Cycle 1
Health 2022-10-27 · Fire 2022-10-27
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Oberlin, OH
Welcome Nursing Home
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
417 South Main Street, Oberlin, OH
(440) 775-1491
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
99
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1980-05-20
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
0.57
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.96
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.32
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.78
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
8%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,916
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.05
Composite VBP score used to determine payment impact.
Payment multiplier
1.0077
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
2.89
Baseline 6.30% · Performance 6.97% · Measure score 2.89 · Achievement 2.89 · Improvement 0
Total nurse turnover
10
Baseline 35.87% · Performance 20.00% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
3.03
Baseline 3.79 hours · Performance 3.94 hours · Measure score 3.03 · Achievement 3.03 · Improvement 0.26
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 15.56% · Lower 95% interval 8.12% |
| Discharge to community | 38.36% |
50.57%
12.2 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 26.67% · Lower 95% interval 26.99% |
| Medicare spending per beneficiary | 1.07 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 31 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 10 · Denominator 23 |
| Discharge mobility score | 47.83% |
50.94%
3.1 pts worse
|
Numerator 11 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 7.41% · Lower 95% interval 3.53% |
| Staff COVID-19 vaccination coverage | 3.47% |
8.2%
4.7 pts worse
|
Numerator 5 · Denominator 144 |
| Staff flu vaccination coverage | 27.06% |
42%
14.9 pts worse
|
Numerator 46 · Denominator 170 |
| Discharge function score | 56.52% |
56.45%
0.1 pts better
|
Numerator 13 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
92.4%
5.4 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.2% · Q4 94.9% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
94.5%
4.3 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.3%
0.2 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.9% · Q3 2.5% · Q4 1.3% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.1% |
26.1%
20 pts better
|
11.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 3.1% · Q3 4.5% · Q4 6.2% · 4Q avg 6.1% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
6.2%
0.3 pts better
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 8.1% · Q3 5.5% · Q4 7.2% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.8% |
25.4%
13.6 pts better
|
19.6%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 14.7% · Q3 9.6% · Q4 8.7% · 4Q avg 11.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
11.5%
4.1 pts worse
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 15.3% · Q3 14.5% · Q4 13.3% · 4Q avg 15.6% · 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 | 17.6% |
7.7%
9.9 pts worse
|
16.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 22.9% · Q3 21.8% · Q4 12.3% · 4Q avg 17.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
6.2%
3 pts worse
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 7.4% · Q3 15.2% · Q4 4.8% · 4Q avg 9.2% · 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 | 0.3% |
0.5%
0.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · 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 | 31.2% |
21.7%
9.5 pts worse
|
19.8%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 38.7% · Q3 26.4% · Q4 29.2% · 4Q avg 31.2% |
| 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 3.6% · Q2 5.3% · Q3 5.3% · Q4 5.8% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
78.1%
10.9 pts better
|
81.7%
7.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 90.7% · Q3 89.1% · Q4 88.1% · 4Q avg 89.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
12.5%
8.2 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 4.8% · Expected 12.5% · 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 · 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 | 84.2% |
75.6%
8.6 pts better
|
79.7%
4.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
25.1%
7.9 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 19.0% · Expected 26.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-11-06 · Fire 2019-11-06
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2018-09-13 · Fire 2018-09-13
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-10-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-10-27
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-12-12
F · Potential for more than minimal harm
2022-10-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-01
F · Potential for more than minimal harm
2022-10-27
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 2022-12-12
E · Potential for more than minimal harm
2022-10-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-12
F · Potential for more than minimal harm
2019-11-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-11-26
E · Potential for more than minimal harm
2019-11-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-11-26
E · Potential for more than minimal harm
2019-11-06
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 2019-11-26
E · Potential for more than minimal harm
2018-09-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-10-12
E · Potential for more than minimal harm
2018-09-13
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2018-10-12
E · Potential for more than minimal harm
2018-09-13
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2018-10-12
E · Potential for more than minimal harm
2018-09-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2018-10-12
E · Potential for more than minimal harm
2018-09-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-10-12
E · Potential for more than minimal harm
2018-09-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-10-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-08
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-10-29
E · Potential for more than minimal harm
2022-10-27
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 2022-12-12
D · Potential for more than minimal harm
2022-10-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-12-12
D · Potential for more than minimal harm
2019-11-06
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 2019-11-26
D · Potential for more than minimal harm
2019-11-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-11-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-11-06
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-11-26
E · Potential for more than minimal harm
2018-09-13
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 2018-10-12
E · Potential for more than minimal harm
2018-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-10-12
D · Potential for more than minimal harm
2018-09-13
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 2018-10-12
D · Potential for more than minimal harm
2018-09-13
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 2018-10-12
D · Potential for more than minimal harm
2018-09-13
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2018-10-12
D · Potential for more than minimal harm
2018-09-13
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-10-12
D · Potential for more than minimal harm
2018-09-13
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 2018-10-12
D · Potential for more than minimal harm
2018-09-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2018-10-12
Penalties and ownership
What sits behind the stars
Ownership
Foisy, Meghan
5% Or Greater Direct Ownership Interest · Individual
Freas, Heidi
5% Or Greater Direct Ownership Interest · Individual
Herron, Jill
5% Or Greater Direct Ownership Interest · Individual
Wessell, Kelly
5% Or Greater Direct Ownership Interest · Individual
Accuscripts Pharmacy LLC
Operational/Managerial Control · Organization
Eren, Itri
Operational/Managerial Control · Individual
Foisy, Meghan
Corporate Director · Individual
Freas, Heidi
Corporate Director · Individual
Freas, Heidi
Corporate Officer · Individual
Healthcare Services Group Inc
Operational/Managerial Control · Organization
Herron, Jill
Operational/Managerial Control · Individual
Herron, Jill
Corporate Director · Individual
Herron, Jill
Corporate Officer · Individual
Rlh Consulting
Operational/Managerial Control · Organization
The Cleveland Clinic Foundation
Operational/Managerial Control · Organization
Wessell, Kelly
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Kendal At Oberlin
Oberlin, OH
5-star overall rating with 5-star inspections with 4 fire-safety deficiencies in the latest cycle
#2
Keystone Pointe Health And Rehabilitation
Lagrange, OH
5-star overall rating with 5-star inspections with 8 fire-safety deficiencies in the latest cycle
#3
Wesleyan Village
Elyria, OH
1-star overall rating with 1-star inspections with $219,798 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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