · 4Q avg 87.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.6% |
12.5%
8.1 pts worse
|
12.0%
8.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 20.2% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.2% |
75.6%
15.6 pts better
|
79.7%
11.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
25.1%
3.4 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 21.3% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-04 · Fire 2021-05-04
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-02-07 · Fire 2019-02-07
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-12-21
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-12-21
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-12-21
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-01-10
F · Potential for more than minimal harm
2023-12-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-10
E · Potential for more than minimal harm
2023-12-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-01-10
E · Potential for more than minimal harm
2021-05-04
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 2021-06-01
E · Potential for more than minimal harm
2021-05-04
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2021-06-01
E · Potential for more than minimal harm
2021-05-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-01
E · Potential for more than minimal harm
2021-05-04
K364 · Smoke Deficiencies
Fire Safety
Install properly constructed windows in hallway walls or doors.
Corrected 2021-06-01
E · Potential for more than minimal harm
2021-05-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-06-01
E · Potential for more than minimal harm
2021-05-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-05-04
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2021-06-01
F · Potential for more than minimal harm
2019-02-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-02-22
F · Potential for more than minimal harm
2019-02-07
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 2019-02-22
E · Potential for more than minimal harm
2019-02-07
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 2019-02-22
E · Potential for more than minimal harm
2019-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-02-22
E · Potential for more than minimal harm
2019-02-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-02-22
E · Potential for more than minimal harm
2019-02-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-02-22
E · Potential for more than minimal harm
2019-02-07
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-02-22
E · Potential for more than minimal harm
2019-02-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-02-22
E · Potential for more than minimal harm
2019-02-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-02-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Not marked corrected
E · Potential for more than minimal harm
2025-03-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-03-25
E · Potential for more than minimal harm
2025-03-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-18
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-03-18
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 2025-03-25
D · Potential for more than minimal harm
2025-03-18
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-03-25
D · Potential for more than minimal harm
2025-01-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-03
D · Potential for more than minimal harm
2023-12-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-09-18
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2023-10-05
E · Potential for more than minimal harm
2021-05-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-05-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-05-04
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 2021-06-01
D · Potential for more than minimal harm
2019-02-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-02-22
Penalties and ownership
What sits behind the stars
Ownership
Benjamin N. Volpe Family Dynasty Trust (Dated December 29, 2020)
5% Or Greater Indirect Ownership Interest · Organization
Bnv Dynasty LLC
5% Or Greater Direct Ownership Interest · Organization
Bnv Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Burke, Karma
Operational/Managerial Control · Individual
Decanted William I. Weisberg Family Dynasty Trust (Dated Sept 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Nicoluzakis, Gregory
Corporate Officer · Individual
Saber Governance LLC
Operational/Managerial Control · Organization
Saber Healthcare Group LLC
Operational/Managerial Control · Organization
Saber Healthcare Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Shg Management LLC
Operational/Managerial Control · Organization
Shh Holdings LLC
5% Or Greater Indirect Ownership Interest · 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 Direct Ownership Interest · Organization
Wiw Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Wwbv Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
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