Cycle 1
Health 2024-05-30 · Fire 2024-05-30
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Hilliard, OH
Norwich Springs Health Campus
4-star overall rating with 3-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
4680 Library Way, Hilliard, OH
(614) 363-1833
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
54
Certified beds
Average residents
49
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2021-12-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 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
Hours and turnover
RN hours / resident day
1.22
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.74
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
1.07
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.05
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,294
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.55% · Performance 21.93% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.49
Baseline 7.57% · Performance 6.79% · Measure score 3.49 · Achievement 3.49 · Improvement 2.53
Total nurse turnover
0.99
Performance 59.65% · Measure score 0.99 · Achievement 0.99 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.47
Performance 3.78 hours · Measure score 2.47 · Achievement 2.47 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.63% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 211 · Observed rate 8.06% · Lower 95% interval 7.18% |
| Discharge to community | 67.4% |
50.57%
16.8 pts better
|
Better than the National Rate · Eligible stays 207 · Observed rate 60.87% · Lower 95% interval 60.51% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 74.86% |
95.27%
20.4 pts worse
|
Numerator 134 · Denominator 179 |
| Falls with major injury | 1.68% |
0.77%
0.9 pts worse
|
Numerator 3 · Denominator 179 |
| Discharge self-care score | 64.12% |
53.69%
10.4 pts better
|
Numerator 84 · Denominator 131 |
| Discharge mobility score | 68.7% |
50.94%
17.8 pts better
|
Numerator 90 · Denominator 131 |
| Pressure ulcers or injuries, new or worsened | 0.56% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 179 · Adjusted rate 0.48% |
| Healthcare-associated infections requiring hospitalization | 6.79% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 176 · Observed rate 6.25% · Lower 95% interval 4.66% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 102 |
| Staff flu vaccination coverage | 5.59% |
42%
36.4 pts worse
|
Numerator 9 · Denominator 161 |
| Discharge function score | 73.28% |
56.45%
16.8 pts better
|
Numerator 96 · Denominator 131 |
| Transfer of health information to provider | 94% |
95.95%
2 pts worse
|
Numerator 47 · Denominator 50 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 111 · Denominator 111 |
| Resident COVID-19 vaccinations up to date | 47.73% |
25.2%
22.5 pts better
|
Numerator 42 · Denominator 88 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q3 100.0% · 4Q avg 100.0% |
| 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 | 3.7% |
3.3%
0.4 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 4.5% · 4Q avg 3.7% · 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% · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
6.2%
2 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
25.4%
11.5 pts better
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.6% |
11.5%
9.9 pts better
|
16.7%
15.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.6% · 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% · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
6.2%
1.5 pts worse
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · 4Q avg 7.7% · 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% · Q3 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.5%
0.7 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.3% |
21.7%
9.6 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.0% · Q3 30.0% · 4Q avg 31.3% |
| 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 · Q1 0.0% · Q3 2.9% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.5% |
78.1%
15.4 pts better
|
81.7%
11.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 94.3% · Q3 93.4% · Q4 90.9% · 4Q avg 93.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.9% |
12.5%
7.6 pts better
|
12.0%
7.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.9% · Observed 4.9% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.2%
0.4 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.7% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.2% |
75.6%
20.6 pts better
|
79.7%
16.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.1% |
25.1%
7 pts better
|
23.9%
5.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.1% · Observed 18.3% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-21 · Fire 2021-12-21
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health · Fire
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-30
K222 · Egress Deficiencies
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 2024-06-28
F · Potential for more than minimal harm
2024-05-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-28
F · Potential for more than minimal harm
2024-05-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-30
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2024-06-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-11-13
F · Potential for more than minimal harm
2024-05-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-30
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 2024-06-28
E · Potential for more than minimal harm
2024-05-30
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-06-28
E · Potential for more than minimal harm
2024-05-30
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 2024-06-28
E · Potential for more than minimal harm
2024-05-30
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-05-30
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 2024-06-28
D · Potential for more than minimal harm
2024-05-30
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 2024-06-28
D · Potential for more than minimal harm
2024-05-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-06-28
D · Potential for more than minimal harm
2023-12-06
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-12-06
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-27
Penalties and ownership
What sits behind the stars
Ownership
Trilogy Opco LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Reit Inc
5% Or Greater Indirect Ownership Interest · Organization
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
Operational/Managerial Control · Individual
Fightmaster, Lisa
Operational/Managerial Control · Individual
Gahc3 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Gahc4 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Moore, Noah
Operational/Managerial Control · Individual
Pietrowski, Cristina
Operational/Managerial Control · Individual
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Real Estate Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Reit Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Darby Glenn Nursing And Rehabilitation Center
Hilliard, OH
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Trueman Pointe Care Center
Hilliard, OH
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Mill Run Care Center
Hilliard, OH
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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