Cycle 1
Health 2023-08-17 · Fire 2023-08-17
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Avon, OH
Woods On French Creek Nursing & Rehab Center The
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
37845 Colorado Avenue, Avon, OH
(440) 695-1400
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
74
Certified beds
Average residents
70
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
2015-05-14
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
0.76
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.55
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
3.12
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.77
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.68
CMS adjusted RN staffing hours
Adjusted total hours
2.77
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
68%
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
6,597
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9870
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.08
Baseline 21.10% · Performance 20.00% · Measure score 3.08 · Achievement 3.08 · Improvement 2.19
Healthcare-associated infections
4.29
Baseline 5.97% · Performance 6.55% · Measure score 4.29 · Achievement 4.29 · Improvement 0
Total nurse turnover
5.55
Baseline 43.08% · Performance 40.98% · Measure score 5.55 · Achievement 5.55 · Improvement 0.65
Adjusted total nurse staffing
0
Baseline 2.73 hours · Performance 2.75 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.57% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 128 · Observed rate 10.94% · Lower 95% interval 6.86% |
| Discharge to community | 50.45% |
50.57%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 125 · Observed rate 45.6% · Lower 95% interval 41.92% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.77% |
95.27%
3.5 pts better
|
Numerator 80 · Denominator 81 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 81 |
| Discharge self-care score | 72.13% |
53.69%
18.4 pts better
|
Numerator 44 · Denominator 61 |
| Discharge mobility score | 90.16% |
50.94%
39.2 pts better
|
Numerator 55 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 1.23% |
2.29%
1.1 pts better
|
Numerator 1 · Denominator 81 · Adjusted rate 1.12% |
| Healthcare-associated infections requiring hospitalization | 6.55% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 5.48% · Lower 95% interval 3.78% |
| Staff COVID-19 vaccination coverage | 6.61% |
8.2%
1.6 pts worse
|
Numerator 8 · Denominator 121 |
| Staff flu vaccination coverage | 15.66% |
42%
26.3 pts worse
|
Numerator 26 · Denominator 166 |
| Discharge function score | 88.52% |
56.45%
32.1 pts better
|
Numerator 54 · Denominator 61 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 47 · Denominator 47 |
| Resident COVID-19 vaccinations up to date | 13.21% |
25.2%
12 pts worse
|
Numerator 7 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
92.4%
2.5 pts better
|
93.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 90.6% · Q3 92.3% · Q4 100.0% · 4Q avg 94.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.5%
3.8 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.3% |
3.3%
1 pts better
|
3.3%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.9% · Q3 1.9% · Q4 3.8% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 66.1% |
26.1%
40 pts worse
|
11.4%
54.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.2% · Q2 68.9% · Q3 68.1% · Q4 56.2% · 4Q avg 66.1% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
6.2%
1.5 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 9.8% · Q3 4.9% · Q4 2.4% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.2% |
25.4%
0.8 pts worse
|
19.6%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 21.4% · Q3 31.0% · Q4 29.3% · 4Q avg 26.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.1% |
11.5%
3.4 pts better
|
16.7%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 5.7% · Q3 10.8% · Q4 11.1% · 4Q avg 8.1% · 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 | 3.9% |
7.7%
3.8 pts better
|
16.3%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.1% |
6.2%
3.1 pts better
|
14.9%
11.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.1% · Q3 0.0% · Q4 5.0% · 4Q avg 3.1% · 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 | 25.0% |
21.7%
3.3 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 36.6% · Q3 21.7% · Q4 22.1% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
3.7%
1.5 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 0.0% · Q3 1.5% · Q4 1.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.3% |
78.1%
4.2 pts better
|
81.7%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 70.6% · Q2 78.9% · Q3 82.4% · Q4 93.2% · 4Q avg 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
12.5%
2.7 pts worse
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 15.7% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.2%
0.9 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 51.2% |
75.6%
24.4 pts worse
|
79.7%
28.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 51.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.8% |
25.1%
8.7 pts worse
|
23.9%
9.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.8% · Observed 36.1% · Expected 25.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-20 · Fire 2020-02-20
8 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2018-12-19 · Fire 2018-12-19
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
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
2023-08-17
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 2023-09-07
F · Potential for more than minimal harm
2023-08-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-07
F · Potential for more than minimal harm
2023-08-17
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 2023-09-07
E · Potential for more than minimal harm
2023-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-07
E · Potential for more than minimal harm
2023-08-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-07
F · Potential for more than minimal harm
2020-02-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-03-22
F · Potential for more than minimal harm
2020-02-20
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 2020-03-22
C · Minimal harm
2020-02-20
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2020-03-22
Inspection history
Recent health citations
G · Actual harm
2025-11-06
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.
Not marked corrected
G · Actual harm
2025-03-27
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 2024-06-27
D · Potential for more than minimal harm
2023-08-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-07
D · Potential for more than minimal harm
2023-08-17
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 2023-09-07
D · Potential for more than minimal harm
2023-08-17
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-09-07
D · Potential for more than minimal harm
2020-02-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-03-22
D · Potential for more than minimal harm
2020-02-20
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2020-03-22
D · Potential for more than minimal harm
2020-02-20
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2020-03-22
D · Potential for more than minimal harm
2020-02-20
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2020-03-22
D · Potential for more than minimal harm
2020-02-20
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2020-03-22
D · Potential for more than minimal harm
2020-02-20
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 2020-03-22
D · Potential for more than minimal harm
2020-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-22
C · Minimal harm
2020-02-20
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2020-03-16
E · Potential for more than minimal harm
2018-12-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-01-22
D · Potential for more than minimal harm
2018-12-19
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2019-01-22
D · Potential for more than minimal harm
2018-12-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-01-22
D · Potential for more than minimal harm
2018-12-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-01-22
D · Potential for more than minimal harm
2018-12-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-01-22
D · Potential for more than minimal harm
2018-12-19
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-01-22
D · Potential for more than minimal harm
2018-12-19
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2019-01-22
D · Potential for more than minimal harm
2018-12-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-01-22
D · Potential for more than minimal harm
2018-12-19
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 2019-01-22
C · Minimal harm
2018-12-19
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-01-22
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
Wakeling, Alexis
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Avon Oaks Nursing Home
Avon, OH
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
St Mary Of The Woods
Avon, OH
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Main Street Care Center
Avon Lake, OH
4-star overall rating with 3-star inspections with $16,801 in total fines with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
Jump out