Cycle 1
Health 2025-06-23 · Fire 2025-06-23
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Columbus, OH
First Community Village Healthcare Ctr
4-star overall rating with 3-star inspections with $26,685 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1800 Riverside Drive, Columbus, OH
(614) 486-9511
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
47
Certified beds
Average residents
36
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.98
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.32
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.73
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.02
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.30
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.56
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.84
CMS adjusted RN staffing hours
Adjusted total hours
4.31
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,203
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.55% · Performance 21.31% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.91
Baseline 6.49% · Performance 7.56% · Measure score 0.91 · Achievement 0.91 · Improvement 0
Total nurse turnover
0
Baseline 58.18% · Performance 62.30% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
4.48
Baseline 4.34 hours · Performance 4.35 hours · Measure score 4.48 · Achievement 4.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.87% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 251 · Observed rate 7.97% · Lower 95% interval 7.44% |
| Discharge to community | 70.27% |
50.57%
19.7 pts better
|
Better than the National Rate · Eligible stays 262 · Observed rate 67.18% · Lower 95% interval 64.15% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 114 · Denominator 114 |
| Falls with major injury | 0.88% |
0.77%
0.1 pts worse
|
Numerator 1 · Denominator 114 |
| Discharge self-care score | 56.34% |
53.69%
2.7 pts better
|
Numerator 40 · Denominator 71 |
| Discharge mobility score | 52.11% |
50.94%
1.2 pts better
|
Numerator 37 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 5.26% |
2.29%
3 pts worse
|
Numerator 6 · Denominator 114 · Adjusted rate 5.02% |
| Healthcare-associated infections requiring hospitalization | 7.56% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 146 · Observed rate 7.53% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 4.84% |
8.2%
3.4 pts worse
|
Numerator 3 · Denominator 62 |
| Staff flu vaccination coverage | 13.21% |
42%
28.8 pts worse
|
Numerator 7 · Denominator 53 |
| Discharge function score | 56.34% |
56.45%
0.1 pts worse
|
Numerator 40 · Denominator 71 |
| Transfer of health information to provider | 98% |
95.95%
2 pts better
|
Numerator 49 · Denominator 50 |
| Transfer of health information to patient | 98.18% |
96.28%
1.9 pts better
|
Numerator 54 · Denominator 55 |
| Resident COVID-19 vaccinations up to date | 93.62% |
25.2%
68.4 pts better
|
Numerator 44 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
92.4%
6.1 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 10.4% |
3.3%
7.1 pts worse
|
3.3%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
26.1%
21.6 pts better
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 14.0% |
6.2%
7.8 pts worse
|
5.4%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.9% |
25.4%
2.5 pts worse
|
19.6%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.8% |
11.5%
2.7 pts better
|
16.7%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
6.2%
0.9 pts worse
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · 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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
21.7%
0.1 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
3.7%
0.5 pts worse
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
78.1%
15 pts better
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.8% · Q2 92.6% · Q3 96.1% · Q4 94.9% · 4Q avg 93.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.5% |
12.5%
5 pts better
|
12.0%
4.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.5% · Observed 7.1% · Expected 10.6% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.3% · Q3 1.5% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.0% |
75.6%
6.4 pts better
|
79.7%
2.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
25.1%
4.6 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 19.0% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-24 · Fire 2023-07-24
19 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2020-03-05 · Fire 2020-03-05
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-31
F · Potential for more than minimal harm
2025-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-31
F · Potential for more than minimal harm
2023-07-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-07-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-09-08
F · Potential for more than minimal harm
2020-03-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-04-17
F · Potential for more than minimal harm
2020-03-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-17
F · Potential for more than minimal harm
2020-03-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-04-17
F · Potential for more than minimal harm
2020-03-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-04-17
E · Potential for more than minimal harm
2020-03-05
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2020-04-17
E · Potential for more than minimal harm
2020-03-05
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2020-04-17
E · Potential for more than minimal harm
2020-03-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-04-17
Inspection history
Recent health citations
G · Actual harm
2025-06-23
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 2025-02-12
D · Potential for more than minimal harm
2025-06-23
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-06-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-31
D · Potential for more than minimal harm
2024-04-09
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-04-22
G · Actual harm
2023-07-24
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 2023-03-29
F · Potential for more than minimal harm
2023-07-24
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-24
F809 · Nutrition and Dietary Deficiencies
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 2023-09-08
F · Potential for more than minimal harm
2023-07-24
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 2023-09-08
F · Potential for more than minimal harm
2023-07-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-08
F · Potential for more than minimal harm
2023-07-24
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-07-24
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-07-24
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-07-24
F803 · Nutrition and Dietary Deficiencies
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 2023-09-08
D · Potential for more than minimal harm
2023-07-24
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-24
F625 · Resident Rights Deficiencies
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 2023-09-08
D · Potential for more than minimal harm
2023-07-24
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 2023-09-08
D · Potential for more than minimal harm
2023-07-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-24
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-07-24
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-08
F · Potential for more than minimal harm
2020-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-04-17
D · Potential for more than minimal harm
2020-03-05
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-04-17
Penalties and ownership
What sits behind the stars
$26,685
2025-06-23
Fine
Fine · fine $26,685
Fine
Ownership
Fcv Corporation
5% Or Greater Direct Ownership Interest · Organization
Adcock, Heather
Corporate Director · Individual
Alexander, Sean
Corporate Officer · Individual
Barkin, Victoria
Corporate Director · Individual
Bloomfield, Sally
Corporate Director · Individual
Davis, John Terrance
Corporate Director · Individual
Dehring, Lindsey
Corporate Officer · Individual
Hoff, Angela
Corporate Director · Individual
Macpherson, Gregory
Operational/Managerial Control · Individual
Mettler, Brianna
Corporate Director · Individual
Meyung, Kelli
Corporate Officer · Individual
National Church Residences Health Care
Operational/Managerial Control · Organization
Rule, Matthew
Corporate Officer · Individual
Woolley, Julie
Corporate Officer · Individual
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#2
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5-star overall rating with 3-star inspections with $14,680 in total fines with 10 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Majestic Care of Columbus LLC
Columbus, OH
5-star overall rating with 4-star inspections with $111,283 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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