Cycle 1
Health 2025-04-17 · Fire 2025-04-17
9 health deficiencies
Top issue: Infection Control (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Lakeside, OH
Otterbein North Shore
4-star overall rating with 4-star inspections with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
9400 North Shore Blvd, Lakeside, OH
(419) 798-8203
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
20
Certified beds
Average residents
17
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Otterbein Seniorlife
Operator or chain grouping
Approved since
2007-10-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.95
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.03
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.44
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.42
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.98
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.83
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
1.42
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.90
CMS adjusted RN staffing hours
Adjusted total hours
5.28
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
71%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,905
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9885
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.77
Baseline 20.23% · Performance 21.07% · Measure score 0.77 · Achievement 0.77 · Improvement 0
Healthcare-associated infections
8.02
Baseline 5.63% · Performance 5.44% · Measure score 8.02 · Achievement 8.02 · Improvement 2.53
Total nurse turnover
1.60
Baseline 51.61% · Performance 57.14% · Measure score 1.60 · Achievement 1.60 · Improvement 0
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.51% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 15.63% · Lower 95% interval 9.26% |
| Discharge to community | 61.62% |
50.57%
11 pts better
|
Better than the National Rate · Eligible stays 99 · Observed rate 57.58% · Lower 95% interval 54.16% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 57 · Denominator 57 |
| Falls with major injury | 1.75% |
0.77%
1 pts worse
|
Numerator 1 · Denominator 57 |
| Discharge self-care score | 70.73% |
53.69%
17 pts better
|
Numerator 29 · Denominator 41 |
| Discharge mobility score | 56.1% |
50.94%
5.2 pts better
|
Numerator 23 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 1.75% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 57 · Adjusted rate 2.95% |
| Healthcare-associated infections requiring hospitalization | 5.44% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 0% · Lower 95% interval 2.73% |
| Staff COVID-19 vaccination coverage | 7.46% |
8.2%
0.7 pts worse
|
Numerator 5 · Denominator 67 |
| Staff flu vaccination coverage | 16.79% |
42%
25.2 pts worse
|
Numerator 23 · Denominator 137 |
| Discharge function score | 60.98% |
56.45%
4.5 pts better
|
Numerator 25 · Denominator 41 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 16.13% |
25.2%
9.1 pts worse
|
Numerator 5 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.6% |
3.3%
5.3 pts worse
|
3.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
26.1%
22.9 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 9.7% |
6.2%
3.5 pts worse
|
5.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 59.4% |
25.4%
34 pts worse
|
19.6%
39.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 59.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.0% |
11.5%
18.5 pts worse
|
16.7%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.6% |
6.2%
2.6 pts better
|
14.9%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · 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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.5% |
21.7%
14.8 pts worse
|
19.8%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 36.5% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
3.7%
2.7 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
78.1%
21.1 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.4% · Q3 98.4% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.2% |
12.5%
1.7 pts worse
|
12.0%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.2% · Observed 12.5% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.9% |
75.6%
10.3 pts better
|
79.7%
6.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.6% |
25.1%
8.5 pts worse
|
23.9%
9.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.6% · Observed 27.1% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-23 · Fire 2023-03-23
5 health deficiencies
Top issue: Administration (2 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2020-02-12 · Fire 2020-02-12
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-17
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-17
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-17
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
2025-04-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-30
F · Potential for more than minimal harm
2025-04-17
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 2025-05-30
F · Potential for more than minimal harm
2025-04-17
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-05-30
E · Potential for more than minimal harm
2025-04-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-30
F · Potential for more than minimal harm
2023-03-23
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 2023-04-27
F · Potential for more than minimal harm
2023-03-23
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-23
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-04-27
F · Potential for more than minimal harm
2023-03-23
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-27
E · Potential for more than minimal harm
2023-03-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-27
F · Potential for more than minimal harm
2020-02-12
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2020-03-23
F · Potential for more than minimal harm
2020-02-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-03-23
F · Potential for more than minimal harm
2020-02-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-03-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-22
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 2025-11-03
F · Potential for more than minimal harm
2025-04-17
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 2025-05-30
D · Potential for more than minimal harm
2025-04-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-17
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-30
D · Potential for more than minimal harm
2025-04-17
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-30
B · Minimal harm
2025-04-17
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2025-04-30
B · Minimal harm
2025-04-17
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-30
F · Potential for more than minimal harm
2024-06-17
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-06-17
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-07-01
E · Potential for more than minimal harm
2023-03-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-27
D · Potential for more than minimal harm
2023-03-23
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-04-27
C · Minimal harm
2023-03-23
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-04-18
D · Potential for more than minimal harm
2020-02-12
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2020-03-23
Penalties and ownership
What sits behind the stars
Ownership
Otterbein Home
5% Or Greater Indirect Ownership Interest · Organization
Otterbein Lsc, LLC
5% Or Greater Direct Ownership Interest · Organization
App, Lynn
Operational/Managerial Control · Individual
App, Lynn
Corporate Director · Individual
Bartlett, Victoria
Operational/Managerial Control · Individual
Bayliff, Becky
Operational/Managerial Control · Individual
Brownson, William
Operational/Managerial Control · Individual
Burke, Daniel
Operational/Managerial Control · Individual
Coleman, Robert
Operational/Managerial Control · Individual
Fraley, Ralph
Operational/Managerial Control · Individual
Functional Pathways Of Tennessee LLC
Operational/Managerial Control · Organization
Glosser, Heidi
Operational/Managerial Control · Individual
Green, James
Operational/Managerial Control · Individual
Green, James
Corporate Officer · Individual
Hawkins, Rita
Operational/Managerial Control · Individual
Hazelbaker, Tomas
Operational/Managerial Control · Individual
Lenthe, Jennifer
Operational/Managerial Control · Individual
Miller, Jason
Corporate Officer · Individual
Otterbein Home
Operational/Managerial Control · Organization
Pierce, John
Operational/Managerial Control · Individual
Vonderhaar, Steve
Operational/Managerial Control · Individual
Wilson, Jill
Corporate Officer · Individual
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#2
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#3
Concord Care And Rehabilitation Center
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4-star overall rating with 3-star inspections with 2 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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