Cycle 1
Health 2024-10-24 · Fire 2024-10-24
1 health deficiencies
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Columbiana, OH
St Mary's Alzheimer's Center
4-star overall rating with 3-star inspections with $66,973 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1899 Garfield Rd, Columbiana, OH
(330) 549-9259
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
90
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Windsor House, Inc.
Operator or chain grouping
Approved since
1988-10-20
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
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.50
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.34
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.79
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,676
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9920
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.92
Baseline 47.89% · Performance 43.56% · Measure score 4.92 · Achievement 4.92 · Improvement 1.38
Adjusted total nurse staffing
2.87
Baseline 3.57 hours · Performance 3.90 hours · Measure score 2.87 · Achievement 2.87 · Improvement 0.96
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.39% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 5.45% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.94% |
8.2%
3.3 pts worse
|
Numerator 4 · Denominator 81 |
| Staff flu vaccination coverage | 10% |
42%
32 pts worse
|
Numerator 16 · Denominator 160 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| 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 |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.5 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.6 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
92.4%
6 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.5% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 98.4% |
| 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 | 5.1% |
3.3%
1.8 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.1% · Q3 5.0% · Q4 4.9% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
26.1%
24.7 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 3.0% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
6.2%
2.7 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 6.1% · Q3 0.0% · Q4 3.2% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.4% |
25.4%
14 pts worse
|
19.6%
19.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 42.4% · Q3 38.1% · Q4 34.9% · 4Q avg 39.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.3% |
11.5%
16.8 pts worse
|
16.7%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 27.3% · Q3 31.1% · Q4 27.1% · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 26.6% |
0.1%
26.5 pts worse
|
0.1%
26.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 26.9% · Q3 22.5% · Q4 28.4% · 4Q avg 26.6% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.7% |
7.7%
2 pts better
|
16.3%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 11.2% · Q3 2.8% · Q4 0.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
6.2%
1.1 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 10.0% · Q3 2.4% · Q4 0.0% · 4Q avg 5.1% · 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 · 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 | 9.4% |
21.7%
12.3 pts better
|
19.8%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 9.8% · Q3 6.6% · Q4 9.5% · 4Q avg 9.4% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
3.7%
2.5 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 2.1% · Q3 0.9% · Q4 0.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.4% |
78.1%
14.7 pts worse
|
81.7%
18.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.1% · Q2 70.0% · Q3 74.1% · Q4 53.8% · 4Q avg 63.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.7% |
1.2%
6.5 pts worse
|
1.6%
6.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.2% |
75.6%
11.6 pts better
|
79.7%
7.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.2% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-18 · Fire 2022-08-18
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-08-22 · Fire 2019-08-22
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-12
F · Potential for more than minimal harm
2024-10-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-12
E · Potential for more than minimal harm
2019-08-22
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2019-09-27
E · Potential for more than minimal harm
2019-08-22
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-09-27
Inspection history
Recent health citations
J · Immediate jeopardy
2024-12-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-12
J · Immediate jeopardy
2024-12-11
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 2024-12-12
J · Immediate jeopardy
2024-12-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-10-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-12
D · Potential for more than minimal harm
2023-03-22
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 2023-04-28
D · Potential for more than minimal harm
2022-08-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-12
D · Potential for more than minimal harm
2022-08-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-09-12
E · Potential for more than minimal harm
2019-08-22
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 2019-09-27
E · Potential for more than minimal harm
2019-08-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-09-27
E · Potential for more than minimal harm
2019-08-22
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 2019-09-27
D · Potential for more than minimal harm
2019-08-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-09-27
Penalties and ownership
What sits behind the stars
$66,973
2024-10-24
Fine
Fine · fine $66,973
Fine
Ownership
Masternick, John
5% Or Greater Direct Ownership Interest · Individual
Masternick, John
Operational/Managerial Control · Individual
Masternick, John
Corporate Director · Individual
Masternick, John
Corporate Officer · Individual
Windsor House Inc.
Operational/Managerial Control · Organization
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