Cycle 1
Health 2025-03-13 · Fire 2025-03-13
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lewis Center, OH
Capri Gardens
5-star overall rating with 4-star inspections with $12,340 in total fines with 3 fire-safety deficiencies in the latest cycle
6975 Graphics Way, Lewis Center, OH
(740) 657-2200
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
82
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
2019-10-01
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
0.93
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
2.79
CMS adjusted total nurse staffing hours
Case-mix index
1.75
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,874
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.55
Baseline 20.00% · Performance 20.25% · Measure score 2.55 · Achievement 2.55 · Improvement 0
Healthcare-associated infections
2.04
Baseline 6.28% · Performance 7.22% · Measure score 2.04 · Achievement 2.04 · Improvement 0
Total nurse turnover
2.53
Baseline 55.68% · Performance 53.33% · Measure score 2.53 · Achievement 2.53 · Improvement 0.26
Adjusted total nurse staffing
0.40
Baseline 2.56 hours · Performance 2.85 hours · Measure score 0.40 · Achievement 0 · Improvement 0.40
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.51% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 83 · Observed rate 2.41% · Lower 95% interval 4.86% |
| Discharge to community | 60.01% |
50.57%
9.4 pts better
|
Better than the National Rate · Eligible stays 73 · Observed rate 57.53% · Lower 95% interval 50.79% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 66 · Denominator 66 |
| Falls with major injury | 3.03% |
0.77%
2.3 pts worse
|
Numerator 2 · Denominator 66 |
| Discharge self-care score | 67.86% |
53.69%
14.2 pts better
|
Numerator 19 · Denominator 28 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 16 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 2 · Denominator 66 · Adjusted rate 3.14% |
| Healthcare-associated infections requiring hospitalization | 7.22% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 8.33% · Lower 95% interval 4.12% |
| Staff COVID-19 vaccination coverage | 4.17% |
8.2%
4 pts worse
|
Numerator 4 · Denominator 96 |
| Staff flu vaccination coverage | 16.92% |
42%
25.1 pts worse
|
Numerator 22 · Denominator 130 |
| Discharge function score | 67.86% |
56.45%
11.4 pts better
|
Numerator 19 · Denominator 28 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 23.53% |
25.2%
1.7 pts worse
|
Numerator 8 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.1% |
92.4%
0.3 pts worse
|
93.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.3% · Q2 92.8% · Q3 95.8% · Q4 95.7% · 4Q avg 92.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
94.5%
2.8 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.3%
0.8 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 2.9% · Q3 2.8% · Q4 1.4% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 40.8% |
26.1%
14.7 pts worse
|
11.4%
29.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 40.6% · Q3 48.4% · Q4 54.0% · 4Q avg 40.8% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
6.2%
About the same
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 3.2% · Q3 9.5% · Q4 8.6% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.8% |
25.4%
2.4 pts worse
|
19.6%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 27.4% · Q3 25.4% · Q4 25.9% · 4Q avg 27.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
11.5%
4.7 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 10.2% · Q3 5.6% · Q4 5.8% · 4Q avg 6.8% · 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 | 1.1% |
7.7%
6.6 pts better
|
16.3%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.2% |
6.2%
3 pts better
|
14.9%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 3.6% · Q3 0.0% · Q4 0.0% · 4Q avg 3.2% · 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 | 0.0% |
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 | 6.2% |
21.7%
15.5 pts better
|
19.8%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.4% · Q3 5.6% · Q4 8.6% · 4Q avg 6.2% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
3.7%
0.9 pts worse
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 7.8% · Q3 3.8% · Q4 2.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.1% |
78.1%
10 pts better
|
81.7%
6.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 89.5% · Q3 88.9% · Q4 88.9% · 4Q avg 88.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
12.5%
1.8 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 10.3% · Expected 10.8% · 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 0.0% · Q2 2.5% · Q3 2.8% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.7% |
75.6%
5.1 pts better
|
79.7%
1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.8% |
25.1%
9.7 pts worse
|
23.9%
10.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.8% · Observed 31.0% · Expected 21.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-28 · Fire 2022-07-28
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-10-01 · Fire 2019-10-01
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-03-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-03-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-03-28
F · Potential for more than minimal harm
2022-07-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-28
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-08-12
Inspection history
Recent health citations
J · Immediate jeopardy
2024-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-20
F · Potential for more than minimal harm
2022-07-28
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 2022-08-12
E · Potential for more than minimal harm
2022-07-28
F761 · Pharmacy Service Deficiencies
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 2022-08-12
D · Potential for more than minimal harm
2022-07-28
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-08-12
D · Potential for more than minimal harm
2022-07-28
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 2022-08-12
D · Potential for more than minimal harm
2022-07-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-12
Penalties and ownership
What sits behind the stars
$12,340
2024-11-19
Fine
Fine · fine $12,340
Fine
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 Director · Individual
Colleran, Brian
Corporate Officer · Individual
Foundations Health Solutions, LLC
Operational/Managerial Control · Organization
Krystowski, John
Operational/Managerial Control · Individual
Krystowski, John
Corporate Officer · Individual
Lytle, Derek
Operational/Managerial Control · Individual
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#3
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