Mentor, OH

Mentor Hills Post Acute

2-star overall rating with 3-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

8200 Mentor Hills Drive, Mentor, OH

(440) 256-1496

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

147

Certified beds

Average residents

102

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Legacy Health Services

Operator or chain grouping

Approved since

1986-12-26

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

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

0.42

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.69

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.03

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.14

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.11

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

2.81

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.23

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

0.41

CMS adjusted RN staffing hours

Adjusted total hours

3.05

CMS adjusted total nurse staffing hours

Case-mix index

1.41

Higher values indicate more complex resident acuity

RN turnover

63%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

72%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,698

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

Performance score

1.52

Composite VBP score used to determine payment impact.

Payment multiplier

0.9804

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 22.20% · Performance 21.94% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0.60

Baseline 4.77% · Performance 7.65% · Measure score 0.60 · Achievement 0.60 · Improvement 0

Total nurse turnover

Baseline 46.90% · Performance 69.16% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

Baseline 3.53 hours · Performance 3.03 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.32%	10.72% 0.4 pts better	No Different than the National Rate · Eligible stays 120 · Observed rate 10% · Lower 95% interval 7.34%
Discharge to community	50.71%	50.57% 0.1 pts better	No Different than the National Rate · Eligible stays 146 · Observed rate 43.15% · Lower 95% interval 43.56%
Medicare spending per beneficiary	0.94	1.02 0.1 pts better
Drug regimen review with follow-up	97.67%	95.27% 2.4 pts better	Numerator 42 · Denominator 43
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 43
Discharge self-care score	60.71%	53.69% 7 pts better	Numerator 17 · Denominator 28
Discharge mobility score	57.14%	50.94% 6.2 pts better	Numerator 16 · Denominator 28
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 43 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	7.65%	7.12% 0.5 pts worse	No Different than the National Rate · Eligible stays 69 · Observed rate 8.7% · Lower 95% interval 4.92%
Staff COVID-19 vaccination coverage	54.55%	8.2% 46.3 pts better	Numerator 60 · Denominator 110
Staff flu vaccination coverage	0%	42% 42 pts worse	Numerator 0 · Denominator 239
Discharge function score	57.14%	56.45% 0.7 pts better	Numerator 16 · Denominator 28
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	95.24%	96.28% 1 pts worse	Numerator 20 · Denominator 21
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

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	90.3%	92.4% 2.1 pts worse	93.4% 3.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 89.6% · Q2 95.6% · Q3 93.8% · Q4 82.1% · 4Q avg 90.3%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.0%	94.5% 0.5 pts better	95.5% 0.5 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.0%
Percentage of long-stay residents experiencing one or more falls with major injury	3.1%	3.3% 0.2 pts better	3.3% 0.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 2.2% · Q3 3.7% · Q4 3.6% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	12.7%	26.1% 13.4 pts better	11.4% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 6.6% · Q3 15.7% · Q4 19.5% · 4Q avg 12.7%
Percentage of long-stay residents who lose too much weight	6.4%	6.2% 0.2 pts worse	5.4% 1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.9% · Q3 9.9% · Q4 8.5% · 4Q avg 6.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.2%	25.4% 5.8 pts worse	19.6% 11.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q2 30.9% · Q3 32.4% · Q4 28.2% · 4Q avg 31.2%
Percentage of long-stay residents who received an antipsychotic medication	14.6%	11.5% 3.1 pts worse	16.7% 2.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 17.6% · Q3 17.3% · Q4 15.4% · 4Q avg 14.6% · 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	8.6%	7.7% 0.9 pts worse	16.3% 7.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q4 3.7% · 4Q avg 8.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.7%	6.2% 0.5 pts worse	14.9% 8.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.1% · Q3 4.5% · Q4 6.0% · 4Q avg 6.7% · 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	31.5%	21.7% 9.8 pts worse	19.8% 11.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 38.3% · Q3 23.1% · Q4 28.2% · 4Q avg 31.5%
Percentage of long-stay residents with pressure ulcers	11.6%	3.7% 7.9 pts worse	5.1% 6.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 12.4% · Q3 14.8% · Q4 7.9% · 4Q avg 11.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	37.6%	78.1% 40.5 pts worse	81.7% 44.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 45.8% · Q2 59.2% · Q3 31.4% · Q4 22.5% · 4Q avg 37.6%
Percentage of short-stay residents who had an outpatient emergency department visit	23.4%	12.5% 10.9 pts worse	12.0% 11.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 23.4% · Observed 23.3% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.0%	1.2% 0.8 pts worse	1.6% 0.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 2.0% · Q4 3.8% · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	47.5%	75.6% 28.1 pts worse	79.7% 32.2 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 47.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.8%	25.1% 4.3 pts better	23.9% 3.1 pts better	Short Stay · 20240701-20250630 · Adjusted 20.8% · Observed 20.9% · Expected 23.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-02-13 · Fire 2025-02-13

4 health deficiencies

Top issue: Administration (1 deficiency)

6 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2022-09-19 · Fire 2022-09-19

15 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

11 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2019-09-13 · Fire 2019-09-13

21 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

9 fire-safety deficiencies

Top issue: Emergency Preparedness (5 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-02-13

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2025-03-19

F · Potential for more than minimal harm 2025-02-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-13

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-13

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2025-03-12

F · Potential for more than minimal harm 2025-02-13

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2025-03-19

E · Potential for more than minimal harm 2025-02-13

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-03-12

F · Potential for more than minimal harm 2022-09-19

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2022-10-25

F · Potential for more than minimal harm 2022-09-19

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2022-10-25

F · Potential for more than minimal harm 2022-09-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-10-25

F · Potential for more than minimal harm 2022-09-19

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-10-25

F · Potential for more than minimal harm 2022-09-19

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2022-10-25

F · Potential for more than minimal harm 2022-09-19

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-10-25

F · Potential for more than minimal harm 2022-09-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2022-10-25

E · Potential for more than minimal harm 2022-09-19

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2022-10-25

E · Potential for more than minimal harm 2022-09-19

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2022-10-25

E · Potential for more than minimal harm 2022-09-19

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-10-25

E · Potential for more than minimal harm 2022-09-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-10-25

F · Potential for more than minimal harm 2019-09-13

E1 · Emergency Preparedness Deficiencies

Fire Safety

Establish an Emergency Preparedness Program (EP).

Corrected 2019-11-19

F · Potential for more than minimal harm 2019-09-13

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2019-12-10

F · Potential for more than minimal harm 2019-09-13

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-11-19

E · Potential for more than minimal harm 2019-09-13

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2019-11-19

E · Potential for more than minimal harm 2019-09-13

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-11-19

E · Potential for more than minimal harm 2019-09-13

K925 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that sources of ignition are removed from patients receiving respiratory therapy.

Corrected 2019-11-19

C · Minimal harm 2019-09-13

E25 · Emergency Preparedness Deficiencies

Fire Safety

Create arrangements with other facilities to receive patients.

Corrected 2019-10-28

C · Minimal harm 2019-09-13

E33 · Emergency Preparedness Deficiencies

Fire Safety

Establish methods for sharing information.

Corrected 2019-10-28

C · Minimal harm 2019-09-13

E35 · Emergency Preparedness Deficiencies

Fire Safety

Provide family notifications of emergency plan.

Corrected 2019-10-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-06-05

F774 · Administration Deficiencies

Health

Help the resident with transportation to and from laboratory services outside of the facility.

Corrected 2025-06-13

F · Potential for more than minimal harm 2025-02-13

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-12

D · Potential for more than minimal harm 2025-02-13

F657 · Resident Assessment and Care Planning Deficiencies

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 2025-03-12

C · Minimal harm 2025-02-13

F585 · Resident Rights Deficiencies

Health

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Corrected 2025-02-26

D · Potential for more than minimal harm 2024-12-23

F803 · Nutrition and Dietary Deficiencies

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 2024-12-30

G · Actual harm 2024-07-25

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-08-06

D · Potential for more than minimal harm 2024-07-25

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-08-06

D · Potential for more than minimal harm 2024-07-25

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 2024-08-06

D · Potential for more than minimal harm 2023-06-23

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 2023-06-27

E · Potential for more than minimal harm 2023-06-01

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 2023-06-27

D · Potential for more than minimal harm 2023-06-01

F657 · Resident Assessment and Care Planning Deficiencies

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 2023-06-27

D · Potential for more than minimal harm 2023-06-01

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 2023-06-27

D · Potential for more than minimal harm 2023-06-01

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 2023-06-27

F · Potential for more than minimal harm 2022-09-19

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 2022-10-25

E · Potential for more than minimal harm 2022-09-19

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2022-10-25

E · Potential for more than minimal harm 2022-09-19

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 2022-10-25

E · Potential for more than minimal harm 2022-09-19

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 2022-10-25

D · Potential for more than minimal harm 2022-09-19

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 2022-10-25

D · Potential for more than minimal harm 2022-09-19

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2022-10-25

D · Potential for more than minimal harm 2022-09-19

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2022-10-25

D · Potential for more than minimal harm 2022-09-19

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2022-10-25

D · Potential for more than minimal harm 2022-09-19

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2022-10-25

D · Potential for more than minimal harm 2022-09-19

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2022-10-25

D · Potential for more than minimal harm 2022-09-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-10-25

F · Potential for more than minimal harm 2019-09-13

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2019-11-20

F · Potential for more than minimal harm 2019-09-13

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 2019-11-20

F · Potential for more than minimal harm 2019-09-13

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2019-11-20

F · Potential for more than minimal harm 2019-09-13

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 2019-11-20