Cycle 1
Health 2024-10-03 · Fire 2024-10-03
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Westlake, OH
Brookdale Westlake Village
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
28450 Westlake Village Drive, Westlake, OH
(440) 892-6200
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
60
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Brookdale Senior Living
Operator or chain grouping
Approved since
2009-02-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 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
0.70
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.36
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
2.71
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.36
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.63
CMS adjusted RN staffing hours
Adjusted total hours
2.43
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,997
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.03% · Performance 22.84% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.08% · Performance 8.79% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.29
Baseline 69.14% · Performance 39.06% · Measure score 6.29 · Achievement 6.02 · Improvement 6.29
Adjusted total nurse staffing
2.43
Baseline 4.39 hours · Performance 3.77 hours · Measure score 2.43 · Achievement 2.43 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.06% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 339 · Observed rate 14.45% · Lower 95% interval 10.06% |
| Discharge to community | 61.34% |
50.57%
10.8 pts better
|
Better than the National Rate · Eligible stays 313 · Observed rate 56.23% · Lower 95% interval 55.18% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.56% |
95.27%
3.3 pts better
|
Numerator 205 · Denominator 208 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 208 |
| Discharge self-care score | 44.03% |
53.69%
9.7 pts worse
|
Numerator 70 · Denominator 159 |
| Discharge mobility score | 54.09% |
50.94%
3.2 pts better
|
Numerator 86 · Denominator 159 |
| Pressure ulcers or injuries, new or worsened | 1.92% |
2.29%
0.4 pts better
|
Numerator 4 · Denominator 208 · Adjusted rate 2.1% |
| Healthcare-associated infections requiring hospitalization | 8.79% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 215 · Observed rate 9.77% · Lower 95% interval 5.88% |
| Staff COVID-19 vaccination coverage | 0.84% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 119 |
| Staff flu vaccination coverage | 42.77% |
42%
0.8 pts better
|
Numerator 68 · Denominator 159 |
| Discharge function score | 48.43% |
56.45%
8 pts worse
|
Numerator 77 · Denominator 159 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 47 · Denominator 47 |
| Transfer of health information to patient | 99.24% |
96.28%
3 pts better
|
Numerator 131 · Denominator 132 |
| Resident COVID-19 vaccinations up to date | 23.73% |
25.2%
1.5 pts worse
|
Numerator 28 · Denominator 118 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 | 82.8% |
94.5%
11.7 pts worse
|
95.5%
12.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.3%
1.1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.4% |
26.1%
22.7 pts better
|
11.4%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 4.8% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who lose too much weight | 6.7% |
6.2%
0.5 pts worse
|
5.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.4% |
25.4%
16 pts better
|
19.6%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.0% |
11.5%
9.5 pts better
|
16.7%
14.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% · 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 need for help with daily activities has increased | 11.5% |
6.2%
5.3 pts worse
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.5% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
0.5%
0.6 pts worse
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.4% |
21.7%
1.7 pts worse
|
19.8%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · 4Q avg 23.4% |
| 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% · Q3 0.0% · Q4 3.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
78.1%
21.3 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.2% · Q3 99.2% · Q4 99.6% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.5% |
12.5%
3 pts better
|
12.0%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 9.4% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.4% |
75.6%
16.8 pts better
|
79.7%
12.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
25.1%
2.7 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 29.4% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-20 · Fire 2022-10-20
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-11-15 · Fire 2019-11-15
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-10-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-10-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-10-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-02
F · Potential for more than minimal harm
2024-10-03
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 2024-12-02
F · Potential for more than minimal harm
2024-10-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-02
F · Potential for more than minimal harm
2022-10-20
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-30
F · Potential for more than minimal harm
2022-10-20
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 2022-11-30
F · Potential for more than minimal harm
2022-10-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-30
E · Potential for more than minimal harm
2022-10-20
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-30
F · Potential for more than minimal harm
2019-11-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-12-18
F · Potential for more than minimal harm
2019-11-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-12-18
D · Potential for more than minimal harm
2019-11-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-10-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-12-02
D · Potential for more than minimal harm
2023-10-06
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-10-07
D · Potential for more than minimal harm
2023-10-06
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 2023-09-13
D · Potential for more than minimal harm
2022-10-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-30
D · Potential for more than minimal harm
2019-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-18
Penalties and ownership
What sits behind the stars
Ownership
Bkd Fm Holding Company LLC
5% Or Greater Direct Ownership Interest · Organization
American Retirement Corporation
5% Or Greater Indirect Ownership Interest · Organization
Brookdale Senior Living Inc
5% Or Greater Indirect Ownership Interest · Organization
Gendics, Augustine
Operational/Managerial Control · Individual
Jones Lang Lasalle Incorporated
5% Or Greater Mortgage Interest · Organization
Kaestner, Henry
Operational/Managerial Control · Individual
Kussow, Dawn
Operational/Managerial Control · Individual
La Marre, Kevin
Operational/Managerial Control · Individual
Munoz, Anna
Operational/Managerial Control · Individual
Nall, Suzanne
Operational/Managerial Control · Individual
Olson, Ardelle
Operational/Managerial Control · Individual
Panwar, Rituraj
Operational/Managerial Control · Individual
Stengle, Nikolas
Operational/Managerial Control · Individual
White, Chadwick
Operational/Managerial Control · Individual
White, Chadwick
Corporate Director · Individual
White, Chadwick
Corporate Officer · Individual
Zraik, Bassem
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Crocker Pointe Health And Rehabilitation
Westlake, OH
0-star overall rating with 0-star inspections
#2
Lutheran Home
Westlake, OH
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Life Care Center Of Westlake
Westlake, OH
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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