Cycle 1
Health 2024-09-18 · Fire 2024-09-18
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Painesville, OH
Embassy Of Painesville
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
70 Normandy Dr, Painesville, OH
(440) 357-1311
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
78
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Embassy Healthcare
Operator or chain grouping
Approved since
1988-06-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 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
0.67
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,611
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
2.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 77.46% · Performance 75.47% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.58
Baseline 2.61 hours · Performance 2.95 hours · Measure score 0.58 · Achievement 0 · Improvement 0.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.09% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 0% · Lower 95% interval 6% |
| Discharge to community | 59.52% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 59.52% · Lower 95% interval 45.05% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 18% |
8.2%
9.8 pts better
|
Numerator 9 · Denominator 50 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 77.0% |
92.4%
15.4 pts worse
|
93.4%
16.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 62.0% · Q2 61.2% · Q3 93.8% · Q4 91.8% · 4Q avg 77.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.5%
1.7 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.3%
2.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.8% |
26.1%
17.3 pts better
|
11.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.3% · Q3 9.3% · Q4 9.5% · 4Q avg 8.8% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
6.2%
3.3 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 17.1% · Q3 2.3% · Q4 4.8% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.3% |
25.4%
0.1 pts better
|
19.6%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 26.2% · Q3 23.3% · Q4 28.6% · 4Q avg 25.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.3% |
11.5%
0.8 pts worse
|
16.7%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 22.9% · Q3 8.3% · Q4 5.9% · 4Q avg 12.3% · 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 | 7.3% |
7.7%
0.4 pts better
|
16.3%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 5.9% · Q3 5.0% · Q4 0.0% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.2% |
6.2%
3 pts better
|
14.9%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 3.2% · 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 | 1.5% |
0.5%
1 pts worse
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 4.1% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
21.7%
8.5 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 39.8% · Q3 34.0% · Q4 30.1% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
3.7%
1 pts worse
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.3% · Q3 5.7% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.8% |
78.1%
0.7 pts better
|
81.7%
2.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 74.4% · Q2 78.8% · Q3 76.4% · Q4 84.2% · 4Q avg 78.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.0% |
1.2%
3.8 pts worse
|
1.6%
3.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 6.9% · Q3 5.9% · Q4 2.9% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.2% |
75.6%
17.4 pts worse
|
79.7%
21.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-03 · Fire 2022-11-03
11 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2019-10-09 · Fire 2019-10-09
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-18
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-09-18
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-09-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-09-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-09-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-09-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-09-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-07
F · Potential for more than minimal harm
2024-09-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-09-18
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-07
F · Potential for more than minimal harm
2023-10-03
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-10-12
E · Potential for more than minimal harm
2022-11-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-29
E · Potential for more than minimal harm
2022-11-03
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-11-29
F · Potential for more than minimal harm
2019-10-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-06
F · Potential for more than minimal harm
2019-10-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-06
E · Potential for more than minimal harm
2019-10-09
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2019-11-06
E · Potential for more than minimal harm
2019-10-09
K255 · Egress Deficiencies
Fire Safety
Ensure that suites are correctly sub-divided by noncombustible or limited-combustible construction.
Corrected 2019-11-06
E · Potential for more than minimal harm
2019-10-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-06
E · Potential for more than minimal harm
2019-10-09
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-06
E · Potential for more than minimal harm
2019-10-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-11-06
C · Minimal harm
2019-10-09
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2019-11-06
C · Minimal harm
2019-10-09
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2019-11-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-09-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-09-18
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 2024-11-07
D · Potential for more than minimal harm
2024-09-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-07
C · Minimal harm
2024-09-18
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2024-10-07
C · Minimal harm
2024-09-18
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-10-07
E · Potential for more than minimal harm
2023-08-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-08-02
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-18
F · Potential for more than minimal harm
2023-06-29
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 2023-07-12
D · Potential for more than minimal harm
2023-06-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-12
E · Potential for more than minimal harm
2023-05-18
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 2023-06-05
D · Potential for more than minimal harm
2023-05-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-05
D · Potential for more than minimal harm
2023-03-24
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-03
F · Potential for more than minimal harm
2022-11-03
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2022-11-29
F · Potential for more than minimal harm
2022-11-03
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 2022-11-29
E · Potential for more than minimal harm
2022-11-03
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-11-29
E · Potential for more than minimal harm
2022-11-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-11-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-11-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-11-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-11-03
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 2022-11-29
D · Potential for more than minimal harm
2022-11-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-11-29
D · Potential for more than minimal harm
2022-11-03
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-11-29
C · Minimal harm
2022-11-03
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2022-11-29
F · Potential for more than minimal harm
2019-10-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-11-06
F · Potential for more than minimal harm
2019-10-09
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-11-06
D · Potential for more than minimal harm
2019-10-09
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 2019-11-06
D · Potential for more than minimal harm
2019-10-09
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 2019-11-06
D · Potential for more than minimal harm
2019-10-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-11-06
D · Potential for more than minimal harm
2019-10-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-06
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
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
#2
Concord Ridge Health And Rehabilitation
Mentor, OH
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Homestead Ii
Painesville, OH
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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