Cycle 1
Health 2025-09-25 · Fire 2025-09-25
3 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)
Toledo, OH
Majestic Care Of Toledo SNF
4-star overall rating with 4-star inspections with $22,432 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
131 North Wheeling Street, Toledo, OH
(419) 693-0751
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
85
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Majestic Care
Operator or chain grouping
Approved since
2000-02-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 3 overall / 2 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
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.80
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
1.56
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.14
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
0.32
CMS adjusted RN staffing hours
Adjusted total hours
3.19
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,489
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.20% · Performance 21.82% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.61
Baseline 6.24% · Performance 7.35% · Measure score 1.61 · Achievement 1.61 · Improvement 0
Total nurse turnover
5.03
Baseline 82.53% · Performance 50.62% · Measure score 5.03 · Achievement 3.20 · Improvement 5.03
Adjusted total nurse staffing
0
Baseline 3.59 hours · Performance 2.98 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.04% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 63 · Observed rate 14.29% · Lower 95% interval 8.04% |
| Discharge to community | 51.7% |
50.57%
1.1 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 44.12% · Lower 95% interval 39.77% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.06% |
95.27%
1.8 pts better
|
Numerator 33 · Denominator 34 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 34 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 16 · 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 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.35% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 9.52% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 4.35% |
8.2%
3.8 pts worse
|
Numerator 4 · Denominator 92 |
| Staff flu vaccination coverage | 12.22% |
42%
29.8 pts worse
|
Numerator 11 · Denominator 90 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 16 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 98.5% |
92.4%
6.1 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 98.5% · Q4 96.9% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.8% |
94.5%
0.3 pts better
|
95.5%
0.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.3%
0.1 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.4% · Q3 4.6% · Q4 4.7% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.3% |
26.1%
7.8 pts better
|
11.4%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 17.7% · Q3 5.5% · Q4 21.1% · 4Q avg 18.3% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.2%
0.3 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 5.8% · Q3 5.9% · Q4 2.1% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.4% |
25.4%
1 pts worse
|
19.6%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 23.1% · Q3 25.5% · Q4 28.0% · 4Q avg 26.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.1% |
11.5%
6.4 pts better
|
16.7%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.4% · Q3 8.1% · Q4 2.5% · 4Q avg 5.1% · 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 | 4.0% |
7.7%
3.7 pts better
|
16.3%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 4.0% · Q4 6.6% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.8% |
6.2%
0.4 pts better
|
14.9%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 3.8% · Q3 2.0% · Q4 4.2% · 4Q avg 5.8% · 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 | 1.9% |
0.5%
1.4 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 3.1% · Q4 3.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
21.7%
5.8 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.4% · Q2 25.8% · Q3 20.9% · Q4 31.3% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
3.7%
0.3 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.1% · Q3 1.4% · Q4 7.7% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.6% |
78.1%
10.5 pts better
|
81.7%
6.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.4% · Q2 88.6% · Q3 86.3% · Q4 90.1% · 4Q avg 88.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.8% |
12.5%
9.7 pts better
|
12.0%
9.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.8% · Observed 3.1% · Expected 12.3% · 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 | 86.8% |
75.6%
11.2 pts better
|
79.7%
7.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
25.1%
6.9 pts better
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 18.8% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-19 · Fire 2023-10-19
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-05-27 · Fire 2021-05-27
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-11-14
E · Potential for more than minimal harm
2025-09-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-11-14
F · Potential for more than minimal harm
2023-10-19
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 2023-11-14
F · Potential for more than minimal harm
2023-10-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-10-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-10-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-10-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-10-19
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 2023-11-14
E · Potential for more than minimal harm
2021-05-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-07-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-14
D · Potential for more than minimal harm
2025-09-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-11-14
D · Potential for more than minimal harm
2025-09-25
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 2025-11-14
G · Actual harm
2023-10-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-10-19
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 2023-11-14
F · Potential for more than minimal harm
2023-10-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-14
F · Potential for more than minimal harm
2023-10-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-19
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 2023-11-14
D · Potential for more than minimal harm
2023-10-19
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 2023-11-14
D · Potential for more than minimal harm
2023-10-19
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 2023-11-14
D · Potential for more than minimal harm
2023-10-19
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 2023-11-14
D · Potential for more than minimal harm
2023-10-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-19
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-19
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-10-19
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 2023-11-14
F · Potential for more than minimal harm
2021-05-27
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 2021-07-27
E · Potential for more than minimal harm
2021-05-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-27
E · Potential for more than minimal harm
2021-05-27
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 2021-07-27
D · Potential for more than minimal harm
2021-05-27
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 2021-07-27
D · Potential for more than minimal harm
2021-05-27
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 2021-07-27
D · Potential for more than minimal harm
2021-05-27
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 2021-07-27
D · Potential for more than minimal harm
2021-05-27
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 2021-07-27
D · Potential for more than minimal harm
2021-05-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-07-27
D · Potential for more than minimal harm
2021-05-27
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 2021-07-27
Penalties and ownership
What sits behind the stars
$22,432
2023-10-19
Fine
Fine · fine $22,432
Fine
Ownership
Majestic Care Of Toledo Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Marx, David
5% Or Greater Indirect Ownership Interest · Individual
131 North Wheeling Street LLC
Operational/Managerial Control · Organization
Chamberlain, Margaret
Operational/Managerial Control · Individual
Majestic Management LLC
Operational/Managerial Control · Organization
Polisetty, Sudheer
Operational/Managerial Control · Individual
Pruitt, Paul
Operational/Managerial Control · Individual
Rewa, Angela
Operational/Managerial Control · Individual
Russell, Robert
Operational/Managerial Control · Individual
Shatrov, Anzhelika
Operational/Managerial Control · Individual
Voyles-Baden, Cathleen
Operational/Managerial Control · Individual
Wolfe, Eric
Operational/Managerial Control · Individual
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#3
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