Cycle 1
Health 2025-01-23 · Fire 2025-01-23
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Brecksville, OH
Oaks Of Brecksville
3-star overall rating with 3-star inspections with $8,057 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
8757 Brecksville Road, Brecksville, OH
(440) 546-0643
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
80
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Saber Healthcare Group
Operator or chain grouping
Approved since
2011-09-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
126 facilities
Chain averages 3 overall / 3 health / 3 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
0.57
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,063
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9848
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.28% · Performance 24.76% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.75
Baseline 7.46% · Performance 6.71% · Measure score 3.75 · Achievement 3.75 · Improvement 2.52
Total nurse turnover
3.97
Baseline 71.29% · Performance 50.53% · Measure score 3.97 · Achievement 3.22 · Improvement 3.97
Adjusted total nurse staffing
3.46
Baseline 3.25 hours · Performance 4.06 hours · Measure score 3.46 · Achievement 3.46 · Improvement 2.72
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.81% |
10.72%
3.1 pts worse
|
No Different than the National Rate · Eligible stays 245 · Observed rate 17.55% · Lower 95% interval 10.33% |
| Discharge to community | 52.24% |
50.57%
1.7 pts better
|
No Different than the National Rate · Eligible stays 244 · Observed rate 44.26% · Lower 95% interval 45.67% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.09% |
95.27%
2.8 pts better
|
Numerator 205 · Denominator 209 |
| Falls with major injury | 0.48% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 209 |
| Discharge self-care score | 71.7% |
53.69%
18 pts better
|
Numerator 114 · Denominator 159 |
| Discharge mobility score | 19.5% |
50.94%
31.4 pts worse
|
Numerator 31 · Denominator 159 |
| Pressure ulcers or injuries, new or worsened | 0.48% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 209 · Adjusted rate 0.65% |
| Healthcare-associated infections requiring hospitalization | 6.71% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 6.2% · Lower 95% interval 4.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 158 |
| Staff flu vaccination coverage | 10.9% |
42%
31.1 pts worse
|
Numerator 17 · Denominator 156 |
| Discharge function score | 41.51% |
56.45%
14.9 pts worse
|
Numerator 66 · Denominator 159 |
| Transfer of health information to provider | 99.35% |
95.95%
3.4 pts better
|
Numerator 154 · Denominator 155 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 47.54% |
25.2%
22.3 pts better
|
Numerator 58 · Denominator 122 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
92.4%
3.9 pts better
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.8% · Q4 87.2% · 4Q avg 96.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.5%
3.6 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.3%
0.9 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 4.1% · Q3 6.5% · Q4 4.3% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 30.3% |
26.1%
4.2 pts worse
|
11.4%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 20.0% · Q3 36.6% · Q4 50.0% · 4Q avg 30.3% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
6.2%
4 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.9% · Q3 0.0% · Q4 2.9% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.6% |
25.4%
6.2 pts worse
|
19.6%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 23.5% · Q3 50.0% · Q4 33.3% · 4Q avg 31.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
11.5%
4.9 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 6.9% · Q3 10.7% · Q4 2.9% · 4Q avg 6.6% · 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 | 6.4% |
7.7%
1.3 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
6.2%
2.4 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.2% · Q3 6.5% · Q4 2.9% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.2%
0.4 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.6% · Q4 0.0% · 4Q avg 0.6% · 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 | 14.7% |
21.7%
7 pts better
|
19.8%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 13.7% · Q3 18.1% · Q4 17.4% · 4Q avg 14.7% |
| Percentage of long-stay residents with pressure ulcers | 1.8% |
3.7%
1.9 pts better
|
5.1%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.8% · Q3 1.8% · Q4 1.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.2% |
78.1%
22.9 pts worse
|
81.7%
26.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 59.5% · Q2 61.0% · Q3 52.9% · Q4 46.1% · 4Q avg 55.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
12.5%
2.7 pts worse
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 13.8% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.9% |
75.6%
18.7 pts worse
|
79.7%
22.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.0% |
25.1%
8.9 pts worse
|
23.9%
10.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.0% · Observed 31.1% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
3 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-08-05 · Fire 2021-08-05
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-23
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-23
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-02-10
F · Potential for more than minimal harm
2023-12-21
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-01-19
F · Potential for more than minimal harm
2023-12-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-19
E · Potential for more than minimal harm
2023-12-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-19
F · Potential for more than minimal harm
2021-08-05
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 2021-09-15
F · Potential for more than minimal harm
2021-08-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-15
F · Potential for more than minimal harm
2021-08-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2021-09-15
F · Potential for more than minimal harm
2021-08-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-09-15
F · Potential for more than minimal harm
2021-08-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-09-15
F · Potential for more than minimal harm
2021-08-05
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 2021-09-15
F · Potential for more than minimal harm
2021-08-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-09-15
E · Potential for more than minimal harm
2021-08-05
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-09-15
E · Potential for more than minimal harm
2021-08-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-09-15
Inspection history
Recent health citations
G · Actual harm
2025-07-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-28
E · Potential for more than minimal harm
2025-07-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-02-23
E · Potential for more than minimal harm
2025-01-23
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 2025-02-10
E · Potential for more than minimal harm
2025-01-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-23
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-08-26
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-28
D · Potential for more than minimal harm
2023-12-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-19
B · Minimal harm
2023-12-21
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-01-02
G · Actual harm
2023-07-27
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 2023-05-18
Penalties and ownership
What sits behind the stars
$8,057
2023-07-27
Fine
Fine · fine $8,057
Fine
Ownership
Saber Healthcare Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Benjamin N. Volpe Family Dynasty Trust (Dated December 29, 2020)
5% Or Greater Indirect Ownership Interest · Organization
Bnv Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Decanted William I. Weisberg Family Dynasty Trust (Dated Sept 30, 2020
5% Or Greater Indirect Ownership Interest · Organization
Dombrowski, John
Operational/Managerial Control · Individual
Nicoluzakis, Gregory
Corporate Officer · Individual
Saber Governance LLC
Operational/Managerial Control · Organization
Shg Management LLC
Operational/Managerial Control · Organization
Volpe, Benjamin
Corporate Director · Individual
Volpe, Benjamin
Corporate Officer · Individual
Weisberg, William
Corporate Director · Individual
Weisberg, William
Corporate Officer · Individual
Wiw Dynasty LLC
5% Or Greater Indirect Ownership Interest · Organization
Youell, Valerie
Operational/Managerial Control · Individual
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#3
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