7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Marietta, OH
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
117 Bartlett Street, Marietta, OH
(740) 434-5900
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
80
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
2020-06-22
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
RN hours / resident day
0.64
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.41
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
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.50
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
9,507
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.02
Baseline 22.23% · Performance 21.44% · Measure score 1.02 · Achievement 0 · Improvement 1.02
Healthcare-associated infections
0
Baseline 5.27% · Performance 8.03% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.66
Baseline 36.77% · Performance 32.35% · Measure score 7.66 · Achievement 7.66 · Improvement 3.20
Adjusted total nurse staffing
0.7
Baseline 2.68 hours · Performance 3.05 hours · Measure score 0.7 · Achievement 0 · Improvement 0.7
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.7% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 153 · Observed rate 9.8% · Lower 95% interval 7.48% |
| Discharge to community | 46.47% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 38.98% · Lower 95% interval 37.07% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 63 · Denominator 63 |
| Falls with major injury | 3.17% |
0.77%
2.4 pts worse
|
Numerator 2 · Denominator 63 |
| Discharge self-care score | 26.67% |
53.69%
27 pts worse
|
Numerator 12 · Denominator 45 |
| Discharge mobility score | 22.22% |
50.94%
28.7 pts worse
|
Numerator 10 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 3.17% |
2.29%
0.9 pts worse
|
Numerator 2 · Denominator 63 · Adjusted rate 2.77% |
| Healthcare-associated infections requiring hospitalization | 8.03% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 10% · Lower 95% interval 4.76% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 105 |
| Staff flu vaccination coverage | 33.83% |
42%
8.2 pts worse
|
Numerator 45 · Denominator 133 |
| Discharge function score | 22.22% |
56.45%
34.2 pts worse
|
Numerator 10 · Denominator 45 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 21 · Denominator 21 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 8.82% |
25.2%
16.4 pts worse
|
Numerator 3 · Denominator 34 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.8 |
1.8
1 pts worse
|
1.9
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.6 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
92.4%
6.8 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.5% · Q3 98.4% · Q4 100.0% · 4Q avg 99.2% |
| 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 | 6.5% |
3.3%
3.2 pts worse
|
3.3%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.5% · Q3 6.3% · Q4 6.3% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.5% |
26.1%
8.6 pts better
|
11.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 7.0% · Q3 15.1% · Q4 23.3% · 4Q avg 17.5% |
| Percentage of long-stay residents who lose too much weight | 6.5% |
6.2%
0.3 pts worse
|
5.4%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.4% · Q3 9.8% · Q4 6.1% · 4Q avg 6.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.8% |
25.4%
14.4 pts worse
|
19.6%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.1% · Q2 36.7% · Q3 45.1% · Q4 36.0% · 4Q avg 39.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
11.5%
0.3 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 2.9% · Q3 13.0% · Q4 12.2% · 4Q avg 11.2% · 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 | 5.1% |
7.7%
2.6 pts better
|
16.3%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 9.7% · Q3 2.8% · Q4 2.8% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
6.2%
3.3 pts worse
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 10.6% · Q3 6.0% · Q4 6.2% · 4Q avg 9.5% · 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 | 20.5% |
21.7%
1.2 pts better
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.7% · Q2 24.1% · Q3 21.6% · Q4 17.9% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
3.7%
3 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.2% |
78.1%
17.1 pts better
|
81.7%
13.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.7% · Q2 94.1% · Q3 97.0% · Q4 97.3% · 4Q avg 95.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.8% |
12.5%
4.3 pts worse
|
12.0%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 13.9% · Expected 9.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 80.0% |
75.6%
4.4 pts better
|
79.7%
0.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.9% |
25.1%
8.8 pts worse
|
23.9%
10 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.9% · Observed 30.6% · Expected 21.5% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-08-12
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-08-12
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-08-12
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-08-12
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-08-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-20
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-06-14
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-06-14
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-14
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-14
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-10
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-02-10
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-10
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-10
Inspection history
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-12
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-12
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 2025-08-12
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-08-12
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-14
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-06-14
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-06-14
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-14
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-22
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-06-22
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-22
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 2023-06-22
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-10
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-02-10
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2023-02-10
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-02-10
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-02-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-10
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-10
Health
Implement a program that monitors antibiotic use.
Corrected 2023-02-10
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-02-10
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-02-10
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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