Parma, OH

Pleasant Lake Villa

4-star overall rating with 4-star inspections with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

7260 Ridge Rd, Parma, OH

(440) 842-2273

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 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

209

Certified beds

Average residents

185

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Legacy Health Services

Operator or chain grouping

Approved since

1987-11-18

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

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

0.45

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.14

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

3.75

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.59

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.25

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.37

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.02

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.41

CMS adjusted RN staffing hours

Adjusted total hours

3.45

CMS adjusted total nurse staffing hours

Case-mix index

1.49

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,209

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

Performance score

30.41

Composite VBP score used to determine payment impact.

Payment multiplier

0.9859

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.29

Baseline 25.24% · Performance 19.67% · Measure score 6.29 · Achievement 3.80 · Improvement 6.29

Healthcare-associated infections

1.75

Baseline 8.49% · Performance 7.70% · Measure score 1.75 · Achievement 0 · Improvement 1.75

Total nurse turnover

4.12

Baseline 55.80% · Performance 46.82% · Measure score 4.12 · Achievement 4.12 · Improvement 2.40

Adjusted total nurse staffing

0

Baseline 3.32 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.59%	10.72% 0.1 pts better	No Different than the National Rate · Eligible stays 184 · Observed rate 10.87% · Lower 95% interval 7.4%
Discharge to community	53.47%	50.57% 2.9 pts better	No Different than the National Rate · Eligible stays 187 · Observed rate 44.92% · Lower 95% interval 45.67%
Medicare spending per beneficiary	0.91	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 109 · Denominator 109
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 109
Discharge self-care score	53.33%	53.69% 0.4 pts worse	Numerator 40 · Denominator 75
Discharge mobility score	41.33%	50.94% 9.6 pts worse	Numerator 31 · Denominator 75
Pressure ulcers or injuries, new or worsened	2.75%	2.29% 0.5 pts worse	Numerator 3 · Denominator 109 · Adjusted rate 3.03%
Healthcare-associated infections requiring hospitalization	7.7%	7.12% 0.6 pts worse	No Different than the National Rate · Eligible stays 95 · Observed rate 8.42% · Lower 95% interval 4.69%
Staff COVID-19 vaccination coverage	8.49%	8.2% 0.3 pts better	Numerator 22 · Denominator 259
Staff flu vaccination coverage	20.07%	42% 21.9 pts worse	Numerator 56 · Denominator 279
Discharge function score	50.67%	56.45% 5.8 pts worse	Numerator 38 · Denominator 75
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 32 · Denominator 32
Transfer of health information to patient	96.67%	96.28% 0.4 pts better	Numerator 58 · Denominator 60
Resident COVID-19 vaccinations up to date	25.81%	25.2% 0.6 pts better	Numerator 16 · Denominator 62

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	90.1%	92.4% 2.3 pts worse	93.4% 3.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 85.9% · Q3 85.5% · Q4 96.7% · 4Q avg 90.1%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	87.4%	94.5% 7.1 pts worse	95.5% 8.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 87.4%
Percentage of long-stay residents experiencing one or more falls with major injury	1.7%	3.3% 1.6 pts better	3.3% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 1.4% · Q4 4.0% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	22.1%	26.1% 4 pts better	11.4% 10.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 30.2% · Q3 15.3% · Q4 7.6% · 4Q avg 22.1%
Percentage of long-stay residents who lose too much weight	4.2%	6.2% 2 pts better	5.4% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.5% · Q3 6.9% · Q4 5.4% · 4Q avg 4.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	16.7%	25.4% 8.7 pts better	19.6% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 18.0% · Q3 19.1% · Q4 15.9% · 4Q avg 16.7%
Percentage of long-stay residents who received an antipsychotic medication	7.8%	11.5% 3.7 pts better	16.7% 8.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 6.4% · Q3 7.9% · Q4 8.8% · 4Q avg 7.8% · 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	14.3%	7.7% 6.6 pts worse	16.3% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 13.7% · Q3 11.4% · Q4 17.1% · 4Q avg 14.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.2%	6.2% 4 pts worse	14.9% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 9.5% · Q3 8.4% · Q4 10.0% · 4Q avg 10.2% · 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 0.7% · Q3 0.7% · Q4 0.5% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.7%	0.5% 1.2 pts worse	1.7% About the same	Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 2.1% · Q4 2.0% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.9%	21.7% 7.2 pts worse	19.8% 9.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 40.8% · Q3 25.5% · Q4 28.7% · 4Q avg 28.9%
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 3.0% · Q2 3.1% · Q3 7.3% · Q4 6.4% · 4Q avg 5.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.3%	78.1% 11.2 pts better	81.7% 7.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 88.9% · Q2 90.8% · Q3 89.2% · Q4 88.2% · 4Q avg 89.3%
Percentage of short-stay residents who had an outpatient emergency department visit	9.3%	12.5% 3.2 pts better	12.0% 2.7 pts better	Short Stay · 20240701-20250630 · Adjusted 9.3% · Observed 9.2% · Expected 11.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.2%	1.2% 1 pts better	1.6% 1.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	78.4%	75.6% 2.8 pts better	79.7% 1.3 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 78.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.9%	25.1% 2.8 pts worse	23.9% 4 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 31.0% · Expected 26.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-06-06 · Fire 2024-06-06

3 health deficiencies

Top issue: Infection Control (1 deficiency)

6 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2023-04-27 · Fire 2023-04-27

10 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2019-11-21 · Fire 2019-11-21

7 health deficiencies

Top issue: Resident Rights (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-06-06

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2024-06-28

F · Potential for more than minimal harm 2024-06-06

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-06-06

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 2024-06-28

E · Potential for more than minimal harm 2024-06-06

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 2024-06-28

E · Potential for more than minimal harm 2024-06-06

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2024-06-28

E · Potential for more than minimal harm 2024-06-06

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-06-28

F · Potential for more than minimal harm 2023-04-27

K345 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-05-10

E · Potential for more than minimal harm 2023-04-27

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2023-05-10

E · Potential for more than minimal harm 2023-04-27

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-05-10

F · Potential for more than minimal harm 2019-11-21

K311 · Smoke Deficiencies

Fire Safety

Have an enclosure around a vertical opening shaft.

Corrected 2019-12-11

F · Potential for more than minimal harm 2019-11-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-12-11

F · Potential for more than minimal harm 2019-11-21

K362 · Smoke Deficiencies

Fire Safety

Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

Corrected 2019-12-11

F · Potential for more than minimal harm 2019-11-21

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-12-11

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-03-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-03-12

D · Potential for more than minimal harm 2024-09-13

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-09-20

E · Potential for more than minimal harm 2024-06-06

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 2024-06-28

D · Potential for more than minimal harm 2024-06-06

F695 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-06-28

D · Potential for more than minimal harm 2024-04-03

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-04-16

D · Potential for more than minimal harm 2024-04-03

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-04-16

D · Potential for more than minimal harm 2024-04-03

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-04-16

E · Potential for more than minimal harm 2023-11-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-11-08

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-11-08

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 2023-11-17

E · Potential for more than minimal harm 2023-04-27

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-05-10

D · Potential for more than minimal harm 2023-04-27

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2023-05-10

D · Potential for more than minimal harm 2023-04-27

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 2023-05-10

D · Potential for more than minimal harm 2023-04-27

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-05-10

D · Potential for more than minimal harm 2023-04-27

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 2023-05-10

B · Minimal harm 2023-04-27

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2023-05-10

G · Actual harm 2019-11-21

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2019-12-11

D · Potential for more than minimal harm 2019-11-21

F582 · Resident Rights Deficiencies

Health

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Corrected 2019-12-11

D · Potential for more than minimal harm 2019-11-21

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 2019-12-11

D · Potential for more than minimal harm 2019-11-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-12-11

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