Cycle 1
Health 2025-06-26 · Fire 2025-06-26
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Sunbury, OH
Country View Of Sunbury
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
14961 N Old 3c Highway, Sunbury, OH
(740) 965-3984
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
1990-01-11
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
0.80
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.13
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.55
Higher values indicate more complex resident acuity
RN turnover
7%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,707
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.83% · Performance 21.32% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.93% · Performance 8.18% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.31
Baseline 45.00% · Performance 37.90% · Measure score 6.31 · Achievement 6.31 · Improvement 3.03
Adjusted total nurse staffing
1.46
Baseline 2.52 hours · Performance 3.16 hours · Measure score 1.46 · Achievement 0 · Improvement 1.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.04% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 10.96% · Lower 95% interval 7.69% |
| Discharge to community | 46.27% |
50.57%
4.3 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 43.24% · Lower 95% interval 36% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98% |
95.27%
2.7 pts better
|
Numerator 49 · Denominator 50 |
| Falls with major injury | 2% |
0.77%
1.2 pts worse
|
Numerator 1 · Denominator 50 |
| Discharge self-care score | 14.71% |
53.69%
39 pts worse
|
Numerator 5 · Denominator 34 |
| Discharge mobility score | 23.53% |
50.94%
27.4 pts worse
|
Numerator 8 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 4% |
2.29%
1.7 pts worse
|
Numerator 2 · Denominator 50 · Adjusted rate 4.06% |
| Healthcare-associated infections requiring hospitalization | 8.17% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 10.2% · Lower 95% interval 4.74% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 161 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 182 |
| Discharge function score | 26.47% |
56.45%
30 pts worse
|
Numerator 9 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 22.22% |
25.2%
3 pts worse
|
Numerator 6 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.6 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
92.4%
7.3 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.7% |
94.5%
2.2 pts better
|
95.5%
1.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.5% |
3.3%
2.2 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.1% · Q3 4.9% · Q4 6.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 61.4% |
26.1%
35.3 pts worse
|
11.4%
50 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.7% · Q2 66.1% · Q3 70.2% · Q4 68.8% · 4Q avg 61.4% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
6.2%
1 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 7.0% · Q3 5.0% · Q4 6.8% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.3% |
25.4%
12.9 pts worse
|
19.6%
18.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.1% · Q2 39.7% · Q3 33.3% · Q4 32.2% · 4Q avg 38.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
11.5%
2.2 pts worse
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 19.5% · Q3 12.2% · Q4 8.2% · 4Q avg 13.7% · 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 | 5.9% |
7.7%
1.8 pts better
|
16.3%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 13.0% · Q3 2.6% · Q4 4.4% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.4% |
6.2%
0.8 pts better
|
14.9%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 1.8% · Q3 7.0% · Q4 1.7% · 4Q avg 5.4% · 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 | 0.9% |
0.5%
0.4 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
21.7%
3.7 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 25.3% · Q3 32.1% · Q4 17.8% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 2.3% |
3.7%
1.4 pts better
|
5.1%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.6% · Q3 1.5% · Q4 3.7% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
78.1%
19.2 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.9% · Q2 97.9% · Q3 98.9% · Q4 94.0% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.6% |
12.5%
2.1 pts worse
|
12.0%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.6% · Observed 13.0% · Expected 9.9% · 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 · Q1 0.0% · 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 | 96.0% |
75.6%
20.4 pts better
|
79.7%
16.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.4% |
25.1%
7.3 pts worse
|
23.9%
8.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.4% · Observed 28.3% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-03 · Fire 2023-08-03
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2021-07-16 · Fire 2021-07-16
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-08-13
F · Potential for more than minimal harm
2023-08-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-08-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-08-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-08-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-03
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-08
E · Potential for more than minimal harm
2021-07-16
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 2021-08-12
E · Potential for more than minimal harm
2021-07-16
K226 · Egress Deficiencies
Fire Safety
Have horizontal exits used in accordance with safety requirements.
Corrected 2021-08-12
E · Potential for more than minimal harm
2021-07-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-08-12
E · Potential for more than minimal harm
2021-07-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-12
E · Potential for more than minimal harm
2021-07-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-08-12
E · Potential for more than minimal harm
2021-07-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-08-12
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-06-26
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 2025-08-13
D · Potential for more than minimal harm
2021-07-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-08-12
D · Potential for more than minimal harm
2021-07-16
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 2021-08-12
D · Potential for more than minimal harm
2021-07-16
F693 · Quality of Life and Care Deficiencies
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 2021-08-12
D · Potential for more than minimal harm
2021-07-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-08-12
D · Potential for more than minimal harm
2021-07-16
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2021-08-12
D · Potential for more than minimal harm
2021-07-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-08-12
D · Potential for more than minimal harm
2021-07-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-12
C · Minimal harm
2021-07-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-08-12
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 Director · Individual
Colleran, Brian
Corporate Officer · Individual
Engert, Carolyn
Operational/Managerial Control · Individual
Foundations Health Solutions, LLC
Operational/Managerial Control · Organization
Krystowski, John
Operational/Managerial Control · Individual
Krystowski, John
Corporate Officer · Individual
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