Cycle 1
Health 2025-05-29 · Fire 2025-05-29
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Granville, OH
Otterbein At Granville
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2158 Columbus Road, Granville, OH
(740) 321-0400
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
22
Certified beds
Average residents
20
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Otterbein Seniorlife
Operator or chain grouping
Approved since
2005-06-24
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
1.78
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.30
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.44
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.09
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
1.05
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
1.55
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,261
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.48
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 16.50% · Performance 22.14% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.82
Baseline 5.50% · Performance 6.69% · Measure score 3.82 · Achievement 3.82 · Improvement 0
Total nurse turnover
1.42
Baseline 66.67% · Performance 58.62% · Measure score 1.42 · Achievement 1.24 · Improvement 1.42
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.92% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 150 · Observed rate 10.67% · Lower 95% interval 7.98% |
| Discharge to community | 61.41% |
50.57%
10.8 pts better
|
Better than the National Rate · Eligible stays 150 · Observed rate 64% · Lower 95% interval 54.43% |
| Medicare spending per beneficiary | 0.72 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 92 · Denominator 92 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 92 |
| Discharge self-care score | 63.29% |
53.69%
9.6 pts better
|
Numerator 50 · Denominator 79 |
| Discharge mobility score | 35.44% |
50.94%
15.5 pts worse
|
Numerator 28 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 92 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.69% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 3.9% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 27.42% |
8.2%
19.2 pts better
|
Numerator 34 · Denominator 124 |
| Staff flu vaccination coverage | 42.59% |
42%
0.6 pts better
|
Numerator 69 · Denominator 162 |
| Discharge function score | 48.1% |
56.45%
8.4 pts worse
|
Numerator 38 · Denominator 79 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 71 · Denominator 71 |
| Resident COVID-19 vaccinations up to date | 42.86% |
25.2%
17.7 pts better
|
Numerator 21 · Denominator 49 |
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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 23.5% |
26.1%
2.6 pts better
|
11.4%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.5% |
| 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 with a catheter inserted and left in their bladder | 3.4% |
0.2%
3.2 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.4% · 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 | 7.8% |
21.7%
13.9 pts better
|
19.8%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.8% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
78.1%
21.3 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.9% · Q4 98.8% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.2% |
12.5%
5.3 pts better
|
12.0%
4.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.2% · Observed 6.5% · Expected 10.1% · 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 | 92.4% |
75.6%
16.8 pts better
|
79.7%
12.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.8% |
25.1%
2.3 pts better
|
23.9%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 19.5% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-29 · Fire 2023-11-29
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-10-14 · Fire 2021-10-14
4 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-13
F · Potential for more than minimal harm
2023-11-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-11-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-01-03
F · Potential for more than minimal harm
2023-11-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-01-03
E · Potential for more than minimal harm
2023-11-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-03
F · Potential for more than minimal harm
2021-10-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-11-12
E · Potential for more than minimal harm
2021-10-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-11-12
E · Potential for more than minimal harm
2021-10-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-11-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-13
D · Potential for more than minimal harm
2025-05-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-13
D · Potential for more than minimal harm
2021-10-14
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 2021-11-12
D · Potential for more than minimal harm
2021-10-14
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 2021-11-12
D · Potential for more than minimal harm
2021-10-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2021-11-12
D · Potential for more than minimal harm
2021-10-14
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 2021-11-12
Penalties and ownership
What sits behind the stars
Ownership
Otterbein Home
5% Or Greater Indirect Ownership Interest · Organization
Otterbein Lsc, LLC
5% Or Greater Direct Ownership Interest · Organization
App, Lynn
Operational/Managerial Control · Individual
Bartlett, Victoria
Operational/Managerial Control · Individual
Bayliff, Becky
Operational/Managerial Control · Individual
Brownson, William
Operational/Managerial Control · Individual
Brownson, William
Corporate Director · Individual
Burke, Daniel
Operational/Managerial Control · Individual
Coleman, Robert
Operational/Managerial Control · Individual
Fraley, Ralph
Operational/Managerial Control · Individual
Functional Pathways Of Tennessee LLC
Operational/Managerial Control · Organization
Glosser, Heidi
Operational/Managerial Control · Individual
Green, James
Corporate Officer · Individual
Hawkins, Rita
Corporate Officer · Individual
Hazelbaker, Tomas
Operational/Managerial Control · Individual
Hollister, Jonathan
Operational/Managerial Control · Individual
Ingold, Molly C
Corporate Director · Individual
Ingold, Molly C
Corporate Officer · Individual
Kroeze, Derik
Operational/Managerial Control · Individual
Miller, Jason
Corporate Officer · Individual
Otterbein Home
Operational/Managerial Control · Organization
Vonderhaar, Steve
Operational/Managerial Control · Individual
Weekly, Jennifer
Corporate Director · Individual
Wilson, Jill
Corporate Officer · Individual
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3-star overall rating with 2-star inspections with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
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2-star overall rating with 1-star inspections with 16 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Arlington Care Center
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4-star overall rating with 4-star inspections with 3 recent health deficiencies
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