15 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cleveland, OH
3-star overall rating with 2-star inspections with 15 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
3600 Franklin Boulevard, Cleveland, OH
(216) 651-1600
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
178
Certified beds
Average residents
163
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Health Services
Operator or chain grouping
Approved since
1978-10-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 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
RN hours / resident day
0.64
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.03
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
10,664
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
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
3
Baseline 64.48% · Performance 51.41% · Measure score 3 · Achievement 3 · Improvement 2.80
Adjusted total nurse staffing
0.91
Baseline 2.95 hours · Performance 3.34 hours · Measure score 0.91 · Achievement 0.91 · Improvement 0.87
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| 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 10 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 10 · 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 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.4% |
8.2%
6.8 pts worse
|
Numerator 3 · Denominator 214 |
| Staff flu vaccination coverage | 6.25% |
42%
35.8 pts worse
|
Numerator 22 · Denominator 352 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 10 · 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 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
92.4%
7.4 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.4% |
94.5%
4.9 pts better
|
95.5%
3.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.7% |
3.3%
0.6 pts better
|
3.3%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.7% · Q3 2.7% · Q4 3.5% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 25.8% |
26.1%
0.3 pts better
|
11.4%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 32.0% · Q3 25.0% · Q4 20.6% · 4Q avg 25.8% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
6.2%
2.8 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.1% · Q3 4.3% · Q4 2.2% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.3% |
25.4%
13.1 pts better
|
19.6%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 11.4% · Q3 12.2% · Q4 12.6% · 4Q avg 12.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
11.5%
3.3 pts worse
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 15.6% · Q3 16.9% · Q4 14.7% · 4Q avg 14.8% · 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 | 8.5% |
7.7%
0.8 pts worse
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 9.5% · Q3 7.4% · Q4 7.0% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.3% |
6.2%
1.1 pts worse
|
14.9%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 3.9% · Q3 8.6% · Q4 8.0% · 4Q avg 7.3% · 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 | 0.2% |
0.5%
0.3 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.7% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
21.7%
2.4 pts worse
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.2% · Q2 24.8% · Q3 24.1% · Q4 20.2% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 0.4% |
3.7%
3.3 pts better
|
5.1%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.8% · Q4 0.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
78.1%
19.6 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 98.6% · Q3 100.0% · Q4 96.7% · 4Q avg 97.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
75.6%
20.3 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
Survey summary
Top issue: Nutrition and Dietary (3 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Fire safety
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 2025-10-24
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-10-24
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-24
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-24
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-24
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-24
Fire Safety
Have enough space near smoke barriers to protect residents.
Corrected 2025-10-24
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-24
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-10-24
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-10-24
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-24
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-10-24
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-10-24
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-10-24
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-24
Fire Safety
Install proper backup exit lighting.
Corrected 2025-10-24
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 2025-10-24
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2025-10-24
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-24
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-10-24
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-24
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-22
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-08-22
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-22
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-22
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-08-22
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 2022-08-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-22
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-08-22
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-06-28
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-06-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-06-28
Fire Safety
Have proper power supply for life support equipment.
Corrected 2019-06-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-28
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-06-28
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2019-06-28
Inspection history
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-24
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-10-24
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 2025-10-24
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-10-24
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 2025-10-24
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-10-24
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-24
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 2025-10-24
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 2025-10-24
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-10-24
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2025-10-24
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-07-18
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-07-18
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-18
Health
Have policies on smoking.
Corrected 2025-07-18
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 2024-11-11
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-11-11
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-11-11
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 2024-11-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-11
Health
Dispose of garbage and refuse properly.
Corrected 2024-06-12
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 2023-04-07
Health
Provide or arrange emergency care by a doctor 24 hours a day.
Corrected 2023-04-07
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-04-07
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-08-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-22
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 2022-08-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-06-28
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-28
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 2019-06-28
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 2019-06-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-28
Health
Dispose of garbage and refuse properly.
Corrected 2019-06-21
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
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