Cycle 1
Health 2023-12-14 · Fire 2023-12-14
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cuyahoga Falls, OH
Falls Village Skilled Nursing & Rehabilitation
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
330 Broadway East, Cuyahoga Falls, OH
(330) 945-9797
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Vrc Management
Operator or chain grouping
Approved since
2001-07-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 4 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
0.66
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.48
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.99
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.13
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.14
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.72
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.60
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,233
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9846
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.95
Baseline 22.34% · Performance 20.51% · Measure score 2.95 · Achievement 1.99 · Improvement 2.95
Healthcare-associated infections
3.83
Baseline 5.51% · Performance 6.69% · Measure score 3.83 · Achievement 3.83 · Improvement 0
Total nurse turnover
2.67
Baseline 63.16% · Performance 52.75% · Measure score 2.67 · Achievement 2.67 · Improvement 2.22
Adjusted total nurse staffing
1.51
Baseline 2.88 hours · Performance 3.46 hours · Measure score 1.51 · Achievement 1.36 · Improvement 1.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.82% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 14.89% · Lower 95% interval 8.16% |
| Discharge to community | 53.35% |
50.57%
2.8 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 47.25% · Lower 95% interval 44.89% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.73% |
95.27%
3.5 pts better
|
Numerator 78 · Denominator 79 |
| Falls with major injury | 1.27% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 79 |
| Discharge self-care score | 42.59% |
53.69%
11.1 pts worse
|
Numerator 23 · Denominator 54 |
| Discharge mobility score | 20.37% |
50.94%
30.6 pts worse
|
Numerator 11 · Denominator 54 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 79 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 5.17% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 3.48% |
8.2%
4.7 pts worse
|
Numerator 4 · Denominator 115 |
| Staff flu vaccination coverage | 17.93% |
42%
24.1 pts worse
|
Numerator 33 · Denominator 184 |
| Discharge function score | 16.67% |
56.45%
39.8 pts worse
|
Numerator 9 · Denominator 54 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 40 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 34.21% |
25.2%
9 pts better
|
Numerator 13 · Denominator 38 |
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 | 96.6% |
94.5%
2.1 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.3%
2.4 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 1.7% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
26.1%
20 pts better
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 6.5% · Q3 6.0% · Q4 5.8% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
6.2%
3.2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.1% · Q3 4.3% · Q4 0.0% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.8% |
25.4%
7.6 pts better
|
19.6%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 18.4% · Q3 16.7% · Q4 18.5% · 4Q avg 17.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
11.5%
1.3 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 14.6% · Q3 9.8% · Q4 7.0% · 4Q avg 10.2% · 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 | 25.5% |
7.7%
17.8 pts worse
|
16.3%
9.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
6.2%
4.4 pts worse
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 11.1% · Q3 11.9% · Q4 4.3% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.2%
0.3 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.5%
About the same
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.9% |
21.7%
1.2 pts worse
|
19.8%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 19.9% · Q3 30.6% · Q4 10.9% · 4Q avg 22.9% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
3.7%
0.2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.8% · Q3 6.8% · Q4 4.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
78.1%
21.8 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.3% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
12.5%
1 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 13.0% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.2%
0.4 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.8% · Q3 2.9% · Q4 1.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.5% |
75.6%
22.9 pts better
|
79.7%
18.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
25.1%
0.9 pts better
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 29.6% · Expected 29.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-20 · Fire 2023-03-20
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-01-06 · Fire 2022-01-06
1 health deficiencies
Top issue: Administration (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-12-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-12-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-12-14
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-12-14
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 2024-01-05
E · Potential for more than minimal harm
2023-12-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-14
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-01-05
F · Potential for more than minimal harm
2023-03-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-08
F · Potential for more than minimal harm
2023-03-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-08
E · Potential for more than minimal harm
2023-03-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-08
E · Potential for more than minimal harm
2023-03-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-08
E · Potential for more than minimal harm
2023-03-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-08
F · Potential for more than minimal harm
2022-01-06
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2022-06-08
F · Potential for more than minimal harm
2022-01-06
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2022-02-12
F · Potential for more than minimal harm
2022-01-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-02-12
F · Potential for more than minimal harm
2022-01-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-02-12
F · Potential for more than minimal harm
2022-01-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-02-12
F · Potential for more than minimal harm
2022-01-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-02-12
F · Potential for more than minimal harm
2022-01-06
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2022-02-12
E · Potential for more than minimal harm
2022-01-06
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 2022-02-12
E · Potential for more than minimal harm
2022-01-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-02-12
E · Potential for more than minimal harm
2022-01-06
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-02-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-02
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 2025-05-22
D · Potential for more than minimal harm
2024-12-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-03
D · Potential for more than minimal harm
2023-12-14
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-14
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-14
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 2024-01-05
D · Potential for more than minimal harm
2023-12-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-14
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-05-11
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-05-12
G · Actual harm
2023-03-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-08
E · Potential for more than minimal harm
2023-03-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-08
D · Potential for more than minimal harm
2023-03-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-04-08
D · Potential for more than minimal harm
2023-03-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-04-08
D · Potential for more than minimal harm
2023-03-20
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-04-08
D · Potential for more than minimal harm
2023-03-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-08
Penalties and ownership
What sits behind the stars
Ownership
Francus, Michael
5% Or Greater Direct Ownership Interest · Individual
Joseph B. Francus Revocable Trust
5% Or Greater Direct Ownership Interest · Organization
Kraus, Andrea
5% Or Greater Direct Ownership Interest · Individual
Davisson, Danielle
Operational/Managerial Control · Individual
Francus, Michael
Operational/Managerial Control · Individual
Francus, Michael
Corporate Officer · Individual
Vrc Management, Inc.
Operational/Managerial Control · Organization
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2-star overall rating with 2-star inspections with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
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#3
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5-star overall rating with 5-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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