Cycle 1
Health 2024-10-15 · Fire 2024-10-15
7 health deficiencies
Top issue: Resident Rights (3 deficiencies)
12 fire-safety deficiencies
Top issue: Miscellaneous (4 deficiencies)
Medina, OH
Medina Bsd Opco LLC
4-star overall rating with 3-star inspections with $55,035 in total fines with 7 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
550 Miner Dr, Medina, OH
(330) 725-1550
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-12-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.58
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.42
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
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
80%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,971
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.04% · Performance 22.18% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.74
Baseline 7.45% · Performance 6.72% · Measure score 3.74 · Achievement 3.74 · Improvement 2.49
Total nurse turnover
0
Performance 69.49% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 2.64 hours · Performance 2.73 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.5% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 20.73% · Lower 95% interval 8.91% |
| Discharge to community | 40.67% |
50.57%
9.9 pts worse
|
Worse than the National Rate · Eligible stays 71 · Observed rate 32.39% · Lower 95% interval 31.64% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 48 · Denominator 48 |
| Falls with major injury | 4.17% |
0.77%
3.4 pts worse
|
Numerator 2 · Denominator 48 |
| Discharge self-care score | 83.33% |
53.69%
29.6 pts better
|
Numerator 30 · Denominator 36 |
| Discharge mobility score | 75% |
50.94%
24.1 pts better
|
Numerator 27 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 48 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.72% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 5.88% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 111 |
| Staff flu vaccination coverage | 54.17% |
42%
12.2 pts better
|
Numerator 65 · Denominator 120 |
| Discharge function score | 86.11% |
56.45%
29.7 pts better
|
Numerator 31 · Denominator 36 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8% |
25.2%
17.2 pts worse
|
Numerator 2 · Denominator 25 |
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 | 98.0% |
94.5%
3.5 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.3%
0.5 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.4% · Q3 2.4% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 43.2% |
26.1%
17.1 pts worse
|
11.4%
31.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 76.6% · Q2 20.5% · Q3 35.1% · Q4 33.3% · 4Q avg 43.2% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
6.2%
3.3 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 10.0% · Q3 2.6% · Q4 7.5% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.2% |
25.4%
6.8 pts worse
|
19.6%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 23.8% · Q3 42.5% · Q4 37.5% · 4Q avg 32.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.1% |
11.5%
0.6 pts worse
|
16.7%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 15.6% · Q3 11.1% · Q4 10.5% · 4Q avg 12.1% · 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 | 9.5% |
7.7%
1.8 pts worse
|
16.3%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 9.2% · Q3 12.7% · Q4 0.0% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.9% |
6.2%
1.7 pts worse
|
14.9%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 14.6% · Q3 11.8% · Q4 2.5% · 4Q avg 7.9% · 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 | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 20.6% |
21.7%
1.1 pts better
|
19.8%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 5.1% · Q3 29.0% · Q4 37.4% · 4Q avg 20.6% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
3.7%
1.6 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 2.5% · Q3 5.5% · Q4 6.2% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
78.1%
21.9 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.1% |
12.5%
10.6 pts worse
|
12.0%
11.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 23.8% · Expected 11.5% · 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 | 90.4% |
75.6%
14.8 pts better
|
79.7%
10.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.2% |
25.1%
8.9 pts better
|
23.9%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.2% · Observed 16.7% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-23 · Fire 2022-06-23
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-07-12 · Fire 2019-07-12
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-15
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 2024-11-08
F · Potential for more than minimal harm
2024-10-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-15
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 2024-11-08
F · Potential for more than minimal harm
2024-10-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-15
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-10-15
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-11-08
F · Potential for more than minimal harm
2022-06-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-20
F · Potential for more than minimal harm
2022-06-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-20
F · Potential for more than minimal harm
2022-06-23
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 2022-07-20
E · Potential for more than minimal harm
2022-06-23
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 2022-07-20
E · Potential for more than minimal harm
2022-06-23
K321 · Smoke Deficiencies
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 2022-07-20
E · Potential for more than minimal harm
2022-06-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-07-20
E · Potential for more than minimal harm
2022-06-23
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-07-20
E · Potential for more than minimal harm
2022-06-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-20
F · Potential for more than minimal harm
2019-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-23
F · Potential for more than minimal harm
2019-07-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-08-23
F · Potential for more than minimal harm
2019-07-12
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2019-08-23
F · Potential for more than minimal harm
2019-07-12
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 2019-08-23
C · Minimal harm
2019-07-12
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-08-23
C · Minimal harm
2019-07-12
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-08-23
C · Minimal harm
2019-07-12
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2019-08-23
C · Minimal harm
2019-07-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-08-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-15
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-11-08
F · Potential for more than minimal harm
2024-10-15
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-15
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 2024-11-08
D · Potential for more than minimal harm
2024-10-15
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-15
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-11-08
D · Potential for more than minimal harm
2019-07-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-08-23
D · Potential for more than minimal harm
2019-07-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-08-23
Penalties and ownership
What sits behind the stars
$4,938
2024-02-20
Fine
Fine · fine $4,938
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$14,814
2024-01-22
Fine
Fine · fine $14,814
Fine
$4,938
2024-01-08
Fine
Fine · fine $4,938
Fine
$4,235
2024-01-02
Fine
Fine · fine $4,235
Fine
$10,586
2023-12-11
Fine
Fine · fine $10,586
Fine
$2,823
2023-11-20
Fine
Fine · fine $2,823
Fine
$2,470
2023-11-13
Fine
Fine · fine $2,470
Fine
$5,293
2023-10-23
Fine
Fine · fine $5,293
Fine
Ownership
Medina Bsf Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Luxor Healthcare Group LLC
Operational/Managerial Control · Organization
Nussbaum, Mattisyahu
5% Or Greater Indirect Ownership Interest · Individual
Nussbaum, Mattisyahu
Corporate Officer · Individual
Wade, Tiffany
Operational/Managerial Control · Individual
Wade, Tiffany
W-2 Managing Employee · Individual
Yyam Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Yyam Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
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