9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Columbus, OH
2-star overall rating with 2-star inspections with $150,145 in total fines with 9 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
2770 Clime Road, Columbus, OH
(614) 276-8222
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
95
Certified beds
Average residents
72
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Embassy Healthcare
Operator or chain grouping
Approved since
1986-04-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
37 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 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
0.40
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.38
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
3.16
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.25
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
0.42
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
73%
Annual nurse turnover · state 50% · national 46%
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 23 · Denominator 23 |
| Falls with major injury | 4.35% |
0.77%
3.6 pts worse
|
Numerator 1 · Denominator 23 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · 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 23 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 12 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 64.2% |
8.2%
56 pts better
|
Numerator 52 · Denominator 81 |
| Staff flu vaccination coverage | 6.32% |
42%
35.7 pts worse
|
Numerator 6 · Denominator 95 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · 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 | 96.0% |
92.4%
3.6 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 98.6% · Q3 100.0% · Q4 98.5% · 4Q avg 96.0% |
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.3%
2.6 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.8% |
26.1%
25.3 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
6.2%
0.4 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.1% · Q3 8.1% · Q4 10.0% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
25.4%
7.8 pts better
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 18.8% · Q3 12.9% · Q4 20.0% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
11.5%
3.2 pts better
|
16.7%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 10.0% · Q3 4.8% · Q4 7.1% · 4Q avg 8.3% · 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 | 3.5% |
7.7%
4.2 pts better
|
16.3%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.2% · Q3 0.0% · Q4 8.5% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.7% |
6.2%
4.5 pts better
|
14.9%
13.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.6% · Q3 0.0% · Q4 3.4% · 4Q avg 1.7% · 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 | 18.2% |
21.7%
3.5 pts better
|
19.8%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 16.5% · Q3 19.8% · Q4 23.7% · 4Q avg 18.2% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
3.7%
0.4 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 1.6% · Q3 4.9% · Q4 2.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.6% |
78.1%
9.5 pts better
|
81.7%
5.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 82.5% · Q2 94.1% · Q3 87.9% · Q4 86.5% · 4Q avg 87.6% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.2%
0.7 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.7% · Q3 3.8% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
75.6%
7.7 pts better
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
Survey summary
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
7 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2026-02-26
Fire Safety
Establish emergency prep training and testing.
Corrected 2026-02-19
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-01-28
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-13
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 2026-03-05
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-02-19
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-12
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-27
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-12
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-12
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-06-12
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-06-12
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-03
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-03
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-02-03
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 2023-02-03
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-02-03
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-02-03
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-02-03
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-05-26
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-05-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-05-26
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-05-26
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2020-05-26
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-05-26
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-05-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-05-26
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-05-26
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-05-26
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-05-26
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-12
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-12
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 2025-06-12
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-06-12
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-12
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-12
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-13
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-05-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-21
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-10-21
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-21
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-10-21
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-21
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-23
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 2024-02-23
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-10-04
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-04
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-04
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-03-17
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-02-03
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-03
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-02-03
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 2023-02-03
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-03
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-02-03
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 2023-02-03
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-03
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-02-03
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-02-03
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-03
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-02-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-03
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 2023-02-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-03
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2023-02-03
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 2023-02-03
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2023-02-03
Health
Provide or obtain dental services for each resident.
Corrected 2023-02-03
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-01-02
Health
Provide activities to meet all resident's needs.
Corrected 2023-01-02
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 2020-05-26
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-05-26
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-05-26
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 2020-05-26
Health
Provide or obtain dental services for each resident.
Corrected 2020-05-26
Penalties and ownership
Fine · fine $58,737
Fine
Payment Denial · denial start 2025-06-11 · 16 days
16 day denial
Fine · fine $91,408
Fine
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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