Cycle 1
Health 2025-08-12 · Fire 2025-08-12
19 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fairlawn, OH
Timberland Ridge Nursing & Rehabilitation
1-star overall rating with 2-star inspections with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
3558 Ridgewood Road, Fairlawn, OH
(243) 466-8689
Overall
1 / 5
CMS overall stars
Health inspections
2 / 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
75
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
2020-06-24
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
0.53
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.12
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
1.57
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,687
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.01
Baseline 17.17% · Performance 20.96% · Measure score 1.01 · Achievement 1.01 · Improvement 0
Healthcare-associated infections
2.78
Baseline 6.80% · Performance 7.00% · Measure score 2.78 · Achievement 2.78 · Improvement 0
Total nurse turnover
2.54
Baseline 75.79% · Performance 60.29% · Measure score 2.54 · Achievement 0.83 · Improvement 2.54
Adjusted total nurse staffing
1.46
Baseline 2.55 hours · Performance 3.19 hours · Measure score 1.46 · Achievement 0 · Improvement 1.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 49 · Observed rate 12.24% · Lower 95% interval 7.58% |
| Discharge to community | 45.26% |
50.57%
5.3 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 31.58% · Lower 95% interval 31.99% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 89.19% |
95.27%
6.1 pts worse
|
Numerator 33 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 2.7% |
2.29%
0.4 pts worse
|
Numerator 1 · Denominator 37 · Adjusted rate 2.18% |
| Healthcare-associated infections requiring hospitalization | 7% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 38 · Observed rate 7.89% · Lower 95% interval 3.63% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 89 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | 91.3% |
95.95%
4.7 pts worse
|
Numerator 21 · Denominator 23 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 95.0% |
92.4%
2.6 pts better
|
93.4%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.2% · Q2 91.2% · Q3 100.0% · Q4 100.0% · 4Q avg 95.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.6% |
94.5%
3.9 pts worse
|
95.5%
4.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.3%
0.1 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.8% · Q3 5.9% · Q4 3.8% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 32.8% |
26.1%
6.7 pts worse
|
11.4%
21.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 26.5% · Q3 37.9% · Q4 37.2% · 4Q avg 32.8% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
6.2%
2.7 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 8.2% · Q3 0.0% · Q4 13.0% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.7% |
25.4%
7.7 pts better
|
19.6%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 20.0% · Q3 15.9% · Q4 17.4% · 4Q avg 17.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.8% |
11.5%
9.3 pts worse
|
16.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 23.7% · Q3 13.5% · Q4 15.8% · 4Q avg 20.8% · 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 | 5.5% |
7.7%
2.2 pts better
|
16.3%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.3% · Q3 9.0% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.2% |
6.2%
About the same
|
14.9%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 6.5% · Q3 0.0% · Q4 9.5% · 4Q avg 6.2% · 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 | 21.4% |
21.7%
0.3 pts better
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 30.3% · Q3 20.0% · Q4 17.3% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
3.7%
0.6 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 5.4% · Q3 4.0% · Q4 1.7% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.1% |
78.1%
13 pts worse
|
81.7%
16.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 57.4% · Q3 82.4% · Q4 89.9% · 4Q avg 65.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
12.5%
0.2 pts better
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 13.6% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.2%
0.7 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 4.3% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 49.3% |
75.6%
26.3 pts worse
|
79.7%
30.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 49.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
25.1%
0.9 pts better
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 31.8% · Expected 31.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-04 · Fire 2023-05-04
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2020-06-18 · Fire 2020-06-18
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-08
F · Potential for more than minimal harm
2025-08-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-08-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-09-08
E · Potential for more than minimal harm
2025-08-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-09-08
F · Potential for more than minimal harm
2023-05-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-02
F · Potential for more than minimal harm
2023-05-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-02
E · Potential for more than minimal harm
2023-05-04
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 2023-06-02
E · Potential for more than minimal harm
2023-05-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-02
E · Potential for more than minimal harm
2023-05-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-02
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-22
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 2026-02-13
D · Potential for more than minimal harm
2026-01-22
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 2026-02-13
D · Potential for more than minimal harm
2025-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-12-04
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 2026-01-22
D · Potential for more than minimal harm
2025-12-04
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 2026-01-22
D · Potential for more than minimal harm
2025-12-04
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 2026-01-22
D · Potential for more than minimal harm
2025-12-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-12-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2026-02-13
G · Actual harm
2025-10-29
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-10-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-22
D · Potential for more than minimal harm
2025-10-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-10-29
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-12-04
F · Potential for more than minimal harm
2025-08-12
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 2025-09-08
F · Potential for more than minimal harm
2025-08-12
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-09-08
F · Potential for more than minimal harm
2025-08-12
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-09-08
F · Potential for more than minimal harm
2025-08-12
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-08-12
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 2025-09-08
D · Potential for more than minimal harm
2025-08-12
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 2025-09-08
D · Potential for more than minimal harm
2025-08-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-08
D · Potential for more than minimal harm
2025-01-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-10-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-18
E · Potential for more than minimal harm
2024-02-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-09
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
Jackson, Charles
Operational/Managerial Control · Individual
Krystowski, John
Operational/Managerial Control · Individual
Krystowski, John
Corporate Officer · Individual
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#2
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#3
Phoenix Of Fairlawn
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3-star overall rating with 3-star inspections with $4,922 in total fines with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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