Cycle 1
Health 2024-02-22 · Fire 2024-02-22
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Mentor, OH
Mentor Ridge Health And Rehabilitation
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
8151 Norton Parkway, Mentor, OH
(440) 299-5500
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
2017-08-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
63 facilities
Chain averages 4 overall / 4 health / 2 staffing / 4 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
0.71
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.44
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
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.28
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,137
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.61% · Performance 22.46% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.64
Baseline 4.55% · Performance 7.05% · Measure score 2.64 · Achievement 2.64 · Improvement 0
Total nurse turnover
5.55
Baseline 50.00% · Performance 41.00% · Measure score 5.55 · Achievement 5.55 · Improvement 3.08
Adjusted total nurse staffing
0.35
Baseline 2.43 hours · Performance 2.72 hours · Measure score 0.35 · Achievement 0 · Improvement 0.35
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.1% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 581 · Observed rate 9.64% · Lower 95% interval 8.51% |
| Discharge to community | 53.05% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 613 · Observed rate 48.61% · Lower 95% interval 48.71% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.16% |
95.27%
3.9 pts better
|
Numerator 354 · Denominator 357 |
| Falls with major injury | 0.56% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 357 |
| Discharge self-care score | 66.5% |
53.69%
12.8 pts better
|
Numerator 131 · Denominator 197 |
| Discharge mobility score | 45.69% |
50.94%
5.2 pts worse
|
Numerator 90 · Denominator 197 |
| Pressure ulcers or injuries, new or worsened | 1.12% |
2.29%
1.2 pts better
|
Numerator 4 · Denominator 357 · Adjusted rate 1.33% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 374 · Observed rate 6.68% · Lower 95% interval 4.66% |
| Staff COVID-19 vaccination coverage | 4.11% |
8.2%
4.1 pts worse
|
Numerator 6 · Denominator 146 |
| Staff flu vaccination coverage | 9.91% |
42%
32.1 pts worse
|
Numerator 23 · Denominator 232 |
| Discharge function score | 56.85% |
56.45%
0.4 pts better
|
Numerator 112 · Denominator 197 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 93 · Denominator 93 |
| Transfer of health information to patient | 99.57% |
96.28%
3.3 pts better
|
Numerator 233 · Denominator 234 |
| Resident COVID-19 vaccinations up to date | 30.64% |
25.2%
5.4 pts better
|
Numerator 53 · Denominator 173 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.1 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
92.4%
7.2 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 72.9% |
94.5%
21.6 pts worse
|
95.5%
22.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 72.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
3.3%
2.6 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.7% · Q3 6.3% · Q4 7.8% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 50.0% |
26.1%
23.9 pts worse
|
11.4%
38.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.0% · Q2 57.6% · Q3 38.3% · Q4 59.3% · 4Q avg 50.0% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
6.2%
0.1 pts better
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 8.2% · Q3 6.5% · Q4 4.0% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.5% |
25.4%
18.9 pts better
|
19.6%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 4.1% · Q3 4.3% · Q4 7.8% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
11.5%
7.9 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.4% · Q3 2.6% · Q4 7.1% · 4Q avg 3.6% · 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 | 6.1% |
7.7%
1.6 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.1% |
6.2%
2.1 pts better
|
14.9%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 2.1% · Q3 2.2% · Q4 4.1% · 4Q avg 4.1% · 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 | 0.8% |
0.5%
0.3 pts worse
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.3% |
21.7%
10.6 pts worse
|
19.8%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 39.3% · Q3 32.2% · Q4 32.4% · 4Q avg 32.3% |
| 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 9.1% · Q2 2.3% · Q3 1.0% · Q4 1.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
78.1%
18.7 pts better
|
81.7%
15.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 95.8% · Q3 96.4% · Q4 99.6% · 4Q avg 96.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
12.5%
4.6 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 16.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 1.2% · Q4 0.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
75.6%
14.1 pts better
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.0% |
25.1%
3.9 pts worse
|
23.9%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.0% · Observed 26.2% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-29 · Fire 2021-11-29
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2020-01-09 · Fire 2020-01-09
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-09
E · Potential for more than minimal harm
2024-02-22
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-03-09
E · Potential for more than minimal harm
2024-02-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-09
F · Potential for more than minimal harm
2021-11-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-06
F · Potential for more than minimal harm
2021-11-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-11-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-06
F · Potential for more than minimal harm
2020-01-09
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 2020-01-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-02-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-09
D · Potential for more than minimal harm
2024-02-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-09
Penalties and ownership
What sits behind the stars
Ownership
Colleran Fam Tr Dated 01-01-2018
5% Or Greater Indirect Ownership Interest · Organization
Foundations Health LLC
5% Or Greater Direct Ownership Interest · Organization
Colleran, Brian
Operational/Managerial Control · Individual
Colleran, Brian
Corporate Director · Individual
Colleran, Brian
Corporate Officer · Individual
Foundations Health Solutions, LLC
Operational/Managerial Control · Organization
Granito, David
Operational/Managerial Control · Individual
Krystowski, John
Operational/Managerial Control · Individual
Krystowski, John
Corporate Officer · Individual
Nearby options
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#2
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#3
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3-star overall rating with 2-star inspections with $52,600 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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