Cycle 1
Health 2024-07-25 · Fire 2024-07-25
3 health deficiencies
Top issue: Administration (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Ashtabula, OH
Saybrook Landing
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2300 Center Road, Ashtabula, OH
(440) 969-1509
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
95
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
2009-12-30
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
0.51
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.34
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
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.01
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,961
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.35% · Performance 23.42% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 4.89% · Performance 8.43% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
9.30
Baseline 15.79% · Performance 25.68% · Measure score 9.30 · Achievement 9.30 · Improvement 0
Adjusted total nurse staffing
0.77
Baseline 2.32 hours · Performance 2.76 hours · Measure score 0.77 · Achievement 0 · Improvement 0.77
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.55% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 273 · Observed rate 13.19% · Lower 95% interval 8.7% |
| Discharge to community | 64.19% |
50.57%
13.6 pts better
|
Better than the National Rate · Eligible stays 248 · Observed rate 58.06% · Lower 95% interval 59.24% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 91.39% |
95.27%
3.9 pts worse
|
Numerator 138 · Denominator 151 |
| Falls with major injury | 1.32% |
0.77%
0.6 pts worse
|
Numerator 2 · Denominator 151 |
| Discharge self-care score | 53.06% |
53.69%
0.6 pts worse
|
Numerator 52 · Denominator 98 |
| Discharge mobility score | 32.65% |
50.94%
18.3 pts worse
|
Numerator 32 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 0.66% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 151 · Adjusted rate 0.73% |
| Healthcare-associated infections requiring hospitalization | 8.43% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 160 · Observed rate 9.38% · Lower 95% interval 5.51% |
| Staff COVID-19 vaccination coverage | 12.86% |
8.2%
4.7 pts better
|
Numerator 18 · Denominator 140 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 195 |
| Discharge function score | 37.76% |
56.45%
18.7 pts worse
|
Numerator 37 · Denominator 98 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 25 · Denominator 25 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 88 · Denominator 88 |
| Resident COVID-19 vaccinations up to date | 38.89% |
25.2%
13.7 pts better
|
Numerator 28 · Denominator 72 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 2.1 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
92.4%
6 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 98.8% · Q3 98.7% · Q4 98.7% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
94.5%
2.1 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.3%
1.4 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 3.7% · Q3 1.3% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 38.6% |
26.1%
12.5 pts worse
|
11.4%
27.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 21.6% · Q3 55.2% · Q4 54.5% · 4Q avg 38.6% |
| Percentage of long-stay residents who lose too much weight | 7.5% |
6.2%
1.3 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 11.3% · Q3 7.7% · Q4 6.2% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.7% |
25.4%
0.3 pts worse
|
19.6%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 23.6% · Q3 27.7% · Q4 29.2% · 4Q avg 25.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.8% |
11.5%
0.7 pts better
|
16.7%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 10.2% · Q3 8.9% · Q4 8.5% · 4Q avg 10.8% · 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 | 7.6% |
7.7%
0.1 pts better
|
16.3%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 5.4% · Q3 6.2% · Q4 6.9% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.0% |
6.2%
2.2 pts better
|
14.9%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.4% · Q3 3.4% · Q4 3.3% · 4Q avg 4.0% · 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 | 25.1% |
21.7%
3.4 pts worse
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.4% · Q2 25.9% · Q3 18.0% · Q4 30.1% · 4Q avg 25.1% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
3.7%
3.8 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 7.6% · Q3 11.0% · Q4 8.7% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
78.1%
19.6 pts better
|
81.7%
16 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 96.5% · Q3 99.0% · Q4 99.0% · 4Q avg 97.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
12.5%
5.8 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 6.4% · Expected 10.6% · 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 | 93.5% |
75.6%
17.9 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
25.1%
2.9 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 22.0% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-09 · Fire 2022-06-09
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Cycle 3
Health 2019-06-06 · Fire 2019-06-06
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-25
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-08-19
E · Potential for more than minimal harm
2024-07-25
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 2024-08-19
F · Potential for more than minimal harm
2022-06-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-06-24
F · Potential for more than minimal harm
2022-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-24
E · Potential for more than minimal harm
2022-06-09
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 2022-06-24
E · Potential for more than minimal harm
2022-06-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-06-24
E · Potential for more than minimal harm
2022-06-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-06-24
F · Potential for more than minimal harm
2019-06-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-07-30
E · Potential for more than minimal harm
2019-06-06
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 2019-07-30
E · Potential for more than minimal harm
2019-06-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-07-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-07-25
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-08-19
F · Potential for more than minimal harm
2024-07-25
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2024-08-19
D · Potential for more than minimal harm
2024-07-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-19
D · Potential for more than minimal harm
2023-11-13
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 2023-11-21
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
Moyers, Rachel
Operational/Managerial Control · Individual
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#2
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4-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
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3-star overall rating with 3-star inspections with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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