Cycle 1
Health 2024-07-25 · Fire 2024-07-25
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Hilliard, OH
Darby Glenn Nursing And Rehabilitation Center
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4787 Tremont Club Drive, Hilliard, OH
(614) 777-6001
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
99
Certified beds
Average residents
94
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Foundations Health Solutions
Operator or chain grouping
Approved since
2010-09-10
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing
LPN hours / resident day
0.66
Licensed practical nurse staffing
Aide hours / resident day
1.97
Nurse aide staffing
Weekend hours
2.92
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
48%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.8
1.3 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
92.4%
6.7 pts better
|
93.4%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 79.4% |
26.1%
53.3 pts worse
|
11.4%
68 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.1% |
6.2%
1.1 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.9% |
25.4%
4.5 pts worse
|
19.6%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
11.5%
1.3 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.2%
About the same
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.8% |
21.7%
12.9 pts better
|
19.8%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
3.7%
0.6 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.1% |
78.1%
12 pts better
|
81.7%
8.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
12.5%
3.1 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.4% |
75.6%
14.8 pts better
|
79.7%
10.7 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.6% |
25.1%
1.5 pts worse
|
23.9%
2.7 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-11 · Fire 2022-02-11
15 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-03-07 · Fire 2019-03-07
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-07-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-07-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-13
E · Potential for more than minimal harm
2024-07-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-13
F · Potential for more than minimal harm
2022-02-11
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2022-03-04
E · Potential for more than minimal harm
2022-02-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-03-04
E · Potential for more than minimal harm
2022-02-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-03-04
F · Potential for more than minimal harm
2019-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-04
E · Potential for more than minimal harm
2019-03-07
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-04-04
E · Potential for more than minimal harm
2019-03-07
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 2019-04-04
E · Potential for more than minimal harm
2019-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-04-04
E · Potential for more than minimal harm
2019-03-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-04-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-14
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-07-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-25
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 2024-08-13
D · Potential for more than minimal harm
2024-07-25
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-25
F693 · Quality of Life and Care Deficiencies
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 2024-08-13
D · Potential for more than minimal harm
2024-04-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-04
D · Potential for more than minimal harm
2024-04-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-04
D · Potential for more than minimal harm
2023-09-25
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 2023-10-06
D · Potential for more than minimal harm
2023-09-25
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 2023-10-06
D · Potential for more than minimal harm
2023-05-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-05-27
D · Potential for more than minimal harm
2023-05-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-27
G · Actual harm
2022-02-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-03-04
E · Potential for more than minimal harm
2022-02-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-11
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-11
F578 · Resident Rights Deficiencies
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 2022-03-04
D · Potential for more than minimal harm
2022-02-11
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 2022-03-04
D · Potential for more than minimal harm
2022-02-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-11
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 2022-03-04
D · Potential for more than minimal harm
2022-02-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-02-11
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 2022-03-04
D · Potential for more than minimal harm
2022-02-11
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-03-04
D · Potential for more than minimal harm
2019-03-07
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2019-04-04
D · Potential for more than minimal harm
2019-03-07
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 2019-04-04
D · Potential for more than minimal harm
2019-03-07
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 2019-04-04
D · Potential for more than minimal harm
2019-03-07
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 2019-04-04
D · Potential for more than minimal harm
2019-03-07
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 2019-04-04
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
Meeks, Amanda
Operational/Managerial Control · Individual
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#2
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#3
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2-star overall rating with 1-star inspections with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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