14 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Wickliffe, OH
3-star overall rating with 2-star inspections with 14 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1919 Bishop Rd, Wickliffe, OH
(440) 944-9400
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
170
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Health Services
Operator or chain grouping
Approved since
1978-07-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 quality stars
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
RN hours / resident day
0.71
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.18
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
1.76
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.30
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
85%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
8,342
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9844
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.17
Baseline 22.25% · Performance 20.33% · Measure score 3.17 · Achievement 2.38 · Improvement 3.17
Healthcare-associated infections
4.78
Baseline 6.21% · Performance 6.41% · Measure score 4.78 · Achievement 4.78 · Improvement 0
Total nurse turnover
2.87
Baseline 76.78% · Performance 59.29% · Measure score 2.87 · Achievement 1.07 · Improvement 2.87
Adjusted total nurse staffing
0
Baseline 3.14 hours · Performance 3.04 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 65 · Observed rate 13.85% · Lower 95% interval 7.08% |
| Discharge to community | 48.96% |
50.57%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 37.68% · Lower 95% interval 35.17% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 44 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 18 · Denominator 27 |
| Discharge mobility score | 48.15% |
50.94%
2.8 pts worse
|
Numerator 13 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.41% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 5% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 171 |
| Staff flu vaccination coverage | 1.13% |
42%
40.9 pts worse
|
Numerator 2 · Denominator 177 |
| Discharge function score | 70.37% |
56.45%
13.9 pts better
|
Numerator 19 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 22 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 10.34% |
25.2%
14.9 pts worse
|
Numerator 3 · Denominator 29 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
92.4%
5.8 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 96.1% · Q3 98.9% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.7% |
94.5%
0.2 pts better
|
95.5%
0.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.9% · Q3 3.3% · Q4 2.2% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.5% |
26.1%
12.6 pts better
|
11.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 9.7% · Q3 10.9% · Q4 12.3% · 4Q avg 13.5% |
| Percentage of long-stay residents who lose too much weight | 11.2% |
6.2%
5 pts worse
|
5.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 13.8% · Q3 13.9% · Q4 10.7% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.4% |
25.4%
12 pts better
|
19.6%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 10.6% · Q3 12.7% · Q4 14.5% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
11.5%
6.1 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 2.7% · Q3 9.3% · Q4 3.5% · 4Q avg 5.4% · 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 | 6.2% |
7.7%
1.5 pts better
|
16.3%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.5% · Q3 11.7% · Q4 3.1% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.4% |
6.2%
2.2 pts worse
|
14.9%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 8.0% · Q3 6.8% · Q4 10.0% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.2%
0.3 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
0.5%
About the same
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.6% |
21.7%
9.9 pts worse
|
19.8%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 35.3% · Q3 35.0% · Q4 33.3% · 4Q avg 31.6% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
3.7%
0.6 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.9% · Q3 1.8% · Q4 0.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.0% |
78.1%
2.9 pts better
|
81.7%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.2% · Q2 78.2% · Q3 76.9% · Q4 83.0% · 4Q avg 81.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.5% |
12.5%
9 pts better
|
12.0%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.5% · Observed 4.4% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.2%
0.6 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 1.5% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.9% |
75.6%
11.7 pts worse
|
79.7%
15.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
25.1%
0.1 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 35.6% · Expected 33.6% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Top issue: Quality of Life and Care (7 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-11
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-11
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 2024-10-11
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-11
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-11
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 2022-10-25
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-10-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-25
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-10-25
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-10-25
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-10-25
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-10-25
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 2019-10-18
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-18
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-10-18
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-10-18
Inspection history
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-11-18
Health
Respond appropriately to all alleged violations.
Corrected 2025-11-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-18
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-02-03
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-11
Health
Dispose of garbage and refuse properly.
Corrected 2024-10-11
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 2024-10-11
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-11
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-10-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-11
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-10-11
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 2024-10-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-11
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-04-08
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-07-20
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-20
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-25
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-10-25
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-10-25
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-25
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-25
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-10-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-10-25
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-10-25
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-10-25
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 2022-10-25
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-25
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-10-25
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-10-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-10-18
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-18
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2019-10-18
Health
Provide activities to meet all resident's needs.
Corrected 2019-10-18
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Nearby options
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Mayfield Village, OH
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