Cycle 1
Health 2025-04-10 · Fire 2025-04-10
3 health deficiencies
Top issue: Administration (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Euclid, OH
Mount Saint Joseph Rehab Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
21800 Chardon Road, Euclid, OH
(216) 531-7426
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
80
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-03-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing
LPN hours / resident day
1.66
Licensed practical nurse staffing
Aide hours / resident day
3.35
Nurse aide staffing
Weekend hours
5.03
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
61%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
1.8
1.6 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.1 |
1.8
2.3 pts worse
|
1.8
2.3 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.2% |
92.4%
4.2 pts worse
|
93.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.3%
1.3 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.4% |
26.1%
18.7 pts better
|
11.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.6% |
6.2%
2.6 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.3% |
25.4%
18.1 pts better
|
19.6%
12.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
11.5%
2.3 pts worse
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.2% |
7.7%
1.5 pts worse
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
6.2%
5.3 pts worse
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.2%
0.1 pts worse
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
0.5%
1.1 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.2% |
21.7%
12.5 pts better
|
19.8%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
3.7%
0.5 pts worse
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 24.1% |
78.1%
54 pts worse
|
81.7%
57.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.3% |
12.5%
12.8 pts worse
|
12.0%
13.3 pts worse
|
Short Stay · 20240701-20250630 |
| 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 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 38.0% |
75.6%
37.6 pts worse
|
79.7%
41.7 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.2% |
25.1%
9.1 pts worse
|
23.9%
10.3 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-04 · Fire 2022-08-04
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-08-29 · Fire 2019-08-29
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-10
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-10
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-10
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-30
F · Potential for more than minimal harm
2022-08-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-09-19
F · Potential for more than minimal harm
2022-08-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-19
F · Potential for more than minimal harm
2022-08-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-19
F · Potential for more than minimal harm
2019-08-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-08-29
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 2019-09-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-10
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-10
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-05-30
C · Minimal harm
2025-04-10
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-05-30
D · Potential for more than minimal harm
2023-10-05
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 2023-10-30
D · Potential for more than minimal harm
2023-10-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-30
D · Potential for more than minimal harm
2023-04-11
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-03
D · Potential for more than minimal harm
2022-08-04
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-08-04
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 2022-09-19
G · Actual harm
2019-08-29
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 2019-09-25
F · Potential for more than minimal harm
2019-08-29
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-08-29
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 2019-09-25
D · Potential for more than minimal harm
2019-08-29
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 2019-09-25
C · Minimal harm
2019-08-29
F844 · Administration Deficiencies
Health
Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.
Corrected 2019-09-25
B · Minimal harm
2019-08-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-09-25
Penalties and ownership
What sits behind the stars
Ownership
Gregg, Mary
Corporate Director · Individual
Gregg, Mary
Corporate Officer · Individual
Gregg, Mary
W-2 Managing Employee · Individual
Holzheimer, Timothy
Corporate Officer · Individual
Sovacool, Sara
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Willows Health And Rehab Ctr
Euclid, OH
4-star overall rating with 3-star inspections with $39,683 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Embassy Of Euclid
Euclid, OH
2-star overall rating with 1-star inspections with 14 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Slovene Home For The Aged
Cleveland, OH
3-star overall rating with 2-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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