Holland, OH

Lutheran Village At Wolfcreek

3-star overall rating with 3-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

2001 Perrysburg Holland Road, Holland, OH

(419) 861-5600

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 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

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2000-01-28

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

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

0.38

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.13

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

1.92

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.43

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.51

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

2.97

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.26

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.35

CMS adjusted RN staffing hours

Adjusted total hours

3.20

CMS adjusted total nurse staffing hours

Case-mix index

1.47

Higher values indicate more complex resident acuity

RN turnover

Annual RN turnover

Total nurse turnover

48%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,289

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

20.87

Composite VBP score used to determine payment impact.

Payment multiplier

0.9825

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 19.12% · Performance 21.23% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

3.17

Baseline 6.72% · Performance 6.89% · Measure score 3.17 · Achievement 3.17 · Improvement 0

Total nurse turnover

5.18

Baseline 54.12% · Performance 42.50% · Measure score 5.18 · Achievement 5.18 · Improvement 3.47

Adjusted total nurse staffing

Baseline 2.93 hours · Performance 2.90 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.62%	10.72% 0.1 pts better	No Different than the National Rate · Eligible stays 58 · Observed rate 10.34% · Lower 95% interval 6.76%
Discharge to community	54.99%	50.57% 4.4 pts better	No Different than the National Rate · Eligible stays 56 · Observed rate 50% · Lower 95% interval 44.3%
Medicare spending per beneficiary	1	1.02 About the same
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 37 · Denominator 37
Falls with major injury	2.7%	0.77% 1.9 pts worse	Numerator 1 · Denominator 37
Discharge self-care score	25%	53.69% 28.7 pts worse	Numerator 6 · Denominator 24
Discharge mobility score	54.17%	50.94% 3.2 pts better	Numerator 13 · Denominator 24
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 37 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.89%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 3.65%
Staff COVID-19 vaccination coverage	12.84%	8.2% 4.6 pts better	Numerator 14 · Denominator 109
Staff flu vaccination coverage	10.17%	42% 31.8 pts worse	Numerator 12 · Denominator 118
Discharge function score	62.5%	56.45% 6 pts better	Numerator 15 · Denominator 24
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 3 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 18 · 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	95.3%	92.4% 2.9 pts better	93.4% 1.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 91.8% · Q2 95.9% · Q3 97.8% · Q4 95.8% · 4Q avg 95.3%
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	4.7%	3.3% 1.4 pts worse	3.3% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.1% · Q3 4.3% · Q4 4.2% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.1%	26.1% 19 pts better	11.4% 4.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 4.9% · Q3 4.8% · Q4 4.8% · 4Q avg 7.1%
Percentage of long-stay residents who lose too much weight	5.4%	6.2% 0.8 pts better	5.4% About the same	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 7.5% · Q3 5.9% · Q4 5.6% · 4Q avg 5.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	17.1%	25.4% 8.3 pts better	19.6% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.1% · Q3 17.1% · Q4 13.9% · 4Q avg 17.1%
Percentage of long-stay residents who received an antipsychotic medication	8.7%	11.5% 2.8 pts better	16.7% 8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 8.6% · Q3 0.0% · Q4 10.3% · 4Q avg 8.7% · 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	16.7%	7.7% 9 pts worse	16.3% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.7%	6.2% 5.5 pts worse	14.9% 3.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 20.0% · Q3 5.9% · Q4 2.9% · 4Q avg 11.7% · 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	1.6%	0.5% 1.1 pts worse	1.7% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 2.2% · Q4 2.1% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.6%	21.7% 1.9 pts worse	19.8% 3.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 17.4% · Q2 24.8% · Q3 24.8% · Q4 27.3% · 4Q avg 23.6%
Percentage of long-stay residents with pressure ulcers	6.0%	3.7% 2.3 pts worse	5.1% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.7% · Q3 8.3% · Q4 10.2% · 4Q avg 6.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	81.7%	78.1% 3.6 pts better	81.7% About the same	Short Stay · 2024Q4-2025Q3 · Q1 73.4% · Q2 82.5% · Q3 90.3% · Q4 79.5% · 4Q avg 81.7%
Percentage of short-stay residents who had an outpatient emergency department visit	7.1%	12.5% 5.4 pts better	12.0% 4.9 pts better	Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 6.7% · Expected 10.4% · 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	80.2%	75.6% 4.6 pts better	79.7% 0.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 80.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	9.1%	25.1% 16 pts better	23.9% 14.8 pts better	Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 6.7% · Expected 17.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-08 · Fire 2025-09-08

9 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-04-13 · Fire 2023-04-13

15 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2019-12-12 · Fire 2019-12-12

7 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-08

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2025-10-17

F · Potential for more than minimal harm 2025-09-08

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-10-17

F · Potential for more than minimal harm 2025-09-08

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 2025-10-17

E · Potential for more than minimal harm 2025-09-08

K223 · Egress Deficiencies

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 2025-10-17

F · Potential for more than minimal harm 2023-04-13

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 2023-05-29

F · Potential for more than minimal harm 2023-04-13

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-05-29

F · Potential for more than minimal harm 2023-04-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-05-29

E · Potential for more than minimal harm 2019-12-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2020-03-04

D · Potential for more than minimal harm 2019-12-12

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2020-03-04

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-09-08

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 2025-10-17

E · Potential for more than minimal harm 2025-09-08

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-10-17

E · Potential for more than minimal harm 2025-09-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-08

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 2025-10-17

D · Potential for more than minimal harm 2025-09-08

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-08

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 2025-10-17

D · Potential for more than minimal harm 2025-09-08

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-09-08

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 2025-10-17

D · Potential for more than minimal harm 2025-09-08

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-10-17

E · Potential for more than minimal harm 2023-04-13

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 2023-05-29