Cycle 1
Health 2024-10-17 · Fire 2024-10-17
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Pickerington, OH
Violet Springs Health Campus
2-star overall rating with 2-star inspections with $16,801 in total fines with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
603 Diley Road, Pickerington, OH
(614) 751-6413
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2019-12-17
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.05
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.15
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.84
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
3.52
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
23%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,894
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.92
Baseline 20.02% · Performance 20.08% · Measure score 2.92 · Achievement 2.92 · Improvement 0
Healthcare-associated infections
0
Baseline 7.71% · Performance 8.85% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.85
Performance 43.86% · Measure score 4.85 · Achievement 4.85 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.62
Baseline 3.99 hours · Performance 4.11 hours · Measure score 3.62 · Achievement 3.62 · Improvement 0.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.25% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 221 · Observed rate 9.5% · Lower 95% interval 7.72% |
| Discharge to community | 67.49% |
50.57%
16.9 pts better
|
Better than the National Rate · Eligible stays 227 · Observed rate 61.23% · Lower 95% interval 60.9% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 157 · Denominator 157 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 157 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 60 · Denominator 105 |
| Discharge mobility score | 49.52% |
50.94%
1.4 pts worse
|
Numerator 52 · Denominator 105 |
| Pressure ulcers or injuries, new or worsened | 1.91% |
2.29%
0.4 pts better
|
Numerator 3 · Denominator 157 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 8.85% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 136 · Observed rate 10.29% · Lower 95% interval 5.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 115 |
| Staff flu vaccination coverage | 17.45% |
42%
24.6 pts worse
|
Numerator 26 · Denominator 149 |
| Discharge function score | 57.14% |
56.45%
0.7 pts better
|
Numerator 60 · Denominator 105 |
| Transfer of health information to provider | 94.94% |
95.95%
1 pts worse
|
Numerator 75 · Denominator 79 |
| Transfer of health information to patient | 95% |
96.28%
1.3 pts worse
|
Numerator 57 · Denominator 60 |
| Resident COVID-19 vaccinations up to date | 64.1% |
25.2%
38.9 pts better
|
Numerator 50 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
1.8
1.2 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 3.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
92.4%
6.5 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.4% |
94.5%
1.9 pts better
|
95.5%
0.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.3%
2.1 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.3% · Q3 4.3% · Q4 4.2% · 4Q avg 5.4% · 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% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 11.1% |
6.2%
4.9 pts worse
|
5.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
25.4%
11.7 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
11.5%
7.9 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 4.3% |
0.1%
4.2 pts worse
|
0.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 4.2% · Q3 4.3% · Q4 4.2% · 4Q avg 4.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.1% |
7.7%
9.4 pts worse
|
16.3%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
6.2%
0.7 pts worse
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.2%
1.1 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 2.7% · 4Q avg 1.3% · 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 | 24.8% |
21.7%
3.1 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 28.8% · Q4 15.0% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
3.7%
0.8 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 2.1% · Q3 2.2% · Q4 7.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.6% |
78.1%
8.5 pts better
|
81.7%
4.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.0% · Q2 82.3% · Q3 94.3% · Q4 89.8% · 4Q avg 86.6% |
| 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 14.5% · Expected 11.3% · 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 0.9% · Q2 1.0% · Q3 1.1% · 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 | 85.7% |
75.6%
10.1 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
25.1%
1 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 22.9% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-08 · Fire 2022-08-08
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-12-17 · Fire 2019-12-17
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-12
E · Potential for more than minimal harm
2024-10-17
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 2024-11-12
F · Potential for more than minimal harm
2022-08-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-02
F · Potential for more than minimal harm
2022-08-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-02
E · Potential for more than minimal harm
2022-08-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-20
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-02-09
D · Potential for more than minimal harm
2025-10-14
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-11-25
G · Actual harm
2025-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-06-12
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 2025-07-03
F · Potential for more than minimal harm
2024-10-17
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-11-12
F · Potential for more than minimal harm
2024-10-17
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 2024-11-12
E · Potential for more than minimal harm
2024-10-17
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 2024-11-12
D · Potential for more than minimal harm
2024-10-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-10-17
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 2024-11-12
D · Potential for more than minimal harm
2024-10-17
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 2024-11-12
D · Potential for more than minimal harm
2024-10-17
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-10-17
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-12
J · Immediate jeopardy
2024-03-12
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 2024-02-29
D · Potential for more than minimal harm
2022-08-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-08
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 2022-09-02
D · Potential for more than minimal harm
2022-08-08
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-09-02
D · Potential for more than minimal harm
2022-08-08
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-09-02
Penalties and ownership
What sits behind the stars
$16,801
2024-03-12
Fine
Fine · fine $16,801
Fine
Ownership
Trilogy Opco LLC
5% Or Greater Direct Ownership Interest · Organization
Altier, Jacqueline
Operational/Managerial Control · Individual
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
Barney, Leigh
Corporate Officer · Individual
Conner, Gregory
Corporate Officer · Individual
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
Corbin, Kathy
Operational/Managerial Control · Individual
Davis, David
Corporate Officer · 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
Griffin-American Healthcare Reit Iii, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Mehaffey, Todd
Corporate Officer · Individual
Northstar Healthcare Income Inc
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Operating Partnership LP
5% Or Greater Indirect Ownership Interest · Organization
Pietrowski, Cristina
Corporate Officer · Individual
Prosky, Danny
Corporate Officer · Individual
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Holdings Nt-Hci, LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Management Services LLC
Operational/Managerial Control · Organization
Trilogy Real Estate Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Reit Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Willhite, Gabriel
Corporate Director · Individual
Willhite, Gabriel
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Pickerington Care And Rehabilitation
Pickerington, OH
3-star overall rating with 2-star inspections with 21 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Robert A Barnes Center
Reynoldsburg, OH
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Embassy Of Winchester
Canal Winchester, OH
2-star overall rating with 1-star inspections with $198,607 in total fines with 30 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out