Cycle 1
Health 2025-10-11 · Fire 2025-10-11
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Milford, OH
S.e.m. Haven Health Care Center
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
225 Cleveland Avenue, Milford, OH
(513) 248-1270
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
77
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-07-30
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
0.73
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.06
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.39
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.78
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.84
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
35%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
257
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
75.44
Composite VBP score used to determine payment impact.
Payment multiplier
1.0246
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.11
Baseline 18.34% · Performance 17.21% · Measure score 9.11 · Achievement 9.11 · Improvement 8.11
Healthcare-associated infections
7.28
Baseline 6.46% · Performance 5.66% · Measure score 7.28 · Achievement 7.28 · Improvement 4.98
Total nurse turnover
7.80
Baseline 51.75% · Performance 31.82% · Measure score 7.80 · Achievement 7.80 · Improvement 6.91
Adjusted total nurse staffing
5.99
Baseline 3.77 hours · Performance 4.78 hours · Measure score 5.99 · Achievement 5.99 · Improvement 4.54
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.14% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 207 · Observed rate 7.25% · Lower 95% interval 7.04% |
| Discharge to community | 67.42% |
50.57%
16.9 pts better
|
Better than the National Rate · Eligible stays 200 · Observed rate 69.5% · Lower 95% interval 61.95% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 120 · Denominator 120 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 120 |
| Discharge self-care score | 61.47% |
53.69%
7.8 pts better
|
Numerator 67 · Denominator 109 |
| Discharge mobility score | 60.55% |
50.94%
9.6 pts better
|
Numerator 66 · Denominator 109 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 120 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.66% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 133 · Observed rate 2.26% · Lower 95% interval 3.68% |
| Staff COVID-19 vaccination coverage | 5.53% |
8.2%
2.7 pts worse
|
Numerator 13 · Denominator 235 |
| Staff flu vaccination coverage | 21.55% |
42%
20.4 pts worse
|
Numerator 64 · Denominator 297 |
| Discharge function score | 69.72% |
56.45%
13.3 pts better
|
Numerator 76 · Denominator 109 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 87 · Denominator 87 |
| Resident COVID-19 vaccinations up to date | 38.6% |
25.2%
13.4 pts better
|
Numerator 22 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
92.4%
7.2 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.3%
1.3 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.9% · Q3 3.3% · Q4 6.6% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
26.1%
26.1 pts better
|
11.4%
11.4 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 who lose too much weight | 5.3% |
6.2%
0.9 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.9% · Q3 4.0% · Q4 11.8% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
25.4%
6 pts better
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 18.5% · Q3 20.0% · Q4 23.5% · 4Q avg 19.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.9% |
11.5%
1.6 pts better
|
16.7%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.5% · Q3 14.3% · Q4 12.5% · 4Q avg 9.9% · 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 | 9.1% |
7.7%
1.4 pts worse
|
16.3%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.6% |
6.2%
4.6 pts better
|
14.9%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 2.3% · Q4 0.0% · 4Q avg 1.6% · 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 · 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 | 25.7% |
21.7%
4 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 21.3% · Q3 28.9% · Q4 23.5% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 0.3% |
3.7%
3.4 pts better
|
5.1%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
78.1%
20.4 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 96.8% · Q3 100.0% · Q4 100.0% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.3% |
12.5%
9.2 pts better
|
12.0%
8.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.3% · Observed 3.0% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.7% |
75.6%
16.1 pts better
|
79.7%
12 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.4% |
25.1%
14.7 pts better
|
23.9%
13.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.4% · Observed 9.1% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-12-14 · Fire 2022-12-14
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-08-22 · Fire 2019-08-22
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-10-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-11-30
E · Potential for more than minimal harm
2025-10-11
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2025-11-30
E · Potential for more than minimal harm
2025-10-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-11-30
F · Potential for more than minimal harm
2022-12-14
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 2023-02-03
F · Potential for more than minimal harm
2022-12-14
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 2023-02-03
F · Potential for more than minimal harm
2022-12-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-03
F · Potential for more than minimal harm
2022-12-14
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 2023-02-03
F · Potential for more than minimal harm
2022-12-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-03
F · Potential for more than minimal harm
2019-08-22
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 2019-10-01
F · Potential for more than minimal harm
2019-08-22
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2019-10-01
F · Potential for more than minimal harm
2019-08-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-01
F · Potential for more than minimal harm
2019-08-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-01
E · Potential for more than minimal harm
2019-08-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-11
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-11-30
D · Potential for more than minimal harm
2025-10-11
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 2025-11-30
D · Potential for more than minimal harm
2025-10-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-11-30
D · Potential for more than minimal harm
2025-10-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-11-30
D · Potential for more than minimal harm
2025-10-11
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 2025-11-30
D · Potential for more than minimal harm
2025-10-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-30
D · Potential for more than minimal harm
2022-12-14
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-02-03
D · Potential for more than minimal harm
2022-12-14
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2023-02-03
D · Potential for more than minimal harm
2022-12-14
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-02-03
D · Potential for more than minimal harm
2022-12-14
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 2023-02-03
D · Potential for more than minimal harm
2022-12-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-03
D · Potential for more than minimal harm
2022-12-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-03
E · Potential for more than minimal harm
2019-08-22
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 2019-10-01
D · Potential for more than minimal harm
2019-08-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-01
D · Potential for more than minimal harm
2019-08-22
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2019-10-01
Penalties and ownership
What sits behind the stars
Ownership
Daniel, Kenneth
Contracted Managing Employee · Individual
Howell, Joyce
Corporate Director · Individual
Howell, Joyce
Corporate Officer · Individual
Kuethe, Joseph
Corporate Director · Individual
Kuethe, Joseph
Corporate Officer · Individual
Mooney, Charles
Operational/Managerial Control · Individual
Renner, John
Contracted Managing Employee · Individual
United Church Homes Management, Inc.
Operational/Managerial Control · Organization
Wolf, Barbara
Contracted Managing Employee · Individual
Nearby options
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#2
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1-star overall rating with 1-star inspections with abuse icon flag with $117,782 in total fines with 16 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Florentine Gardens
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3-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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