Cycle 1
Health 2025-06-18 · Fire 2025-06-18
7 health deficiencies
Top issue: Infection Control (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
West Lafayette, OH
Lafayette Pointe Nursing & Rehab Ctr
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
620 East Main Street, West Lafayette, OH
(740) 545-6355
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
65
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
1992-11-12
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
0.70
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.74
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.98
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
0.60
CMS adjusted RN staffing hours
Adjusted total hours
2.86
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,526
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9894
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.38
Baseline 17.49% · Performance 20.79% · Measure score 1.38 · Achievement 1.38 · Improvement 0
Healthcare-associated infections
7.09
Baseline 6.69% · Performance 5.71% · Measure score 7.09 · Achievement 7.09 · Improvement 5.27
Total nurse turnover
5.89
Baseline 40.38% · Performance 39.62% · Measure score 5.89 · Achievement 5.89 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.78 hours · Performance 2.84 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.97% |
10.72%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 18.56% · Lower 95% interval 9.87% |
| Discharge to community | 58.32% |
50.57%
7.8 pts better
|
No Different than the National Rate · Eligible stays 86 · Observed rate 51.16% · Lower 95% interval 48.16% |
| 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 60 · Denominator 60 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 60 |
| Discharge self-care score | 45.65% |
53.69%
8 pts worse
|
Numerator 21 · Denominator 46 |
| Discharge mobility score | 34.78% |
50.94%
16.2 pts worse
|
Numerator 16 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.67% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 60 · Adjusted rate 1.7% |
| Healthcare-associated infections requiring hospitalization | 5.72% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 56 · Observed rate 1.79% · Lower 95% interval 3.13% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 65 |
| Staff flu vaccination coverage | 26.58% |
42%
15.4 pts worse
|
Numerator 21 · Denominator 79 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 23 · Denominator 46 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 11.76% |
25.2%
13.4 pts worse
|
Numerator 4 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.6 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.2 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
92.4%
2.5 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 90.9% · Q3 95.6% · Q4 100.0% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.5% |
94.5%
3 pts worse
|
95.5%
4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 4.4% · Q4 2.4% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 24.7% |
26.1%
1.4 pts better
|
11.4%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 25.6% · Q3 31.6% · Q4 23.7% · 4Q avg 24.7% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
6.2%
2.8 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 7.7% · Q4 2.8% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.5% |
25.4%
0.9 pts better
|
19.6%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 18.4% · Q3 27.5% · Q4 29.7% · 4Q avg 24.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.9% |
11.5%
10.6 pts better
|
16.7%
15.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · 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 | 2.1% |
7.7%
5.6 pts better
|
16.3%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 7.3% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.3% |
6.2%
0.9 pts better
|
14.9%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 12.5% · Q4 5.4% · 4Q avg 5.3% · 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 | 21.2% |
21.7%
0.5 pts better
|
19.8%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 28.0% · Q3 21.6% · Q4 10.5% · 4Q avg 21.2% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
3.7%
2.6 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 2.1% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.8% |
78.1%
2.3 pts worse
|
81.7%
5.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.9% · Q2 67.1% · Q3 88.3% · Q4 94.9% · 4Q avg 75.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
12.5%
3.2 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 16.4% · Expected 11.6% · 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 | 65.3% |
75.6%
10.3 pts worse
|
79.7%
14.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
25.1%
2.4 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 26.9% · Expected 23.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-04-28 · Fire 2022-04-28
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-06-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-06-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-24
F · Potential for more than minimal harm
2025-06-18
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-06-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-06-18
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 2025-07-24
F · Potential for more than minimal harm
2024-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-16
F · Potential for more than minimal harm
2024-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-16
F · Potential for more than minimal harm
2022-04-28
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-05-31
F · Potential for more than minimal harm
2022-04-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-04-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-05-31
E · Potential for more than minimal harm
2022-04-28
K913 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
Corrected 2022-05-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-04
F · Potential for more than minimal harm
2025-06-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-24
E · Potential for more than minimal harm
2025-06-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-24
D · Potential for more than minimal harm
2025-06-18
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 2025-07-24
D · Potential for more than minimal harm
2025-06-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-07-24
F · Potential for more than minimal harm
2024-03-21
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-01-01
D · Potential for more than minimal harm
2024-03-21
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 2024-04-16
D · Potential for more than minimal harm
2022-04-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-04-28
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-04-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-05-31
D · Potential for more than minimal harm
2022-04-28
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 2022-05-31
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
Jewell, Heather
Operational/Managerial Control · Individual
Krystowski, John
Operational/Managerial Control · Individual
Krystowski, John
Corporate Officer · Individual
Nearby options
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4-star overall rating with 3-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Signature Healthcare Of Coshocton
Coshocton, OH
2-star overall rating with 1-star inspections with $60,645 in total fines with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Riverside Manor Nrsg & Rehab Ctr
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3-star overall rating with 3-star inspections with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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