Cycle 1
Health 2024-06-27 · Fire 2024-06-27
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Huron, OH
Admiral's Pointe Nursing & Rehabilitation
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1920 Cleveland Rd W, Huron, OH
(419) 433-4990
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
1994-05-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
63 facilities
Chain averages 4 overall / 4 health / 2 staffing / 4 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
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.21
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.64
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.44
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.29
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.16
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,438
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.80
Baseline 20.23% · Performance 20.14% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Healthcare-associated infections
1.64
Baseline 5.35% · Performance 7.34% · Measure score 1.64 · Achievement 1.64 · Improvement 0
Total nurse turnover
4.18
Baseline 58.90% · Performance 46.59% · Measure score 4.18 · Achievement 4.18 · Improvement 3.12
Adjusted total nurse staffing
0.84
Baseline 2.67 hours · Performance 3.09 hours · Measure score 0.84 · Achievement 0 · Improvement 0.84
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.66% |
10.72%
3.9 pts worse
|
No Different than the National Rate · Eligible stays 129 · Observed rate 19.38% · Lower 95% interval 10.45% |
| Discharge to community | 54.33% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 116 · Observed rate 50.86% · Lower 95% interval 42.92% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 87 · Denominator 87 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 87 |
| Discharge self-care score | 53.85% |
53.69%
0.2 pts better
|
Numerator 28 · Denominator 52 |
| Discharge mobility score | 59.62% |
50.94%
8.7 pts better
|
Numerator 31 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 1.15% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 87 · Adjusted rate 1.07% |
| Healthcare-associated infections requiring hospitalization | 7.34% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 7.46% · Lower 95% interval 4.3% |
| Staff COVID-19 vaccination coverage | 6.25% |
8.2%
1.9 pts worse
|
Numerator 8 · Denominator 128 |
| Staff flu vaccination coverage | 13.66% |
42%
28.3 pts worse
|
Numerator 25 · Denominator 183 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 39 · Denominator 52 |
| 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 42 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 20% |
25.2%
5.2 pts worse
|
Numerator 9 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 1.9 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.3% |
92.4%
2.1 pts worse
|
93.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 85.3% · Q3 89.2% · Q4 92.5% · 4Q avg 90.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.5%
4.1 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.3%
0.4 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.4% · Q3 4.6% · Q4 3.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.3% |
26.1%
4.8 pts better
|
11.4%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 21.1% · Q3 13.8% · Q4 13.0% · 4Q avg 21.3% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
6.2%
1.7 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 0.0% · Q3 5.2% · Q4 1.7% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.1% |
25.4%
4.7 pts worse
|
19.6%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 29.6% · Q3 27.6% · Q4 36.7% · 4Q avg 30.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
11.5%
0.6 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 17.1% · Q3 8.9% · Q4 8.7% · 4Q avg 10.9% · 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 | 1.9% |
7.7%
5.8 pts better
|
16.3%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 3.5% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.8% |
6.2%
3.4 pts better
|
14.9%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.9% · Q3 3.6% · Q4 3.4% · 4Q avg 2.8% · 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 · 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 | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 20.8% |
21.7%
0.9 pts better
|
19.8%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 24.9% · Q3 18.6% · Q4 21.2% · 4Q avg 20.8% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
3.7%
1.1 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 1.6% · Q4 4.3% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
78.1%
19.5 pts better
|
81.7%
15.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 98.0% · Q3 100.0% · Q4 97.3% · 4Q avg 97.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
12.5%
5.1 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.4% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.2%
1.8 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.9% · Q3 1.8% · Q4 6.1% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.4% |
75.6%
11.8 pts better
|
79.7%
7.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.0% |
25.1%
5.9 pts worse
|
23.9%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.0% · Observed 29.6% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-16 · Fire 2021-12-16
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-05-22 · Fire 2019-05-22
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-08-16
F · Potential for more than minimal harm
2024-06-27
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 2024-08-16
F · Potential for more than minimal harm
2024-06-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-08-16
F · Potential for more than minimal harm
2024-06-27
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 2024-08-16
F · Potential for more than minimal harm
2024-06-27
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-16
F · Potential for more than minimal harm
2024-06-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-16
F · Potential for more than minimal harm
2024-06-27
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-16
F · Potential for more than minimal harm
2024-06-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-16
F · Potential for more than minimal harm
2024-06-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-16
F · Potential for more than minimal harm
2021-12-16
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-01-20
F · Potential for more than minimal harm
2021-12-16
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-01-20
F · Potential for more than minimal harm
2021-12-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-03-09
F · Potential for more than minimal harm
2021-12-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-01-20
F · Potential for more than minimal harm
2021-12-16
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 2022-01-20
F · Potential for more than minimal harm
2021-12-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-20
E · Potential for more than minimal harm
2021-12-16
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 2022-01-20
E · Potential for more than minimal harm
2021-12-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-01-20
F · Potential for more than minimal harm
2019-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-06-27
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-06-29
F · Potential for more than minimal harm
2021-12-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-01-20
D · Potential for more than minimal harm
2021-12-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-01-20
D · Potential for more than minimal harm
2021-12-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-01-20
D · Potential for more than minimal harm
2021-12-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-01-20
D · Potential for more than minimal harm
2019-05-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-06-14
Penalties and ownership
What sits behind the stars
Ownership
Colleran Fam Tr Dated 01-01-2018
5% Or Greater Indirect Ownership Interest · Organization
Foundations Health LLC
5% Or Greater Direct Ownership Interest · Organization
Colleran, Brian
Operational/Managerial Control · Individual
Colleran, Brian
Corporate Officer · Individual
Foundations Health Solutions, LLC
Operational/Managerial Control · Organization
Krystowski, John
Corporate Officer · Individual
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#3
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