Cycle 1
Health 2024-09-04 · Fire 2024-09-04
12 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
15 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Moraine, OH
Respiratory And Nursing Center Of Dayton
4-star overall rating with 3-star inspections with 12 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
3421 Pinnacle Road, Moraine, OH
(937) 268-3488
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
82
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
1980-06-06
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
1.40
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.80
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.36
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
0.43
CMS adjusted RN staffing hours
Adjusted total hours
2.67
CMS adjusted total nurse staffing hours
Case-mix index
1.95
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,985
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.41
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
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
2.88
Baseline 47.83% · Performance 51.90% · Measure score 2.88 · Achievement 2.88 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.44 hours · Performance 2.48 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 17 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 6 · 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 111 |
| Staff flu vaccination coverage | 6.02% |
42%
36 pts worse
|
Numerator 8 · Denominator 133 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · 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 |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
94.5%
4.2 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.3%
2.6 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 1.5% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 23.0% |
26.1%
3.1 pts better
|
11.4%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 25.0% · Q3 10.3% · Q4 25.5% · 4Q avg 23.0% |
| Percentage of long-stay residents who lose too much weight | 6.9% |
6.2%
0.7 pts worse
|
5.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 6.0% · Q3 4.7% · Q4 6.3% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 43.0% |
25.4%
17.6 pts worse
|
19.6%
23.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.5% · Q2 44.8% · Q3 43.8% · Q4 39.7% · 4Q avg 43.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.2% |
11.5%
3.3 pts better
|
16.7%
8.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.9% · Q3 13.9% · Q4 10.8% · 4Q avg 8.2% · 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 | 4.2% |
7.7%
3.5 pts better
|
16.3%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.4% |
6.2%
2.8 pts better
|
14.9%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.4% · Q3 2.1% · Q4 4.2% · 4Q avg 3.4% · 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 | 0.0% |
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 | 8.5% |
21.7%
13.2 pts better
|
19.8%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 5.9% · Q3 9.7% · Q4 7.0% · 4Q avg 8.5% |
| Percentage of long-stay residents with pressure ulcers | 11.7% |
3.7%
8 pts worse
|
5.1%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 14.2% · Q3 10.4% · Q4 11.8% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
78.1%
21.9 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 1.4% · 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% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-16 · Fire 2022-05-16
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-04-25 · Fire 2019-04-25
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-09-04
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-04
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-04
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-04
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-04
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-27
F · Potential for more than minimal harm
2024-09-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-04
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-04
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-09-04
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-09-27
F · Potential for more than minimal harm
2022-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-02
F · Potential for more than minimal harm
2022-05-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-06-02
E · Potential for more than minimal harm
2022-05-16
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2022-06-02
E · Potential for more than minimal harm
2022-05-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-06-02
F · Potential for more than minimal harm
2019-04-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-05-22
F · Potential for more than minimal harm
2019-04-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-05-22
F · Potential for more than minimal harm
2019-04-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-05-22
E · Potential for more than minimal harm
2019-04-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-05-22
E · Potential for more than minimal harm
2019-04-25
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 2019-05-22
E · Potential for more than minimal harm
2019-04-25
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2019-05-22
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-09-04
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-09-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-09-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-09-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-09-04
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-09-04
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 2024-09-13
D · Potential for more than minimal harm
2024-09-04
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 2024-09-13
D · Potential for more than minimal harm
2024-09-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-09-04
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-09-04
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-09-04
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 2024-09-13
C · Minimal harm
2024-09-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-13
D · Potential for more than minimal harm
2023-12-20
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-12-28
D · Potential for more than minimal harm
2023-12-20
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 2023-12-28
D · Potential for more than minimal harm
2023-05-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-17
D · Potential for more than minimal harm
2023-05-12
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 2023-05-17
D · Potential for more than minimal harm
2023-04-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-25
E · Potential for more than minimal harm
2022-05-16
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 2022-06-02
D · Potential for more than minimal harm
2022-05-16
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 2022-06-02
D · Potential for more than minimal harm
2022-05-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-05-16
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 2022-06-02
D · Potential for more than minimal harm
2022-05-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-05-16
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-06-02
D · Potential for more than minimal harm
2022-05-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-06-02
D · Potential for more than minimal harm
2019-04-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-05-22
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
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
Smith, Brittany
Operational/Managerial Control · Individual
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2-star overall rating with 1-star inspections with $8,648 in total fines with 18 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
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Kettering, OH
2-star overall rating with 2-star inspections with $75,572 in total fines with 12 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Laurels Of West Carrollton The
West Carrollton, OH
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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