41 health deficiencies
Top issue: Quality of Life and Care (18 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Dublin, OH
1-star overall rating with 1-star inspections with Special Focus status with $197,547 in total fines with 41 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
4075 West Dublin-Granville Road, Dublin, OH
(614) 210-0541
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2014-07-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.86
Registered nurse staffing
LPN hours / resident day
0.75
Licensed practical nurse staffing
Aide hours / resident day
2.16
Nurse aide staffing
Weekend hours
3.27
Weekend nurse staffing
RN turnover
74%
Annual RN turnover
Total nurse turnover
63%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.3% |
92.4%
3.9 pts better
|
93.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.4% |
94.5%
0.1 pts worse
|
95.5%
1.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 21.9% |
26.1%
4.2 pts better
|
11.4%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.2%
1.4 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
25.4%
4.2 pts better
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.3% |
11.5%
4.8 pts worse
|
16.7%
0.4 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 | 7.4% |
7.7%
0.3 pts better
|
16.3%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
6.2%
3.2 pts worse
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
0.5%
0.2 pts worse
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.9% |
21.7%
2.2 pts worse
|
19.8%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
3.7%
1.2 pts worse
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.4% |
78.1%
6.7 pts worse
|
81.7%
10.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
12.5%
3.6 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.2%
1.2 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.6% |
75.6%
12 pts worse
|
79.7%
16.1 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.6% |
25.1%
10.5 pts worse
|
23.9%
11.7 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (18 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Pharmacy Service (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-11-19
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 2024-11-19
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-11-19
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2024-11-19
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-11-19
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-19
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-11-19
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-19
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-12-20
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-12-20
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 2019-06-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-26
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-06-26
Inspection history
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-12
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2026-02-12
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 2026-02-12
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 2026-02-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-02-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-02-12
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-12
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 2026-02-12
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-02-12
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2026-02-12
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-12
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-19
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-11-19
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-11-19
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-19
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-11-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-19
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-11-19
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-11-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-19
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-11-19
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-19
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-11-19
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-11-19
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-11-19
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 2024-11-19
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-11-19
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-11-19
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-11-19
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-11-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-11-19
Health
Provide activities to meet all resident's needs.
Corrected 2024-11-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-11-19
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 2024-11-19
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-11-19
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 2024-11-19
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-19
Health
Provide or obtain dental services for each resident.
Corrected 2024-11-19
Health
Implement a program that monitors antibiotic use.
Corrected 2024-11-19
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-11-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-16
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 2024-08-23
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-16
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-07-16
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-07-16
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 2024-07-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-16
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-16
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 2024-07-16
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 2024-07-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-16
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-02-26
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-26
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-02-26
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-26
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-26
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-02-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-24
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-26
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-05-09
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-04-28
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 2021-12-20
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 2021-12-20
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 2021-12-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-26
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 2019-07-10
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-26
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-06-26
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-06-26
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-06-26
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-07-10
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2019-06-26
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-06-26
Penalties and ownership
Fine · fine $52,992
Fine
Fine · fine $128,935
Fine
Payment Denial · denial start 2024-07-11 · 5 days
5 day denial
Fine · fine $15,620
Fine
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
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