Cycle 1
Health 2025-05-29 · Fire 2025-05-29
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Columbus, OH
Ohio Living Westminster-Thurber
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
717 Neil Avenue, Columbus, OH
(614) 228-8888
Overall
5 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
35
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ohio Living Communities
Operator or chain grouping
Approved since
1979-04-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 5 overall / 4 health / 4 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
1.52
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.80
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.48
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.68
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.63
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.76
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.51
CMS adjusted RN staffing hours
Adjusted total hours
5.44
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,009
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9998
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.82
Baseline 22.94% · Performance 19.21% · Measure score 5.82 · Achievement 4.8 · Improvement 5.82
Healthcare-associated infections
3.49
Baseline 6.40% · Performance 6.79% · Measure score 3.49 · Achievement 3.49 · Improvement 0
Total nurse turnover
2.57
Baseline 52.83% · Performance 53.19% · Measure score 2.57 · Achievement 2.57 · Improvement 0
Adjusted total nurse staffing
6.7
Baseline 3.75 hours · Performance 4.98 hours · Measure score 6.7 · Achievement 6.7 · Improvement 5.57
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.13% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 0% · Lower 95% interval 5.67% |
| Discharge to community | 68.97% |
50.57%
18.4 pts better
|
Better than the National Rate · Eligible stays 49 · Observed rate 85.71% · Lower 95% interval 59.12% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 27 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | 88% |
53.69%
34.3 pts better
|
Numerator 22 · Denominator 25 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 15 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.79% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 2.56% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 6.83% |
8.2%
1.4 pts worse
|
Numerator 11 · Denominator 161 |
| Staff flu vaccination coverage | 19.72% |
42%
22.3 pts worse
|
Numerator 42 · Denominator 213 |
| Discharge function score | 72% |
56.45%
15.5 pts better
|
Numerator 18 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 85% |
96.28%
11.3 pts worse
|
Numerator 17 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
92.4%
1.5 pts better
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 91.7% · Q3 96.0% · Q4 91.7% · 4Q avg 93.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.7% |
94.5%
2.8 pts worse
|
95.5%
3.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
3.3%
3.8 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 8.3% · Q3 0.0% · Q4 8.3% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
26.1%
22.9 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 13.6% · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
6.2%
3.2 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.6% |
25.4%
14.8 pts better
|
19.6%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.6% |
| 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 · 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 | 15.6% |
7.7%
7.9 pts worse
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.5% |
6.2%
1.7 pts better
|
14.9%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · 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 | 4.7% |
21.7%
17 pts better
|
19.8%
15.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.1% · Q3 4.8% · Q4 4.5% · 4Q avg 4.7% |
| Percentage of long-stay residents with pressure ulcers | 2.5% |
3.7%
1.2 pts better
|
5.1%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.9% · Q3 2.5% · Q4 1.8% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.1% |
78.1%
8 pts worse
|
81.7%
11.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 73.2% · Q3 70.0% · Q4 61.2% · 4Q avg 70.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
12.5%
12.5 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.7% |
75.6%
2.9 pts worse
|
79.7%
7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
25.1%
3.5 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 21.4% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-31 · Fire 2022-05-31
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-08-01 · Fire 2019-08-01
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-05-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-05-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-30
F · Potential for more than minimal harm
2022-05-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-02
E · Potential for more than minimal harm
2022-05-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-08-02
E · Potential for more than minimal harm
2022-05-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-02
E · Potential for more than minimal harm
2022-05-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-08-02
E · Potential for more than minimal harm
2022-05-31
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-08-02
E · Potential for more than minimal harm
2019-08-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-08-23
E · Potential for more than minimal harm
2019-08-01
K913 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure operating rooms are properly protected and written records are maintained and available for inspection.
Corrected 2019-08-23
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-29
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 2025-06-30
F · Potential for more than minimal harm
2025-05-29
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-29
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 2025-06-30
D · Potential for more than minimal harm
2025-05-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-29
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 2025-06-30
D · Potential for more than minimal harm
2025-05-29
F688 · Quality of Life and Care Deficiencies
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 2025-06-30
D · Potential for more than minimal harm
2025-05-29
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 2025-06-30
D · Potential for more than minimal harm
2025-05-29
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-05-29
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-06-30
D · Potential for more than minimal harm
2025-01-02
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 2025-01-15
B · Minimal harm
2025-01-02
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-01-15
G · Actual harm
2023-08-17
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-07
G · Actual harm
2023-05-24
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 2023-05-25
E · Potential for more than minimal harm
2022-05-31
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 2022-08-02
D · Potential for more than minimal harm
2022-05-31
F584 · Resident Rights Deficiencies
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 2022-08-02
D · Potential for more than minimal harm
2022-05-31
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 2022-08-02
D · Potential for more than minimal harm
2022-05-31
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 2022-08-02
D · Potential for more than minimal harm
2022-05-31
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-02
F · Potential for more than minimal harm
2019-08-01
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 2019-08-23
D · Potential for more than minimal harm
2019-08-01
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 2019-08-23
D · Potential for more than minimal harm
2019-08-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-08-23
Penalties and ownership
What sits behind the stars
$14,680
2023-08-17
Fine
Fine · fine $14,680
Fine
Ownership
Adam, Sandra
Corporate Director · Individual
Belfance, Leslie
Corporate Director · Individual
Gumina, Laurence
Operational/Managerial Control · Individual
Gumina, Laurence
Corporate Officer · Individual
Ingwersen, Melissa
Corporate Director · Individual
Joyce, James
Corporate Director · Individual
Stillman, Robert
Corporate Officer · Individual
Thorpe, Rebecca
Operational/Managerial Control · Individual
White, Terry
Corporate Director · Individual
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#2
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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
#3
Scioto Pointe
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4-star overall rating with 2-star inspections with 18 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
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