15 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
West Jefferson, OH
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
375 West Main Street, West Jefferson, OH
(614) 879-7661
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
94
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Arbors At Ohio
Operator or chain grouping
Approved since
1979-10-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 2 overall / 2 health / 3 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
RN hours / resident day
0.58
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.13
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.73
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.32
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
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
11,577
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.22
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Performance 8.62% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.26
Baseline 48.33% · Performance 46.27% · Measure score 4.26 · Achievement 4.26 · Improvement 0.38
Adjusted total nurse staffing
0.61
Baseline 3.03 hours · Performance 3.25 hours · Measure score 0.61 · Achievement 0.61 · Improvement 0.31
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.3% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 34 · Observed rate 8.82% · Lower 95% interval 6.9% |
| Discharge to community | 51.14% |
50.57%
0.6 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 42.86% · Lower 95% interval 36.59% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 26 · Denominator 26 |
| Falls with major injury | 7.69% |
0.77%
6.9 pts worse
|
Numerator 2 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 26 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.63% |
7.12%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 17.86% · Lower 95% interval 5.21% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 18.87% |
42%
23.1 pts worse
|
Numerator 20 · Denominator 106 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · 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
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.5% |
92.4%
1.9 pts worse
|
93.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 92.6% · Q3 84.0% · Q4 88.7% · 4Q avg 90.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.5%
4.1 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.3%
0.7 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.9% · Q3 4.0% · Q4 7.0% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
26.1%
26.1 pts better
|
11.4%
11.4 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 who lose too much weight | 10.3% |
6.2%
4.1 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 7.1% · Q3 14.0% · Q4 11.5% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.6% |
25.4%
2.2 pts worse
|
19.6%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 21.1% · Q3 22.4% · Q4 39.6% · 4Q avg 27.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.6% |
11.5%
4.9 pts better
|
16.7%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 10.5% · Q3 7.3% · Q4 2.6% · 4Q avg 6.6% · 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 | 1.5% |
7.7%
6.2 pts better
|
16.3%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.9% |
6.2%
4.3 pts better
|
14.9%
13 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.6% · Q3 0.0% · Q4 2.0% · 4Q avg 1.9% · 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 | 0.4% |
0.5%
0.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
21.7%
6.2 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 22.6% · Q3 8.6% · Q4 17.7% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
3.7%
3.7 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 10.1% · Q3 8.5% · Q4 2.7% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.9% |
78.1%
2.2 pts worse
|
81.7%
5.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 98.0% · Q2 83.2% · Q3 53.9% · Q4 54.8% · 4Q avg 75.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
12.5%
6.5 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 6.5% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.6% |
1.2%
3.4 pts worse
|
1.6%
3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 9.1% · Q3 2.9% · Q4 2.5% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.0% |
75.6%
1.6 pts worse
|
79.7%
5.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 40.1% |
25.1%
15 pts worse
|
23.9%
16.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 40.1% · Observed 41.9% · Expected 24.9% · Used in QM five-star |
Survey summary
Top issue: Pharmacy Service (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
13 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-30
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-04-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-30
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-30
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-30
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-30
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-04-29
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-04-29
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-04-29
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-04-29
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-04-29
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-29
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2022-04-29
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 2022-04-29
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-29
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-04-29
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-04-29
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-04-29
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-04-29
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-07-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-26
Fire Safety
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
Corrected 2019-07-26
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-30
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-04-30
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 2025-04-30
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 2025-04-30
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-04-30
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-04-30
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-04-30
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-30
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-30
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-30
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-30
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 2025-04-30
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-30
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-30
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-30
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-12-05
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-06
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-11-06
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-06
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-11-06
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-19
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-04-26
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 2022-04-29
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 2022-04-29
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 2022-04-29
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-04-29
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-29
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-04-29
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-04-29
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-04-29
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-04-29
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-04-29
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 2019-07-26
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 2019-07-26
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2019-07-26
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 2019-07-26
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-07-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-07-26
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-07-26
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Organization
Corporate Officer · Individual
Contracted Managing Employee · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Contracted Managing Employee · Individual
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London, OH
2-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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