2 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Columbiana, OH
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
930 East Park Avenue, Columbiana, OH
(330) 482-5547
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
95
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Windsor House, Inc.
Operator or chain grouping
Approved since
1989-10-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 4 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
RN hours / resident day
0.66
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
4.02
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
3,844
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9954
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.35% · Performance 21.23% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.38
Baseline 5.25% · Performance 6.23% · Measure score 5.38 · Achievement 5.38 · Improvement 0
Total nurse turnover
8.87
Baseline 54.84% · Performance 27.42% · Measure score 8.87 · Achievement 8.87 · Improvement 8.64
Adjusted total nurse staffing
2.73
Baseline 3.05 hours · Performance 3.85 hours · Measure score 2.73 · Achievement 2.73 · Improvement 2.46
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.37% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 8.51% · Lower 95% interval 6.88% |
| Discharge to community | 43.91% |
50.57%
6.7 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 38.78% · Lower 95% interval 31.27% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 41.67% |
95.27%
53.6 pts worse
|
Numerator 15 · Denominator 36 |
| Falls with major injury | 5.56% |
0.77%
4.8 pts worse
|
Numerator 2 · Denominator 36 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 8 · Denominator 24 |
| Discharge mobility score | 29.17% |
50.94%
21.8 pts worse
|
Numerator 7 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.23% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 0% · Lower 95% interval 2.97% |
| Staff COVID-19 vaccination coverage | 1.22% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 82 |
| Staff flu vaccination coverage | 5.13% |
42%
36.9 pts worse
|
Numerator 6 · Denominator 117 |
| Discharge function score | 37.5% |
56.45%
19 pts worse
|
Numerator 9 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.04% |
25.2%
12.2 pts worse
|
Numerator 3 · Denominator 23 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
92.4%
0.2 pts better
|
93.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.6% · Q2 97.6% · Q3 87.5% · Q4 91.7% · 4Q avg 92.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
94.5%
2.3 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.4% · Q3 0.0% · Q4 2.1% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.9% |
26.1%
17.2 pts better
|
11.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 0.0% · Q3 13.2% · Q4 14.3% · 4Q avg 8.9% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
6.2%
0.7 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 0.0% · Q3 0.0% · Q4 11.4% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.3% |
25.4%
5.9 pts worse
|
19.6%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 33.3% · Q3 33.3% · Q4 27.3% · 4Q avg 31.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.4% |
11.5%
2.1 pts better
|
16.7%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 10.3% · Q3 12.1% · Q4 12.1% · 4Q avg 9.4% · 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 | 3.0% |
7.7%
4.7 pts better
|
16.3%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.1% |
6.2%
2.1 pts better
|
14.9%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.6% · Q3 0.0% · Q4 7.3% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.2%
0.4 pts worse
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.3% · 4Q avg 0.6% · 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 | 19.2% |
21.7%
2.5 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 12.7% · Q3 6.0% · Q4 21.1% · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
3.7%
2.3 pts worse
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 11.4% · Q3 2.4% · Q4 8.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.0% |
78.1%
22.1 pts worse
|
81.7%
25.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.3% · Q2 53.5% · Q3 50.0% · Q4 62.2% · 4Q avg 56.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
12.5%
1.8 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 16.1% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.2%
About the same
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.4% · Q4 1.9% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 54.2% |
75.6%
21.4 pts worse
|
79.7%
25.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 54.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
25.1%
5.6 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 19.4% · Expected 23.7% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-08-28
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-11
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-11-11
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-11
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-10-18
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2019-10-04
Inspection history
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-08-28
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-28
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-11
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-04-11
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-11
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-04-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-11
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-11
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-11
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-17
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-11-11
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-11-11
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 2022-11-11
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2022-11-11
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-11-11
Health
Respond appropriately to all alleged violations.
Corrected 2022-11-11
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-11
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-11-11
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-18
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-10-18
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-10-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-10-18
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2019-10-18
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 2019-10-18
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 2019-10-18
Penalties and ownership
5% Or Greater Direct Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Nearby options
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