Middleburg Heights, OH

Parkside Villa

4-star overall rating with 3-star inspections with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

7040 Hepburn Road, Middleburg Heights, OH

(440) 260-7626

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

178

Certified beds

Average residents

152

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Legacy Health Services

Operator or chain grouping

Approved since

2001-12-05

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

14 facilities

Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars

Changed ownership

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

0.79

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.80

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.16

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.76

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.60

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.34

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.58

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.66

CMS adjusted RN staffing hours

Adjusted total hours

3.11

CMS adjusted total nurse staffing hours

Case-mix index

1.65

Higher values indicate more complex resident acuity

RN turnover

34%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,726

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

Composite VBP score used to determine payment impact.

Payment multiplier

0.9803

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 20.63% · Performance 23.64% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 7.79% · Performance 8.60% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

Baseline 3.33 hours · Performance 3.21 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.33%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 541 · Observed rate 12.01% · Lower 95% interval 9.07%
Discharge to community	61.47%	50.57% 10.9 pts better	Better than the National Rate · Eligible stays 566 · Observed rate 56.36% · Lower 95% interval 56.81%
Medicare spending per beneficiary	0.9	1.02 0.1 pts better
Drug regimen review with follow-up	99.67%	95.27% 4.4 pts better	Numerator 300 · Denominator 301
Falls with major injury	0.66%	0.77% 0.1 pts better	Numerator 2 · Denominator 301
Discharge self-care score	44.05%	53.69% 9.6 pts worse	Numerator 100 · Denominator 227
Discharge mobility score	31.28%	50.94% 19.7 pts worse	Numerator 71 · Denominator 227
Pressure ulcers or injuries, new or worsened	1%	2.29% 1.3 pts better	Numerator 3 · Denominator 301 · Adjusted rate 1.26%
Healthcare-associated infections requiring hospitalization	8.6%	7.12% 1.5 pts worse	No Different than the National Rate · Eligible stays 331 · Observed rate 9.06% · Lower 95% interval 6.13%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 253
Staff flu vaccination coverage	18.68%	42% 23.3 pts worse	Numerator 68 · Denominator 364
Discharge function score	44.93%	56.45% 11.5 pts worse	Numerator 102 · Denominator 227
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 70 · Denominator 70
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 200 · Denominator 200
Resident COVID-19 vaccinations up to date	16.88%	25.2% 8.3 pts worse	Numerator 26 · Denominator 154

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.5%	92.4% 2.1 pts better	93.4% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 95.4% · Q3 95.2% · Q4 92.2% · 4Q avg 94.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	88.4%	94.5% 6.1 pts worse	95.5% 7.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 88.4%
Percentage of long-stay residents experiencing one or more falls with major injury	2.4%	3.3% 0.9 pts better	3.3% 0.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.9% · Q3 3.8% · Q4 2.0% · 4Q avg 2.4% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	36.3%	26.1% 10.2 pts worse	11.4% 24.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 39.3% · Q2 44.4% · Q3 35.2% · Q4 26.1% · 4Q avg 36.3%
Percentage of long-stay residents who lose too much weight	4.3%	6.2% 1.9 pts better	5.4% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 4.0% · Q3 1.0% · Q4 4.2% · 4Q avg 4.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	18.4%	25.4% 7 pts better	19.6% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 19.6% · Q3 14.3% · Q4 17.7% · 4Q avg 18.4%
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% · Q2 0.0% · Q3 4.2% · Q4 1.3% · 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	4.3%	7.7% 3.4 pts better	16.3% 12 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.8% · Q3 3.7% · Q4 5.7% · 4Q avg 4.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	6.4%	6.2% 0.2 pts worse	14.9% 8.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 4.3% · Q3 6.6% · Q4 7.9% · 4Q avg 6.4% · 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	0.5%	0.5% About the same	1.7% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 1.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.4%	21.7% 0.7 pts worse	19.8% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 19.5% · Q2 21.7% · Q3 28.0% · Q4 20.3% · 4Q avg 22.4%
Percentage of long-stay residents with pressure ulcers	10.2%	3.7% 6.5 pts worse	5.1% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 12.7% · Q3 10.6% · Q4 7.9% · 4Q avg 10.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	98.8%	78.1% 20.7 pts better	81.7% 17.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.5% · Q3 99.1% · Q4 99.1% · 4Q avg 98.8%
Percentage of short-stay residents who had an outpatient emergency department visit	6.6%	12.5% 5.9 pts better	12.0% 5.4 pts better	Short Stay · 20240701-20250630 · Adjusted 6.6% · Observed 6.7% · Expected 11.3% · 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 0.0% · Q2 0.0% · Q3 0.4% · Q4 0.8% · 4Q avg 0.3% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	85.1%	75.6% 9.5 pts better	79.7% 5.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 85.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	30.2%	25.1% 5.1 pts worse	23.9% 6.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 32.3% · Expected 25.6% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-30 · Fire 2025-04-30

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2024-02-20 · Fire 2024-02-20

9 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2021-11-04 · Fire 2021-11-04

5 health deficiencies

Top issue: Resident Rights (2 deficiencies)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-30

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2025-05-21

F · Potential for more than minimal harm 2025-04-30

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-05-21

F · Potential for more than minimal harm 2025-04-30

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-05-21

F · Potential for more than minimal harm 2025-04-30

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-05-21

F · Potential for more than minimal harm 2025-04-30

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-05-21

F · Potential for more than minimal harm 2025-04-30

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 2025-05-21

E · Potential for more than minimal harm 2025-04-30

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-05-21

E · Potential for more than minimal harm 2025-04-30

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-05-21

F · Potential for more than minimal harm 2024-02-20

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-03-18

E · Potential for more than minimal harm 2024-02-20

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2024-03-18

E · Potential for more than minimal harm 2024-02-20

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 2024-03-18

F · Potential for more than minimal harm 2021-11-04

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 2021-11-19

E · Potential for more than minimal harm 2021-11-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-11-19

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-04-30

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2025-05-21

F · Potential for more than minimal harm 2025-04-30

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 2025-05-21

E · Potential for more than minimal harm 2025-04-30

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-05-21

E · Potential for more than minimal harm 2025-04-30

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 2025-05-21

D · Potential for more than minimal harm 2025-04-30

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2025-05-21

D · Potential for more than minimal harm 2025-04-30

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2025-05-21

D · Potential for more than minimal harm 2025-04-30

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-05-21

D · Potential for more than minimal harm 2025-04-30

F770 · Administration Deficiencies

Health

Provide timely, quality laboratory services/tests to meet the needs of residents.

Corrected 2025-05-21

D · Potential for more than minimal harm 2025-04-30

F926 · Environmental Deficiencies

Health

Have policies on smoking.

Corrected 2025-05-21

D · Potential for more than minimal harm 2024-11-07

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2024-11-21

E · Potential for more than minimal harm 2024-04-30

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-30

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-30

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-05-15

D · Potential for more than minimal harm 2024-04-30

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-15

E · Potential for more than minimal harm 2024-02-20

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2024-03-18

E · Potential for more than minimal harm 2024-02-20

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 2024-03-18

D · Potential for more than minimal harm 2024-02-20

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 2024-03-18

D · Potential for more than minimal harm 2024-02-20

F761 · Pharmacy Service Deficiencies

Health

Corrected 2024-03-18

D · Potential for more than minimal harm 2023-07-26

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2023-08-11

E · Potential for more than minimal harm 2021-11-04

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2021-11-19

E · Potential for more than minimal harm 2021-11-04

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2021-11-19

D · Potential for more than minimal harm 2021-11-04

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 2021-11-19

D · Potential for more than minimal harm 2021-11-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2021-11-19

Penalties and ownership

What sits behind the stars

Ownership

Oh 10 Holdco LLC

5% Or Greater Direct Ownership Interest · Organization

100% 10 facilities 2022-07-06

Cc Oh10 Opco LLC