Cycle 1
Health 2024-08-15 · Fire 2024-08-15
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Mentor, OH
Concord Ridge Health And Rehabilitation
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
9901 Johnnycake Ridge Rd, Mentor, OH
(440) 357-7900
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
119
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
1995-07-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
63 facilities
Chain averages 4 overall / 4 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.49
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.75
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.61
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
2.65
CMS adjusted total nurse staffing hours
Case-mix index
1.74
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,974
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.18
Baseline 18.72% · Performance 19.49% · Measure score 4.18 · Achievement 4.18 · Improvement 0
Healthcare-associated infections
3.20
Baseline 6.54% · Performance 6.88% · Measure score 3.20 · Achievement 3.20 · Improvement 0
Total nurse turnover
0
Baseline 60.78% · Performance 76.22% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.14 hours · Performance 2.96 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.99% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 7.84% · Lower 95% interval 6.42% |
| Discharge to community | 50.77% |
50.57%
0.2 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 44.68% · Lower 95% interval 38.6% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 90.2% |
95.27%
5.1 pts worse
|
Numerator 46 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 29.03% |
53.69%
24.7 pts worse
|
Numerator 9 · Denominator 31 |
| Discharge mobility score | 32.26% |
50.94%
18.7 pts worse
|
Numerator 10 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 3.92% |
2.29%
1.6 pts worse
|
Numerator 2 · Denominator 51 · Adjusted rate 3.13% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.51% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 106 |
| Staff flu vaccination coverage | 11.41% |
42%
30.6 pts worse
|
Numerator 17 · Denominator 149 |
| Discharge function score | 45.16% |
56.45%
11.3 pts worse
|
Numerator 14 · Denominator 31 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 23.33% |
25.2%
1.9 pts worse
|
Numerator 7 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
92.4%
6.6 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.2% · Q2 100.0% · Q3 98.6% · Q4 100.0% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.3%
2 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.4% · Q4 2.3% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 62.4% |
26.1%
36.3 pts worse
|
11.4%
51 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.8% · Q2 51.9% · Q3 67.8% · Q4 74.0% · 4Q avg 62.4% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
6.2%
1.7 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.0% · Q3 5.1% · Q4 1.5% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
25.4%
10.1 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 16.7% · Q3 13.3% · Q4 17.6% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.2% |
11.5%
4.3 pts better
|
16.7%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 12.2% · Q3 4.2% · Q4 1.8% · 4Q avg 7.2% · 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 | 5.2% |
7.7%
2.5 pts better
|
16.3%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 10.6% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.6% |
6.2%
3.6 pts better
|
14.9%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 1.9% · Q3 5.4% · Q4 0.0% · 4Q avg 2.6% · 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 | 30.9% |
21.7%
9.2 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 37.2% · Q3 29.8% · Q4 23.6% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
3.7%
1.4 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.0% · Q3 2.1% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
78.1%
10.8 pts better
|
81.7%
7.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 75.9% · Q2 88.4% · Q3 93.0% · Q4 100.0% · 4Q avg 88.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.4% |
12.5%
10.9 pts worse
|
12.0%
11.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 26.3% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.0% |
75.6%
11.4 pts better
|
79.7%
7.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.2% |
25.1%
9.1 pts worse
|
23.9%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.2% · Observed 39.5% · Expected 27.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-16 · Fire 2022-06-16
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-05-02 · Fire 2019-05-02
9 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-30
F · Potential for more than minimal harm
2024-08-15
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 2024-09-30
F · Potential for more than minimal harm
2024-08-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-30
F · Potential for more than minimal harm
2022-06-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-07-11
F · Potential for more than minimal harm
2022-06-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-11
F · Potential for more than minimal harm
2019-05-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-05-24
F · Potential for more than minimal harm
2019-05-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-05-24
F · Potential for more than minimal harm
2019-05-02
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 2019-05-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-30
B · Minimal harm
2024-08-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-02
D · Potential for more than minimal harm
2023-10-17
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 2023-10-18
D · Potential for more than minimal harm
2023-10-17
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 2023-10-18
D · Potential for more than minimal harm
2023-07-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-08-11
F · Potential for more than minimal harm
2022-06-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-06-16
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-06-16
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-07-11
D · Potential for more than minimal harm
2022-06-16
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 2022-07-11
D · Potential for more than minimal harm
2022-06-16
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 2022-07-11
J · Immediate jeopardy
2019-05-02
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 2019-05-24
E · Potential for more than minimal harm
2019-05-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-05-02
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 2019-05-24
D · Potential for more than minimal harm
2019-05-02
F688 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-05-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-05-24
D · Potential for more than minimal harm
2019-05-02
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-05-24
Penalties and ownership
What sits behind the stars
Ownership
Colleran Fam Tr Dated 01-01-2018
5% Or Greater Indirect Ownership Interest · Organization
Foundations Health LLC
5% Or Greater Direct Ownership Interest · Organization
Colleran, Brian
Operational/Managerial Control · Individual
Colleran, Brian
Corporate Director · Individual
Colleran, Brian
Corporate Officer · Individual
Foundations Health Solutions, LLC
Operational/Managerial Control · Organization
Krystowski, John
Operational/Managerial Control · Individual
Krystowski, John
Corporate Officer · Individual
West, Beth
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Embassy Of Painesville
Painesville, OH
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Concord Village Skilled Nursing & Rehabilitation
Concord, OH
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
#3
Grand River Health & Rehab Center
Painesville, OH
3-star overall rating with 2-star inspections with $66,420 in total fines with 14 recent health deficiencies
Jump out