Cycle 1
Health 2024-04-04 · Fire 2024-04-04
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Columbus, OH
Westerwood Rehabilitation
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
5757 Ponderosa Drive, Columbus, OH
(614) 890-8282
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
75
Certified beds
Average residents
62
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-11-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.92
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
4.30
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.70
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.84
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.92
CMS adjusted RN staffing hours
Adjusted total hours
4.32
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,832
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.46
Composite VBP score used to determine payment impact.
Payment multiplier
1.0010
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.49
Baseline 18.49% · Performance 19.81% · Measure score 3.49 · Achievement 3.49 · Improvement 0
Healthcare-associated infections
6.79
Baseline 7.05% · Performance 5.81% · Measure score 6.79 · Achievement 6.79 · Improvement 5.56
Total nurse turnover
4.74
Baseline 40.00% · Performance 44.32% · Measure score 4.74 · Achievement 4.74 · Improvement 0
Adjusted total nurse staffing
3.97
Baseline 3.55 hours · Performance 4.21 hours · Measure score 3.97 · Achievement 3.97 · Improvement 2.44
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.94% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 230 · Observed rate 8.26% · Lower 95% interval 7.23% |
| Discharge to community | 68.76% |
50.57%
18.2 pts better
|
Better than the National Rate · Eligible stays 226 · Observed rate 66.81% · Lower 95% interval 62.75% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 156 · Denominator 156 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 156 |
| Discharge self-care score | 53.72% |
53.69%
About the same
|
Numerator 65 · Denominator 121 |
| Discharge mobility score | 44.63% |
50.94%
6.3 pts worse
|
Numerator 54 · Denominator 121 |
| Pressure ulcers or injuries, new or worsened | 4.49% |
2.29%
2.2 pts worse
|
Numerator 7 · Denominator 156 · Adjusted rate 4.23% |
| Healthcare-associated infections requiring hospitalization | 5.81% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 3.52% · Lower 95% interval 3.74% |
| Staff COVID-19 vaccination coverage | 7.52% |
8.2%
0.7 pts worse
|
Numerator 10 · Denominator 133 |
| Staff flu vaccination coverage | 11.36% |
42%
30.6 pts worse
|
Numerator 15 · Denominator 132 |
| Discharge function score | 59.5% |
56.45%
3 pts better
|
Numerator 72 · Denominator 121 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 100 · Denominator 100 |
| Transfer of health information to patient | 97.56% |
96.28%
1.3 pts better
|
Numerator 40 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 43.21% |
25.2%
18 pts better
|
Numerator 35 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
92.4%
6.1 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.1% · Q3 100.0% · Q4 97.1% · 4Q avg 98.5% |
| 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 | 0.8% |
3.3%
2.5 pts better
|
3.3%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
26.1%
19 pts better
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 11.1% · Q3 3.7% · Q4 3.3% · 4Q avg 7.1% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.2%
1.2 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.0% |
25.4%
9.6 pts worse
|
19.6%
15.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.7% |
11.5%
6.2 pts worse
|
16.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.7% · 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 | 7.2% |
7.7%
0.5 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.9% |
6.2%
2.3 pts better
|
14.9%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% · 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 | 1.5% |
0.5%
1 pts worse
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.0% · Q3 3.2% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.7% |
21.7%
9 pts worse
|
19.8%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 37.1% · Q3 27.3% · Q4 28.1% · 4Q avg 30.7% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
3.7%
1.7 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.3% · Q3 1.5% · Q4 2.2% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
78.1%
18.6 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 95.8% · Q3 96.2% · Q4 97.3% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
12.5%
3.5 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 9.2% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.2%
0.5 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.5% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.9% |
75.6%
20.3 pts better
|
79.7%
16.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
25.1%
7.5 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 17.1% · Expected 23.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-07 · Fire 2022-04-07
3 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-11-07 · Fire 2019-11-07
7 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-04-04
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-05-01
F · Potential for more than minimal harm
2024-04-04
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 2024-05-01
F · Potential for more than minimal harm
2022-04-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-05-11
E · Potential for more than minimal harm
2022-04-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-05-11
E · Potential for more than minimal harm
2022-04-07
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-05-11
C · Minimal harm
2022-04-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-05-11
E · Potential for more than minimal harm
2019-11-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-12-05
E · Potential for more than minimal harm
2019-11-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-02
D · Potential for more than minimal harm
2024-05-21
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 2024-05-07
D · Potential for more than minimal harm
2024-04-04
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-04
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-04
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-04-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-01
D · Potential for more than minimal harm
2024-01-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-06
D · Potential for more than minimal harm
2024-01-11
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 2024-02-06
D · Potential for more than minimal harm
2023-12-06
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 2024-02-06
E · Potential for more than minimal harm
2022-04-07
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 2022-05-11
D · Potential for more than minimal harm
2022-04-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-11
D · Potential for more than minimal harm
2019-11-07
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 2019-12-05
D · Potential for more than minimal harm
2019-11-07
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 2019-12-05
C · Minimal harm
2019-11-07
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-12-05
C · Minimal harm
2019-11-07
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 2019-12-05
Penalties and ownership
What sits behind the stars
Ownership
Chanak, Laura
Corporate Director · Individual
Chanak, Laura
W-2 Managing Employee · Individual
Eley, Aubrey
Operational/Managerial Control · Individual
Eley, Aubrey
Corporate Director · Individual
Eley, Aubrey
W-2 Managing Employee · Individual
United Church Homes Management, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Forest Hills Center
Columbus, OH
3-star overall rating with 2-star inspections with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Westerville Post Acute.
Westerville, OH
2-star overall rating with 1-star inspections with $315,699 in total fines with 17 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Laurels Of Walden Park
Columbus, OH
2-star overall rating with 1-star inspections with $167,400 in total fines with 24 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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