Cycle 1
Health 2025-05-30 · Fire 2025-05-30
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Medina, OH
Western Reserve Masonic Comm
5-star overall rating with 5-star inspections with $8,090 in total fines with 4 fire-safety deficiencies in the latest cycle
4931 Nettleton Road, Medina, OH
(330) 721-3000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
46
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-06-21
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
1.01
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.53
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.71
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.17
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.19
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.82
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.01
CMS adjusted RN staffing hours
Adjusted total hours
4.68
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,057
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 23.02% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 7.99% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
1.39
Baseline 59.52% · Performance 58.00% · Measure score 1.39 · Achievement 1.39 · Improvement 0
Adjusted total nurse staffing
5.88
Baseline 4.56 hours · Performance 4.75 hours · Measure score 5.88 · Achievement 5.88 · Improvement 1.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.37% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 146 · Observed rate 7.53% · Lower 95% interval 6.42% |
| Discharge to community | 55.92% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 51.41% · Lower 95% interval 48.34% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 91.19% |
95.27%
4.1 pts worse
|
Numerator 145 · Denominator 159 |
| Falls with major injury | 0.63% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 159 |
| Discharge self-care score | 59.43% |
53.69%
5.7 pts better
|
Numerator 63 · Denominator 106 |
| Discharge mobility score | 67.92% |
50.94%
17 pts better
|
Numerator 72 · Denominator 106 |
| Pressure ulcers or injuries, new or worsened | 4.4% |
2.29%
2.1 pts worse
|
Numerator 7 · Denominator 159 · Adjusted rate 4.88% |
| Healthcare-associated infections requiring hospitalization | 7.99% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 132 · Observed rate 8.33% · Lower 95% interval 4.98% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 233 |
| Staff flu vaccination coverage | 7.43% |
42%
34.6 pts worse
|
Numerator 24 · Denominator 323 |
| Discharge function score | 65.09% |
56.45%
8.6 pts better
|
Numerator 69 · Denominator 106 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 49 · Denominator 49 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 90 · Denominator 90 |
| Resident COVID-19 vaccinations up to date | 28.79% |
25.2%
3.6 pts better
|
Numerator 19 · Denominator 66 |
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 · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 7.1% |
3.3%
3.8 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 4.8% · Q3 3.7% · Q4 14.3% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
26.1%
23.7 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 10.8% |
6.2%
4.6 pts worse
|
5.4%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 4.8% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.0% |
25.4%
12.4 pts better
|
19.6%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 13.6% · 4Q avg 13.0% |
| 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 · Q4 18.2% · 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 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.2% |
7.7%
9.5 pts worse
|
16.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.8% |
6.2%
1.6 pts worse
|
14.9%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 7.8% · 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 · 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 · 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 | 25.0% |
21.7%
3.3 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 35.4% · Q4 25.7% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
3.7%
0.7 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 3.9% · Q3 1.7% · Q4 2.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
78.1%
19.9 pts better
|
81.7%
16.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 97.9% · Q3 100.0% · Q4 98.9% · 4Q avg 98.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
12.5%
2.5 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.5% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.2%
0.6 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.2% · Q3 1.6% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.8% |
75.6%
18.2 pts better
|
79.7%
14.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.4% |
25.1%
10.3 pts worse
|
23.9%
11.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.4% · Observed 32.4% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-25 · Fire 2022-08-25
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2019-08-22 · Fire 2019-08-22
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-13
F · Potential for more than minimal harm
2025-05-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-30
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-06-13
E · Potential for more than minimal harm
2025-05-30
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-06-13
F · Potential for more than minimal harm
2022-08-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-08-26
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 2019-09-20
F · Potential for more than minimal harm
2019-08-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-20
F · Potential for more than minimal harm
2019-08-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-09-20
C · Minimal harm
2019-08-22
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2019-09-20
C · Minimal harm
2019-08-22
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-09-20
C · Minimal harm
2019-08-22
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2019-09-20
C · Minimal harm
2019-08-22
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2019-09-20
C · Minimal harm
2019-08-22
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2019-09-20
C · Minimal harm
2019-08-22
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2019-09-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-07-23
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-01-31
D · Potential for more than minimal harm
2023-10-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-10-12
D · Potential for more than minimal harm
2023-10-24
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-21
F · Potential for more than minimal harm
2019-08-22
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2019-09-20
E · Potential for more than minimal harm
2019-08-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-09-20
C · Minimal harm
2019-08-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-09-20
Penalties and ownership
What sits behind the stars
$2,797
2023-09-11
Fine
Fine · fine $2,797
Fine
$5,293
2023-08-14
Fine
Fine · fine $5,293
Fine
Ownership
Beckner, Robert
Corporate Director · Individual
Buchanan, Scott
Corporate Officer · Individual
French, Jason
Corporate Officer · Individual
Hager, Robert
Corporate Director · Individual
Herring, Adrienne
Corporate Officer · Individual
Jackson, Frederick
Corporate Director · Individual
Meyerson, Adam
Corporate Director · Individual
Nilsen, Robert
Corporate Director · Individual
Rice, Colleen
Corporate Director · Individual
Surso, John
Operational/Managerial Control · Individual
Taylor, Dallas
Operational/Managerial Control · Individual
Williams, Gary
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Samaritan Care Center And Villa
Medina, OH
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Avenue At Medina
Medina, OH
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Medina Center For Rehabilitation And Nursing
Medina, OH
2-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $135,470 in total fines with 29 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Jump out