Cycle 1
Health 2025-05-01 · Fire 2025-05-01
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cincinnati, OH
Residence At Salem Woods
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
6164 Salem Road, Cincinnati, OH
(513) 231-8292
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
1980-03-14
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
0.49
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.40
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
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.21
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,229
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50.82
Composite VBP score used to determine payment impact.
Payment multiplier
1.0050
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
8.24
Baseline 40.00% · Performance 30.00% · Measure score 8.24 · Achievement 8.24 · Improvement 6.10
Adjusted total nurse staffing
1.92
Baseline 2.54 hours · Performance 3.33 hours · Measure score 1.92 · Achievement 0.88 · Improvement 1.92
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.74% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 6.05% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 98 |
| Staff flu vaccination coverage | 6.11% |
42%
35.9 pts worse
|
Numerator 8 · Denominator 131 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.5 |
1.8
1.7 pts worse
|
1.9
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 2.6 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
92.4%
5.9 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.6% · Q2 100.0% · Q3 100.0% · Q4 96.6% · 4Q avg 98.3% |
| 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 | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.3% · Q3 1.2% · Q4 1.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 43.0% |
26.1%
16.9 pts worse
|
11.4%
31.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 47.5% · Q3 39.2% · Q4 58.6% · 4Q avg 43.0% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
6.2%
3.2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.3% · Q3 4.1% · Q4 3.9% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.3% |
25.4%
4.9 pts worse
|
19.6%
10.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.9% · Q2 30.4% · Q3 31.5% · Q4 26.6% · 4Q avg 30.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.9% |
11.5%
8.4 pts worse
|
16.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.7% · Q2 17.3% · Q3 18.5% · Q4 17.2% · 4Q avg 19.9% · 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 | 8.5% |
7.7%
0.8 pts worse
|
16.3%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 12.7% · Q3 5.0% · Q4 4.9% · 4Q avg 8.5% · 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 8.6% · Q2 4.1% · Q3 0.0% · Q4 2.7% · 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 | 0.0% |
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 | 13.8% |
21.7%
7.9 pts better
|
19.8%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.6% · Q2 16.1% · Q3 12.1% · Q4 10.3% · 4Q avg 13.8% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
3.7%
0.4 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.6% · Q3 3.8% · Q4 3.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.2% |
78.1%
17.9 pts worse
|
81.7%
21.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 80.0% · Q3 55.2% · Q4 42.9% · 4Q avg 60.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
12.5%
2.7 pts worse
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 19.0% · Expected 14.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.4% |
1.2%
2.2 pts worse
|
1.6%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.2% |
75.6%
0.6 pts better
|
79.7%
3.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.8% |
25.1%
6.7 pts worse
|
23.9%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.8% · Observed 38.1% · Expected 28.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-14 · Fire 2022-04-14
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-10-03 · Fire 2019-10-03
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-31
F · Potential for more than minimal harm
2022-04-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-05-03
F · Potential for more than minimal harm
2022-04-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-03
E · Potential for more than minimal harm
2022-04-14
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 2022-05-03
E · Potential for more than minimal harm
2022-04-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-05-03
F · Potential for more than minimal harm
2019-10-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2019-11-22
F · Potential for more than minimal harm
2019-10-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-22
F · Potential for more than minimal harm
2019-10-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-11-22
F · Potential for more than minimal harm
2019-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-22
F · Potential for more than minimal harm
2019-10-03
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2019-11-22
F · Potential for more than minimal harm
2019-10-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-22
E · Potential for more than minimal harm
2019-10-03
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 2019-11-22
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-31
F · Potential for more than minimal harm
2022-04-14
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 2022-05-03
E · Potential for more than minimal harm
2022-04-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-05-03
D · Potential for more than minimal harm
2022-04-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-05-03
C · Minimal harm
2022-04-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-05-03
D · Potential for more than minimal harm
2019-10-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-11-22
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
Coffey, Brian
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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#3
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1-star overall rating with 2-star inspections with $112,473 in total fines with 2 recent health deficiencies
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