Cycle 1
Health 2024-05-22 · Fire 2024-05-22
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cleveland, OH
St Augustine Manor
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
7801 Detroit Ave, Cleveland, OH
(216) 634-7400
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
234
Certified beds
Average residents
187
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-01-01
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
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
7,597
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9854
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.79
Baseline 20.58% · Performance 20.14% · Measure score 2.79 · Achievement 2.79 · Improvement 0.74
Healthcare-associated infections
3.19
Baseline 8.16% · Performance 7.00% · Measure score 3.19 · Achievement 2.81 · Improvement 3.19
Total nurse turnover
4.02
Baseline 39.22% · Performance 47.26% · Measure score 4.02 · Achievement 4.02 · Improvement 0
Adjusted total nurse staffing
1.73
Baseline 3.38 hours · Performance 3.57 hours · Measure score 1.73 · Achievement 1.73 · Improvement 0.3
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.94% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 13.48% · Lower 95% interval 7.64% |
| Discharge to community | 51.5% |
50.57%
0.9 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 41.76% · Lower 95% interval 42.37% |
| 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 112 · Denominator 112 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 112 |
| Discharge self-care score | 70% |
53.69%
16.3 pts better
|
Numerator 49 · Denominator 70 |
| Discharge mobility score | 68.57% |
50.94%
17.6 pts better
|
Numerator 48 · Denominator 70 |
| Pressure ulcers or injuries, new or worsened | 1.79% |
2.29%
0.5 pts better
|
Numerator 2 · Denominator 112 · Adjusted rate 1.23% |
| Healthcare-associated infections requiring hospitalization | 7% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 79 · Observed rate 10.13% · Lower 95% interval 4.6% |
| Staff COVID-19 vaccination coverage | 3.18% |
8.2%
5 pts worse
|
Numerator 12 · Denominator 377 |
| Staff flu vaccination coverage | 41.39% |
42%
0.6 pts worse
|
Numerator 202 · Denominator 488 |
| Discharge function score | 77.14% |
56.45%
20.7 pts better
|
Numerator 54 · Denominator 70 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 17 · Denominator 51 |
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 2.9 · Expected 3.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.8 · Expected 2.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
92.4%
7.4 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 3.3% |
3.3%
About the same
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 3.8% · Q4 4.4% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.8% |
26.1%
10.3 pts better
|
11.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 17.5% · Q3 11.9% · Q4 16.0% · 4Q avg 15.8% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
6.2%
0.1 pts better
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 6.0% · Q3 6.2% · Q4 7.5% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
25.4%
7.8 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 18.5% · Q3 17.9% · Q4 17.1% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.4% |
11.5%
3.1 pts better
|
16.7%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 7.3% · Q3 6.1% · Q4 9.4% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.8% |
0.1%
0.7 pts worse
|
0.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.6% · Q3 0.6% · Q4 0.6% · 4Q avg 0.8% |
| Percentage of long-stay residents whose ability to walk independently worsened | 2.6% |
7.7%
5.1 pts better
|
16.3%
13.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.4% · Q3 0.0% · Q4 3.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
6.2%
0.8 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 6.3% · Q3 3.6% · Q4 7.1% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.2%
About the same
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.5% · Q4 0.4% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.5%
0.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.4% |
21.7%
11.3 pts better
|
19.8%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 14.9% · Q3 6.9% · Q4 13.5% · 4Q avg 10.4% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
3.7%
2.9 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 6.8% · Q3 6.5% · Q4 5.7% · 4Q avg 6.6% · 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 98.3% · Q2 98.7% · Q3 99.4% · Q4 98.7% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
12.5%
1.8 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 13.3% · Expected 13.8% · 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 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
75.6%
22 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.8% |
25.1%
8.3 pts better
|
23.9%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 24.1% · Expected 34.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-10 · Fire 2023-05-10
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-12-05 · Fire 2019-12-05
3 health deficiencies
Top issue: Environmental (1 deficiency)
20 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-05
F · Potential for more than minimal harm
2024-05-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-05-22
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-05-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-05
E · Potential for more than minimal harm
2024-05-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-05
F · Potential for more than minimal harm
2023-05-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-10
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 2023-06-16
E · Potential for more than minimal harm
2023-05-10
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 2023-06-16
E · Potential for more than minimal harm
2023-05-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-16
E · Potential for more than minimal harm
2023-05-10
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-06-16
F · Potential for more than minimal harm
2019-12-05
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2020-04-27
F · Potential for more than minimal harm
2019-12-05
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2020-05-19
F · Potential for more than minimal harm
2019-12-05
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 2020-01-23
F · Potential for more than minimal harm
2019-12-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-01-23
F · Potential for more than minimal harm
2019-12-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-01-23
F · Potential for more than minimal harm
2019-12-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2020-01-23
F · Potential for more than minimal harm
2019-12-05
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2020-01-23
F · Potential for more than minimal harm
2019-12-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-01-23
F · Potential for more than minimal harm
2019-12-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-01-23
F · Potential for more than minimal harm
2019-12-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-23
E · Potential for more than minimal harm
2019-12-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-01-23
E · Potential for more than minimal harm
2019-12-05
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-01-23
E · Potential for more than minimal harm
2019-12-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-01-23
E · Potential for more than minimal harm
2019-12-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-23
E · Potential for more than minimal harm
2019-12-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-01-23
E · Potential for more than minimal harm
2019-12-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-01-23
E · Potential for more than minimal harm
2019-12-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-01-23
D · Potential for more than minimal harm
2019-12-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-23
C · Minimal harm
2019-12-05
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Not marked corrected
C · Minimal harm
2019-12-05
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Not marked corrected
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-05-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-05
D · Potential for more than minimal harm
2024-05-22
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 2024-07-05
D · Potential for more than minimal harm
2024-05-22
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-07-05
E · Potential for more than minimal harm
2023-05-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-05-10
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 2023-06-16
D · Potential for more than minimal harm
2023-05-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-16
D · Potential for more than minimal harm
2019-12-05
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 2020-01-23
D · Potential for more than minimal harm
2019-12-05
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 2020-01-23
D · Potential for more than minimal harm
2019-12-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2020-01-23
Penalties and ownership
What sits behind the stars
Ownership
Catholic Charities Corporation
5% Or Greater Direct Ownership Interest · Organization
Dawson, Theresa
Corporate Director · Individual
Gosche, Janet
Corporate Director · Individual
Huba, Frank
Corporate Officer · Individual
Mccarthy, Karen
Corporate Director · Individual
Mcgrievy, Mark
Corporate Director · Individual
Meserini, Rick
Corporate Officer · Individual
Newcomb, Elayne
W-2 Managing Employee · Individual
Pumphrey, Robert
Corporate Director · Individual
Sciarrillo, Joseph
Corporate Director · Individual
Sheehan, Linda
Corporate Director · Individual
Streeter, Marilyn
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Algart Health Care
Cleveland, OH
4-star overall rating with 5-star inspections with 12 fire-safety deficiencies in the latest cycle
#2
Eliza Jennings Home
Cleveland, OH
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Franklin Plaza Extended Care
Cleveland, OH
3-star overall rating with 2-star inspections with 15 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
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