Cycle 1
Health 2024-09-26 · Fire 2024-09-26
16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Millersburg, OH
Majora Lane Ctr For Rehab & Nsg Care Inc
4-star overall rating with 3-star inspections with 16 recent health deficiencies
105 Majora Lane, Millersburg, OH
(330) 674-4444
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
61
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Altercare
Operator or chain grouping
Approved since
1984-08-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 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
Hours and turnover
RN hours / resident day
0.70
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,741
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.28
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.07% · Performance 21.75% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.96
Baseline 5.91% · Performance 6.95% · Measure score 2.96 · Achievement 2.96 · Improvement 0
Total nurse turnover
4.75
Baseline 45.31% · Performance 44.26% · Measure score 4.75 · Achievement 4.75 · Improvement 0.01
Adjusted total nurse staffing
0
Baseline 3.24 hours · Performance 3.18 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.71% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 75 · Observed rate 9.33% · Lower 95% interval 6.97% |
| Discharge to community | 53.98% |
50.57%
3.4 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 55.56% · Lower 95% interval 43.42% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 2.5% |
0.77%
1.7 pts worse
|
Numerator 1 · Denominator 40 |
| Discharge self-care score | 63.33% |
53.69%
9.6 pts better
|
Numerator 19 · Denominator 30 |
| Discharge mobility score | 53.33% |
50.94%
2.4 pts better
|
Numerator 16 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 1 · Denominator 40 · Adjusted rate 2.01% |
| Healthcare-associated infections requiring hospitalization | 6.95% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 5.26% · Lower 95% interval 3.46% |
| Staff COVID-19 vaccination coverage | 3.13% |
8.2%
5.1 pts worse
|
Numerator 3 · Denominator 96 |
| Staff flu vaccination coverage | 10.66% |
42%
31.3 pts worse
|
Numerator 13 · Denominator 122 |
| Discharge function score | 73.33% |
56.45%
16.9 pts better
|
Numerator 22 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · 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 | 97.0% |
92.4%
4.6 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 91.8% · Q4 96.1% · 4Q avg 97.0% |
| 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 | 6.0% |
3.3%
2.7 pts worse
|
3.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 6.1% · Q3 6.1% · Q4 5.9% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.8% |
26.1%
10.3 pts better
|
11.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 14.9% · Q3 15.6% · Q4 14.6% · 4Q avg 15.8% |
| 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 4.8% · Q2 4.4% · Q3 2.3% · Q4 2.3% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.3% |
25.4%
4.9 pts worse
|
19.6%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 26.7% · Q3 34.1% · Q4 27.3% · 4Q avg 30.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.6% |
11.5%
2.9 pts better
|
16.7%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 8.8% · Q3 5.7% · Q4 8.1% · 4Q avg 8.6% · 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 | 3.4% |
7.7%
4.3 pts better
|
16.3%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.8% |
6.2%
1.4 pts better
|
14.9%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 4.8% · Q3 0.0% · Q4 2.4% · 4Q avg 4.8% · 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 | 0.5% |
0.5%
About the same
|
1.7%
1.2 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 new or worsened bowel or bladder incontinence | 19.2% |
21.7%
2.5 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 13.8% · Q3 16.9% · Q4 27.5% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
3.7%
3.2 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.2% |
78.1%
0.1 pts better
|
81.7%
3.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 81.1% · Q3 73.8% · Q4 65.9% · 4Q avg 78.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
12.5%
4.9 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 8.3% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.2%
0.9 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 2.0% · Q3 1.9% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.9% |
75.6%
9.3 pts better
|
79.7%
5.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
25.1%
1.4 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 29.2% · Expected 26.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-21 · Fire 2022-07-21
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-09-05 · Fire 2019-09-05
6 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-07-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-05
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-08
F688 · Quality of Life and Care Deficiencies
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 2026-02-03
D · Potential for more than minimal harm
2026-01-08
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 2026-02-03
D · Potential for more than minimal harm
2026-01-08
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2026-02-03
D · Potential for more than minimal harm
2026-01-08
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 2026-02-03
D · Potential for more than minimal harm
2026-01-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-03
E · Potential for more than minimal harm
2025-07-29
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 2025-08-14
D · Potential for more than minimal harm
2025-07-29
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 2025-08-14
D · Potential for more than minimal harm
2025-07-29
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-08-14
D · Potential for more than minimal harm
2025-07-29
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 2025-08-14
D · Potential for more than minimal harm
2025-07-29
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 2025-08-14
D · Potential for more than minimal harm
2025-07-29
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 2025-08-14
F · Potential for more than minimal harm
2024-09-26
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 2024-10-04
D · Potential for more than minimal harm
2024-09-26
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 2024-10-04
D · Potential for more than minimal harm
2024-09-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-06-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-01-08
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 2024-01-15
D · Potential for more than minimal harm
2023-11-06
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 2023-11-13
E · Potential for more than minimal harm
2019-09-05
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 2019-10-01
D · Potential for more than minimal harm
2019-09-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-09-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-09-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-10-01
Penalties and ownership
What sits behind the stars
Ownership
Tsg Nursing Centers, Inc
5% Or Greater Direct Ownership Interest · Organization
Altercare Of Ohio, Inc
Operational/Managerial Control · Organization
Film, George
Corporate Officer · Individual
Gerald F Schroer Dynasty Tr Ua 12312009 Fbo Andrew M Schroer
5% Or Greater Indirect Ownership Interest · Organization
Gerald F Schroer Dynasty Tr Ua 12312009 Fbo Gerald F Schroer Jr
5% Or Greater Indirect Ownership Interest · Organization
Gerald F Schroer Dynasty Tr Ua 12312009 Fbo Matthew Schroer
5% Or Greater Indirect Ownership Interest · Organization
Gerald F Schroer Dynasty Tr Ua 12312009 Margaret S Goodman
5% Or Greater Indirect Ownership Interest · Organization
Goodman, John
Corporate Officer · Individual
Logan, Justin
Corporate Officer · Individual
Mock, Douglas
Corporate Director · Individual
Mock, Douglas
Corporate Officer · Individual
Mock, Douglas
W-2 Managing Employee · Individual
Nutter, Orian
Corporate Officer · Individual
Susanne Schroer Dynasty Trust U/A
5% Or Greater Indirect Ownership Interest · Organization
The Schroer Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Tikkanen, David
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Scenic Pointe Nursing And Rehab Ctr
Millersburg, OH
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Sycamore Run Nursing And Rehab Ctr
Millersburg, OH
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Walnut Hills Nursing Home
Walnut Creek, OH
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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