Cycle 1
Health 2025-08-28 · Fire 2025-08-28
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Avon, OH
St Mary Of The Woods
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
35755 Detroit Road, Avon, OH
(440) 937-6869
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
42
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Saint Therese Senior Communities
Operator or chain grouping
Approved since
2007-05-22
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
4 facilities
Chain averages 5 overall / 4 health / 5 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.28
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.37
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.94
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.65
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.23
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.18
CMS adjusted RN staffing hours
Adjusted total hours
4.55
CMS adjusted total nurse staffing hours
Case-mix index
1.48
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
3,911
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9951
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.06
Baseline 18.46% · Performance 20.48% · Measure score 2.06 · Achievement 2.06 · Improvement 0
Healthcare-associated infections
3.62
Baseline 7.73% · Performance 6.75% · Measure score 3.62 · Achievement 3.62 · Improvement 3.06
Total nurse turnover
1.19
Baseline 62.10% · Performance 58.82% · Measure score 1.19 · Achievement 1.19 · Improvement 0.38
Adjusted total nurse staffing
10
Baseline 5.56 hours · Performance 5.81 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.91% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 347 · Observed rate 12.1% · Lower 95% interval 9.56% |
| Discharge to community | 67.76% |
50.57%
17.2 pts better
|
Better than the National Rate · Eligible stays 369 · Observed rate 60.98% · Lower 95% interval 63.45% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.28% |
95.27%
4 pts better
|
Numerator 275 · Denominator 277 |
| Falls with major injury | 1.08% |
0.77%
0.3 pts worse
|
Numerator 3 · Denominator 277 |
| Discharge self-care score | 49.25% |
53.69%
4.4 pts worse
|
Numerator 98 · Denominator 199 |
| Discharge mobility score | 44.22% |
50.94%
6.7 pts worse
|
Numerator 88 · Denominator 199 |
| Pressure ulcers or injuries, new or worsened | 1.44% |
2.29%
0.9 pts better
|
Numerator 4 · Denominator 277 · Adjusted rate 1.79% |
| Healthcare-associated infections requiring hospitalization | 6.75% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 241 · Observed rate 6.64% · Lower 95% interval 4.48% |
| Staff COVID-19 vaccination coverage | 6.1% |
8.2%
2.1 pts worse
|
Numerator 13 · Denominator 213 |
| Staff flu vaccination coverage | 21.15% |
42%
20.9 pts worse
|
Numerator 66 · Denominator 312 |
| Discharge function score | 51.26% |
56.45%
5.2 pts worse
|
Numerator 102 · Denominator 199 |
| Transfer of health information to provider | 97.98% |
95.95%
2 pts better
|
Numerator 97 · Denominator 99 |
| Transfer of health information to patient | 95.48% |
96.28%
0.8 pts worse
|
Numerator 148 · Denominator 155 |
| Resident COVID-19 vaccinations up to date | 40.56% |
25.2%
15.4 pts better
|
Numerator 58 · Denominator 143 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.3% |
26.1%
20.8 pts better
|
11.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.3% |
| Percentage of long-stay residents who lose too much weight | 17.9% |
6.2%
11.7 pts worse
|
5.4%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.4% |
25.4%
22 pts better
|
19.6%
16.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.0% |
11.5%
8.5 pts worse
|
16.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.0% |
6.2%
13.8 pts worse
|
14.9%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
0.2%
1.3 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.5% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.6% |
21.7%
10.1 pts better
|
19.8%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
3.7%
0.2 pts worse
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
78.1%
18.9 pts better
|
81.7%
15.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 99.1% · Q3 97.4% · Q4 92.3% · 4Q avg 97.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
12.5%
0.7 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 13.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.5% · Q3 1.3% · Q4 0.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
75.6%
24 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
25.1%
1.5 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 26.0% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-23 · Fire 2022-06-23
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-05-30 · Fire 2019-05-30
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-10-14
F · Potential for more than minimal harm
2025-08-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-10-14
F · Potential for more than minimal harm
2025-08-28
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-10-14
E · Potential for more than minimal harm
2025-08-28
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 2025-10-14
F · Potential for more than minimal harm
2022-06-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-06-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-06-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-15
F · Potential for more than minimal harm
2022-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-15
E · Potential for more than minimal harm
2022-06-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-07-15
F · Potential for more than minimal harm
2019-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-27
C · Minimal harm
2019-05-30
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-06-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-28
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 2025-10-14
D · Potential for more than minimal harm
2025-08-28
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-10-14
D · Potential for more than minimal harm
2025-08-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-14
D · Potential for more than minimal harm
2022-06-23
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 2022-07-15
D · Potential for more than minimal harm
2022-06-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-15
D · Potential for more than minimal harm
2019-05-30
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 2019-06-27
D · Potential for more than minimal harm
2019-05-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-06-27
D · Potential for more than minimal harm
2019-05-30
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 2019-06-27
D · Potential for more than minimal harm
2019-05-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-06-27
D · Potential for more than minimal harm
2019-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-27
Penalties and ownership
What sits behind the stars
Ownership
Saint Therese
5% Or Greater Indirect Ownership Interest · Organization
Saint Therese Communities
5% Or Greater Direct Ownership Interest · Organization
Abbott, Craig
Corporate Director · Individual
Abbott, Craig
Corporate Officer · Individual
Eren, Itri
Operational/Managerial Control · Individual
Gillespie, Joseph
Corporate Director · Individual
Heller, David
Operational/Managerial Control · Individual
Herb, Mary
Corporate Director · Individual
Hoffmann, David
Corporate Director · Individual
Hoffmann, David
Corporate Officer · Individual
Horstmann, Steven
Corporate Director · Individual
Krenn, David
Corporate Director · Individual
Mccluskey, Patricia
Corporate Director · Individual
Mccrossan, Jane
Corporate Director · Individual
Meads, Steven
Corporate Director · Individual
Parmar, Mona
Corporate Director · Individual
Saint Therese
Operational/Managerial Control · Organization
Saint Therese Communities
Operational/Managerial Control · Organization
Saint Therese Management Services, LLC
Operational/Managerial Control · Organization
Shelangoski, Cal
Corporate Officer · Individual
Taffe, Patrick
Corporate Director · Individual
Wornson, Kathryn
Corporate Director · Individual
Wornson, Kathryn
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Woods On French Creek Nursing & Rehab Center The
Avon, OH
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Avon Oaks Nursing Home
Avon, OH
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Avon Place Healthcare Center
Avon, OH
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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