Cycle 1
Health 2025-05-15 · Fire 2025-05-15
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Willoughby, OH
Ohio Living Breckenridge Village
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
36855 Ridge Rd, Willoughby, OH
(440) 942-4342
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
72
Certified beds
Average residents
63
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ohio Living Communities
Operator or chain grouping
Approved since
1982-06-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 5 overall / 4 health / 4 staffing / 5 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
0.88
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.38
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.38
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.00
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.86
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.46
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
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.11
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,550
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9831
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.39% · Performance 25.76% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.23% · Performance 9.70% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.68
Baseline 52.85% · Performance 44.56% · Measure score 4.68 · Achievement 4.68 · Improvement 2.46
Adjusted total nurse staffing
4.65
Baseline 4.54 hours · Performance 4.40 hours · Measure score 4.65 · Achievement 4.65 · 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 189 · Observed rate 14.81% · Lower 95% interval 10.24% |
| Discharge to community | 51.42% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 187 · Observed rate 46.52% · Lower 95% interval 44.28% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.24% |
95.27%
4 pts better
|
Numerator 131 · Denominator 132 |
| Falls with major injury | 0.76% |
0.77%
About the same
|
Numerator 1 · Denominator 132 |
| Discharge self-care score | 74.19% |
53.69%
20.5 pts better
|
Numerator 69 · Denominator 93 |
| Discharge mobility score | 51.61% |
50.94%
0.7 pts better
|
Numerator 48 · Denominator 93 |
| Pressure ulcers or injuries, new or worsened | 0.76% |
2.29%
1.5 pts better
|
Numerator 1 · Denominator 132 · Adjusted rate 0.9% |
| Healthcare-associated infections requiring hospitalization | 9.7% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 121 · Observed rate 11.57% · Lower 95% interval 6.49% |
| Staff COVID-19 vaccination coverage | 7.75% |
8.2%
0.4 pts worse
|
Numerator 10 · Denominator 129 |
| Staff flu vaccination coverage | 28.57% |
42%
13.4 pts worse
|
Numerator 48 · Denominator 168 |
| Discharge function score | 56.99% |
56.45%
0.5 pts better
|
Numerator 53 · Denominator 93 |
| Transfer of health information to provider | 94.55% |
95.95%
1.4 pts worse
|
Numerator 52 · Denominator 55 |
| Transfer of health information to patient | 95.31% |
96.28%
1 pts worse
|
Numerator 61 · Denominator 64 |
| Resident COVID-19 vaccinations up to date | 32.39% |
25.2%
7.2 pts better
|
Numerator 23 · Denominator 71 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.8
1.1 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.1 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.8
1.6 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
92.4%
2 pts better
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 95.5% · Q3 100.0% · Q4 90.2% · 4Q avg 94.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 49.0% |
94.5%
45.5 pts worse
|
95.5%
46.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 49.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.3% · Q3 0.0% · Q4 2.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
26.1%
21.6 pts better
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 5.1% · Q3 0.0% · Q4 5.6% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 10.9% |
6.2%
4.7 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 17.4% · Q3 8.7% · Q4 7.7% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.9% |
25.4%
17.5 pts better
|
19.6%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.3% · Q3 8.7% · Q4 15.4% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.3% |
11.5%
9.2 pts better
|
16.7%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.3% · 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 | 40.2% |
7.7%
32.5 pts worse
|
16.3%
23.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 40.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
6.2%
3.1 pts worse
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 19.0% · Q4 5.0% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.2%
0.3 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.5%
0.1 pts worse
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.3% |
21.7%
13.6 pts worse
|
19.8%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.8% · Q2 36.2% · Q3 36.5% · Q4 24.5% · 4Q avg 35.3% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
3.7%
1.3 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 5.1% · Q3 4.8% · Q4 6.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 66.0% |
78.1%
12.1 pts worse
|
81.7%
15.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 62.8% · Q2 70.4% · Q3 68.6% · Q4 62.1% · 4Q avg 66.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
12.5%
1.6 pts better
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 10.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.9% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.3% |
75.6%
2.3 pts worse
|
79.7%
6.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
25.1%
0.3 pts better
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 24.0% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-30 · Fire 2022-06-30
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-06-27 · Fire 2019-06-27
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-05-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-29
E · Potential for more than minimal harm
2025-05-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-05-29
E · Potential for more than minimal harm
2025-05-15
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 2025-05-29
E · Potential for more than minimal harm
2025-05-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-29
F · Potential for more than minimal harm
2022-06-30
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-06-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-06-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-30
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-07-15
Inspection history
Recent health citations
G · Actual harm
2025-11-25
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.
Not marked corrected
F · Potential for more than minimal harm
2025-05-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-29
D · Potential for more than minimal harm
2022-06-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-07-15
C · Minimal harm
2022-06-30
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2022-07-15
E · Potential for more than minimal harm
2019-06-27
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 2019-07-10
Penalties and ownership
What sits behind the stars
Ownership
Adam, Sandra
Corporate Director · Individual
Belfance, Leslie
Corporate Director · Individual
Gumina, Laurence
Operational/Managerial Control · Individual
Gumina, Laurence
Corporate Officer · Individual
Ingwersen, Melissa
Corporate Director · Individual
Joyce, James
Corporate Director · Individual
Stillman, Robert
Corporate Officer · Individual
White, Terry
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Willoughby Post Acute
Willoughby, OH
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
#2
Wickliffe Country Place
Wickliffe, OH
3-star overall rating with 2-star inspections with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Altercare Of Mayfield Village, Inc
Mayfield Village, OH
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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