Cycle 1
Health 2024-11-18 · Fire 2024-11-18
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Jefferson, OH
Jefferson Healthcare Center
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
222 E Beech St, Jefferson, OH
(440) 576-0060
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
1984-10-25
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.33
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
0.40
CMS adjusted RN staffing hours
Adjusted total hours
2.69
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,496
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.17
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.71
Baseline 17.44% · Performance 19.71% · Measure score 3.71 · Achievement 3.71 · Improvement 0
Healthcare-associated infections
0
Baseline 7.44% · Performance 8.13% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.18
Baseline 39.44% · Performance 46.58% · Measure score 4.18 · Achievement 4.18 · Improvement 0
Adjusted total nurse staffing
0.17
Baseline 2.19 hours · Performance 2.43 hours · Measure score 0.17 · Achievement 0 · Improvement 0.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.96% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 176 · Observed rate 13.07% · Lower 95% interval 8.09% |
| Discharge to community | 62.81% |
50.57%
12.2 pts better
|
Better than the National Rate · Eligible stays 179 · Observed rate 53.07% · Lower 95% interval 54.81% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 94.85% |
95.27%
0.4 pts worse
|
Numerator 92 · Denominator 97 |
| Falls with major injury | 2.06% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 97 |
| Discharge self-care score | 65.67% |
53.69%
12 pts better
|
Numerator 44 · Denominator 67 |
| Discharge mobility score | 32.84% |
50.94%
18.1 pts worse
|
Numerator 22 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 2.06% |
2.29%
0.2 pts better
|
Numerator 2 · Denominator 97 · Adjusted rate 2.53% |
| Healthcare-associated infections requiring hospitalization | 8.13% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 106 · Observed rate 10.38% · Lower 95% interval 5.1% |
| Staff COVID-19 vaccination coverage | 0.92% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 109 |
| Staff flu vaccination coverage | 18.27% |
42%
23.7 pts worse
|
Numerator 19 · Denominator 104 |
| Discharge function score | 35.82% |
56.45%
20.6 pts worse
|
Numerator 24 · Denominator 67 |
| Transfer of health information to provider | 91.89% |
95.95%
4.1 pts worse
|
Numerator 68 · Denominator 74 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 21.15% |
25.2%
4.1 pts worse
|
Numerator 11 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
92.4%
6.2 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.1% · Q3 98.7% · Q4 100.0% · 4Q avg 98.6% |
| 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 | 1.4% |
3.3%
1.9 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.3% · Q3 1.3% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 93.3% |
26.1%
67.2 pts worse
|
11.4%
81.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 95.8% · Q3 94.1% · Q4 92.4% · 4Q avg 93.3% |
| Percentage of long-stay residents who lose too much weight | 12.8% |
6.2%
6.6 pts worse
|
5.4%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.9% · Q3 5.3% · Q4 9.4% · 4Q avg 12.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.3% |
25.4%
13.9 pts worse
|
19.6%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.0% · Q2 42.4% · Q3 40.4% · Q4 35.8% · 4Q avg 39.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.4% |
11.5%
6.9 pts worse
|
16.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 20.4% · Q3 20.4% · Q4 12.8% · 4Q avg 18.4% · 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 | 2.7% |
7.7%
5 pts better
|
16.3%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.6% · Q3 0.0% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.8% |
6.2%
2.4 pts better
|
14.9%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.5% · Q3 0.0% · Q4 9.6% · 4Q avg 3.8% · 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 | 0.3% |
0.5%
0.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.9% |
21.7%
2.8 pts better
|
19.8%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 21.5% · Q3 17.6% · Q4 21.1% · 4Q avg 18.9% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
3.7%
0.5 pts worse
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 4.2% · Q3 3.9% · Q4 2.8% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
78.1%
16.1 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 93.2% · Q3 95.8% · Q4 96.2% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.5% |
12.5%
4 pts worse
|
12.0%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.5% · Observed 17.3% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.2%
1.7 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.3% · Q3 2.7% · Q4 2.2% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.3% |
75.6%
4.7 pts better
|
79.7%
0.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
25.1%
1.1 pts better
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 25.5% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-22 · Fire 2022-07-22
5 health deficiencies
Top issue: Administration (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-07-11 · Fire 2019-07-11
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-11-18
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 2024-12-13
E · Potential for more than minimal harm
2024-11-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-13
F · Potential for more than minimal harm
2022-07-22
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 2022-09-12
F · Potential for more than minimal harm
2022-07-22
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 2022-09-12
F · Potential for more than minimal harm
2022-07-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-12
F · Potential for more than minimal harm
2022-07-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-09-12
E · Potential for more than minimal harm
2022-07-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-12
F · Potential for more than minimal harm
2019-07-11
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2019-08-26
F · Potential for more than minimal harm
2019-07-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-08-26
E · Potential for more than minimal harm
2019-07-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-08-26
E · Potential for more than minimal harm
2019-07-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-08-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-07-22
F725 · Nursing and Physician Services Deficiencies
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 2022-09-12
F · Potential for more than minimal harm
2022-07-22
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-09-12
E · Potential for more than minimal harm
2022-07-22
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-09-12
E · Potential for more than minimal harm
2022-07-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-12
D · Potential for more than minimal harm
2022-07-22
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 2022-09-12
D · Potential for more than minimal harm
2019-07-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-08-26
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
Foundations Health Solutions, LLC
Operational/Managerial Control · Organization
Krystowski, John
Operational/Managerial Control · Individual
Krystowski, John
Corporate Officer · Individual
Pratt, Tishia
Operational/Managerial Control · Individual
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