Cycle 1
Health 2024-02-08 · Fire 2024-02-08
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Westlake, OH
Rae-Ann Westlake
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
28303 Detroit Rd, Westlake, OH
(440) 871-0500
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
130
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.59
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
2.75
CMS adjusted total nurse staffing hours
Case-mix index
1.78
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,344
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.77
Performance 20.15% · Measure score 2.77 · Achievement 2.77 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 6.25% · Performance 8.26% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.35
Performance 50.00% · Measure score 3.35 · Achievement 3.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.74
Baseline 3.24 hours · Performance 3.29 hours · Measure score 0.74 · Achievement 0.74 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.44% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 6.9% · Lower 95% interval 6.25% |
| Discharge to community | 33.81% |
50.57%
16.8 pts worse
|
Worse than the National Rate · Eligible stays 38 · Observed rate 21.05% · Lower 95% interval 19.11% |
| Medicare spending per beneficiary | 1.2 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 82 · Denominator 82 |
| Falls with major injury | 1.22% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 82 |
| Discharge self-care score | 36.51% |
53.69%
17.2 pts worse
|
Numerator 23 · Denominator 63 |
| Discharge mobility score | 46.03% |
50.94%
4.9 pts worse
|
Numerator 29 · Denominator 63 |
| Pressure ulcers or injuries, new or worsened | 3.66% |
2.29%
1.4 pts worse
|
Numerator 3 · Denominator 82 · Adjusted rate 3.17% |
| Healthcare-associated infections requiring hospitalization | 8.26% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 13.33% · Lower 95% interval 4.32% |
| Staff COVID-19 vaccination coverage | 2.04% |
8.2%
6.2 pts worse
|
Numerator 3 · Denominator 147 |
| Staff flu vaccination coverage | 12.04% |
42%
30 pts worse
|
Numerator 26 · Denominator 216 |
| Discharge function score | 55.56% |
56.45%
0.9 pts worse
|
Numerator 35 · Denominator 63 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 58.54% |
25.2%
33.3 pts better
|
Numerator 24 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.3 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.8% |
92.4%
7.6 pts worse
|
93.4%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.2% · Q2 83.3% · Q3 85.1% · Q4 90.6% · 4Q avg 84.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.9% |
94.5%
6.6 pts worse
|
95.5%
7.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.3%
1.5 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.1% · Q3 2.1% · Q4 2.1% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 53.1% |
26.1%
27 pts worse
|
11.4%
41.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 55.6% · Q3 51.2% · Q4 69.3% · 4Q avg 53.1% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
6.2%
0.3 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 4.8% · Q3 6.2% · Q4 5.0% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.6% |
25.4%
3.2 pts worse
|
19.6%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 27.7% · Q3 29.6% · Q4 29.3% · 4Q avg 28.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.1% |
11.5%
5.4 pts better
|
16.7%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.6% · Q3 7.5% · Q4 3.7% · 4Q avg 6.1% · 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 | 7.2% |
7.7%
0.5 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 10.1% · Q3 5.4% · Q4 4.6% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.2% |
6.2%
1 pts better
|
14.9%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.8% · Q3 2.8% · Q4 5.7% · 4Q avg 5.2% · 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 | 0.0% |
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 | 14.1% |
21.7%
7.6 pts better
|
19.8%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 18.2% · Q3 3.5% · Q4 8.4% · 4Q avg 14.1% |
| Percentage of long-stay residents with pressure ulcers | 3.7% |
3.7%
About the same
|
5.1%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 6.2% · Q3 2.0% · Q4 1.8% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.5% |
78.1%
2.6 pts worse
|
81.7%
6.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.8% · Q2 81.1% · Q3 76.3% · Q4 79.1% · 4Q avg 75.5% |
| 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 11.1% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.2%
0.5 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 2.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 59.6% |
75.6%
16 pts worse
|
79.7%
20.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 59.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.1% |
25.1%
11 pts better
|
23.9%
9.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.1% · Observed 15.6% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-30 · Fire 2021-09-30
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-05-16 · Fire 2019-05-16
11 health deficiencies
Top issue: Infection Control (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-15
F · Potential for more than minimal harm
2024-02-08
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2024-02-15
F · Potential for more than minimal harm
2024-02-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-15
F · Potential for more than minimal harm
2024-02-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-02-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-02-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-02-08
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 2024-02-15
E · Potential for more than minimal harm
2024-02-08
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-02-08
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-02-15
F · Potential for more than minimal harm
2021-09-30
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-11-19
F · Potential for more than minimal harm
2021-09-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-11-19
F · Potential for more than minimal harm
2021-09-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-11-19
F · Potential for more than minimal harm
2021-09-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-11-19
E · Potential for more than minimal harm
2021-09-30
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 2021-11-19
E · Potential for more than minimal harm
2021-09-30
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-11-19
E · Potential for more than minimal harm
2021-09-30
K925 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that sources of ignition are removed from patients receiving respiratory therapy.
Corrected 2021-11-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-02-08
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 2024-02-15
D · Potential for more than minimal harm
2024-02-08
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-02-08
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 2024-02-15
D · Potential for more than minimal harm
2024-02-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-02-08
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-02-08
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2024-02-15
E · Potential for more than minimal harm
2023-11-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-07-26
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-27
D · Potential for more than minimal harm
2023-06-01
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 2023-06-02
D · Potential for more than minimal harm
2023-06-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-04-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-11
E · Potential for more than minimal harm
2023-03-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-22
G · Actual harm
2021-09-30
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 2021-11-19
F · Potential for more than minimal harm
2021-09-30
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 2021-11-19
E · Potential for more than minimal harm
2021-09-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-11-19
D · Potential for more than minimal harm
2021-09-30
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
2019-05-16
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 2019-06-14
D · Potential for more than minimal harm
2019-05-16
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-16
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 2019-06-14
D · Potential for more than minimal harm
2019-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-14
Penalties and ownership
What sits behind the stars
Ownership
Ra Assets Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Ra Opco LLC
5% Or Greater Indirect Ownership Interest · Organization
Ra Investment Oh LLC
5% Or Greater Indirect Ownership Interest · Organization
Gewirtz, Jonathan
5% Or Greater Indirect Ownership Interest · Individual
Gewirtz, Jonathan
Operational/Managerial Control · Individual
Gewirtz, Jonathan
Corporate Director · Individual
Gewirtz, Jonathan
Corporate Officer · Individual
Gewirtz, Jonathan
W-2 Managing Employee · Individual
Marcum, Dylon
Corporate Director · Individual
Neil Bay Management LLC
Operational/Managerial Control · Organization
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5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
#3
Lutheran Home
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4-star overall rating with 4-star inspections with 7 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
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