Cycle 1
Health 2025-01-02 · Fire 2025-01-02
3 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Johnstown, OH
Johnstown Pointe Nursing & Rehabilitation Center
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
383 West Coshocton Street, Johnstown, OH
(740) 809-1700
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
80
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
2021-04-21
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
0.61
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.50
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.41
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
0.55
CMS adjusted RN staffing hours
Adjusted total hours
3.17
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,396
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.52
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.37
Baseline 21.17% · Performance 20.80% · Measure score 1.37 · Achievement 1.37 · Improvement 0.40
Healthcare-associated infections
3.05
Baseline 6.51% · Performance 6.92% · Measure score 3.05 · Achievement 3.05 · Improvement 0
Total nurse turnover
3.05
Baseline 57.14% · Performance 51.22% · Measure score 3.05 · Achievement 3.05 · Improvement 1.33
Adjusted total nurse staffing
0.73
Baseline 2.57 hours · Performance 2.96 hours · Measure score 0.73 · Achievement 0 · Improvement 0.73
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.39% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 124 · Observed rate 7.26% · Lower 95% interval 6.68% |
| Discharge to community | 58.01% |
50.57%
7.4 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 56.44% · Lower 95% interval 49.75% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 102 · Denominator 102 |
| Falls with major injury | 2.94% |
0.77%
2.2 pts worse
|
Numerator 3 · Denominator 102 |
| Discharge self-care score | 40.38% |
53.69%
13.3 pts worse
|
Numerator 21 · Denominator 52 |
| Discharge mobility score | 42.31% |
50.94%
8.6 pts worse
|
Numerator 22 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 0.98% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 102 · Adjusted rate 0.97% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 5.8% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 1.71% |
8.2%
6.5 pts worse
|
Numerator 2 · Denominator 117 |
| Staff flu vaccination coverage | 46.7% |
42%
4.7 pts better
|
Numerator 92 · Denominator 197 |
| Discharge function score | 48.08% |
56.45%
8.4 pts worse
|
Numerator 25 · Denominator 52 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 46 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 6 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.0% |
92.4%
10.4 pts worse
|
93.4%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 79.0% · Q3 82.5% · Q4 83.1% · 4Q avg 82.0% |
| 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 | 3.9% |
3.3%
0.6 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 1.6% · Q3 1.6% · Q4 4.6% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 24.9% |
26.1%
1.2 pts better
|
11.4%
13.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 26.7% · Q3 23.7% · Q4 27.1% · 4Q avg 24.9% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
6.2%
4.4 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 1.9% · Q4 1.8% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.4% |
25.4%
5 pts better
|
19.6%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.3% · Q2 22.2% · Q3 20.4% · Q4 19.6% · 4Q avg 20.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.6% |
11.5%
5.9 pts better
|
16.7%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.7% · Q3 4.9% · Q4 2.3% · 4Q avg 5.6% · 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 | 3.7% |
7.7%
4 pts better
|
16.3%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 3.7% · Q3 0.0% · Q4 2.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.3% |
6.2%
3.9 pts better
|
14.9%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 3.8% · Q4 3.6% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.2%
0.5 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.5% · Q4 0.0% · 4Q avg 0.7% · 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 | 9.4% |
21.7%
12.3 pts better
|
19.8%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 13.3% · Q3 6.2% · Q4 10.4% · 4Q avg 9.4% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
3.7%
1.7 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.2% · Q3 0.0% · Q4 1.8% · 4Q avg 2.0% · 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 97.6% · Q2 96.6% · Q3 97.6% · Q4 97.6% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.6% |
12.5%
1.1 pts worse
|
12.0%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.6% · Observed 13.5% · Expected 11.1% · 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 | 93.3% |
75.6%
17.7 pts better
|
79.7%
13.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.8% |
25.1%
2.3 pts better
|
23.9%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 22.5% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-16 · Fire 2023-02-16
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-04-21 · Fire 2021-04-21
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
2025-01-02
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 2025-01-17
E · Potential for more than minimal harm
2025-01-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-17
E · Potential for more than minimal harm
2025-01-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-17
F · Potential for more than minimal harm
2023-02-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-03
F · Potential for more than minimal harm
2023-02-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-03-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-17
D · Potential for more than minimal harm
2025-01-02
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-17
D · Potential for more than minimal harm
2025-01-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-17
D · Potential for more than minimal harm
2023-02-16
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-03-03
D · Potential for more than minimal harm
2023-02-16
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 2023-03-03
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
Berger, Melissa
Operational/Managerial Control · Individual
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
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