Cycle 1
Health 2024-06-13 · Fire 2024-06-13
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Marysville, OH
The Gables Of Marysville Health And Rehabilitation
2-star overall rating with 3-star inspections with 8 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
390 Gables Drive, Marysville, OH
(937) 642-3893
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
90
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
1992-03-06
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
Yes
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
0.29
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.45
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
0.18
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
0.24
CMS adjusted RN staffing hours
Adjusted total hours
3.08
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,147
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.67
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.36
Baseline 19.68% · Performance 20.34% · Measure score 2.36 · Achievement 2.36 · Improvement 0
Healthcare-associated infections
0
Baseline 7.17% · Performance 9.00% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
1.25
Baseline 55.56% · Performance 58.56% · Measure score 1.25 · Achievement 1.25 · Improvement 0
Adjusted total nurse staffing
1.85
Baseline 3.09 hours · Performance 3.60 hours · Measure score 1.85 · Achievement 1.85 · Improvement 1.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.19% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 182 · Observed rate 6.04% · Lower 95% interval 6.34% |
| Discharge to community | 62.69% |
50.57%
12.1 pts better
|
Better than the National Rate · Eligible stays 180 · Observed rate 61.11% · Lower 95% interval 56.41% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 119 · Denominator 119 |
| Falls with major injury | 0.84% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 119 |
| Discharge self-care score | 40.96% |
53.69%
12.7 pts worse
|
Numerator 34 · Denominator 83 |
| Discharge mobility score | 38.55% |
50.94%
12.4 pts worse
|
Numerator 32 · Denominator 83 |
| Pressure ulcers or injuries, new or worsened | 6.72% |
2.29%
4.4 pts worse
|
Numerator 8 · Denominator 119 · Adjusted rate 7.38% |
| Healthcare-associated infections requiring hospitalization | 9% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 10.17% · Lower 95% interval 6.32% |
| Staff COVID-19 vaccination coverage | 1.33% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 150 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 57.83% |
56.45%
1.4 pts better
|
Numerator 48 · Denominator 83 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 79 · Denominator 79 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 62 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.3 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.8
0.3 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| 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 | 73.5% |
94.5%
21 pts worse
|
95.5%
22 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 73.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.1% |
3.3%
0.8 pts worse
|
3.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 3.7% · Q3 3.7% · Q4 6.4% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 50.5% |
26.1%
24.4 pts worse
|
11.4%
39.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.8% · Q2 51.4% · Q3 47.3% · Q4 53.0% · 4Q avg 50.5% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
6.2%
3.1 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.5% · Q3 1.6% · Q4 3.2% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.1% |
25.4%
9.3 pts better
|
19.6%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 16.7% · Q3 16.9% · Q4 17.5% · 4Q avg 16.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
11.5%
2.4 pts worse
|
16.7%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 16.9% · Q3 9.4% · Q4 3.8% · 4Q avg 13.9% · 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 | 0.0% |
7.7%
7.7 pts better
|
16.3%
16.3 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 whose need for help with daily activities has increased | 0.0% |
6.2%
6.2 pts better
|
14.9%
14.9 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 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 | 29.1% |
21.7%
7.4 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 25.6% · Q3 33.1% · Q4 30.4% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 0.3% |
3.7%
3.4 pts better
|
5.1%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 97.2% · Q2 97.4% · Q3 97.8% · Q4 96.9% · 4Q avg 97.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
12.5%
0.2 pts worse
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 12.0% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.6% · Q4 1.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
75.6%
11.1 pts better
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.2% |
25.1%
1.1 pts worse
|
23.9%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.2% · Observed 25.9% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-07-14 · Fire 2022-07-14
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-07-11 · Fire 2019-07-11
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-12
F · Potential for more than minimal harm
2024-06-13
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-06-13
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-06-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-12
E · Potential for more than minimal harm
2024-06-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-07-12
C · Minimal harm
2024-06-13
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-07-12
F · Potential for more than minimal harm
2022-07-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-26
F · Potential for more than minimal harm
2022-07-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-26
E · Potential for more than minimal harm
2019-07-11
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 2019-08-16
E · Potential for more than minimal harm
2019-07-11
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-08-16
E · Potential for more than minimal harm
2019-07-11
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-08-16
E · Potential for more than minimal harm
2019-07-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-16
E · Potential for more than minimal harm
2019-07-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-08-16
E · Potential for more than minimal harm
2019-07-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-08-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-06-13
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 2024-07-12
F · Potential for more than minimal harm
2024-06-13
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-06-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-06-13
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 2024-07-12
D · Potential for more than minimal harm
2024-03-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-22
D · Potential for more than minimal harm
2023-04-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-04-21
E · Potential for more than minimal harm
2022-07-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-07-14
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-07-14
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 2022-08-26
E · Potential for more than minimal harm
2019-07-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-16
E · Potential for more than minimal harm
2019-07-11
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-11
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-11
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-11
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 2019-08-16
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 Officer · Individual
Foundations Health Solutions, LLC
Operational/Managerial Control · Organization
Krystowski, John
Operational/Managerial Control · Individual
Krystowski, John
Corporate Officer · Individual
Limbacher, Lauren
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Milcrest Nursing Center
Marysville, OH
3-star overall rating with 2-star inspections with $68,006 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Prestige Gardens Rehabilitation And Nursing Center
Marysville, OH
2-star overall rating with 1-star inspections with 21 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Als Woodstock Inc
Woodstock, OH
1-star overall rating with 2-star inspections with $42,094 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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