Cycle 1
Health 2024-11-07 · Fire 2024-11-07
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Columbus, OH
Willow Brook Christian Home
3-star overall rating with 2-star inspections with 15 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
55 Lazelle Rd, Columbus, OH
(614) 885-3300
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
50
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-01-16
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
1.13
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.22
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.29
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.71
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
1.17
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,575
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.31
Baseline 20.54% · Performance 18.51% · Measure score 6.31 · Achievement 6.31 · Improvement 5.29
Healthcare-associated infections
1.38
Baseline 6.55% · Performance 7.42% · Measure score 1.38 · Achievement 1.38 · Improvement 0
Total nurse turnover
5.26
Baseline 37.04% · Performance 42.19% · Measure score 5.26 · Achievement 5.26 · Improvement 0
Adjusted total nurse staffing
2.81
Baseline 3.75 hours · Performance 3.88 hours · Measure score 2.81 · Achievement 2.81 · Improvement 0.11
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.58% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 5.32% · Lower 95% interval 6.64% |
| Discharge to community | 56.67% |
50.57%
6.1 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 59.09% · Lower 95% interval 49.09% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.55% |
95.27%
1.7 pts worse
|
Numerator 58 · Denominator 62 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 62 |
| Discharge self-care score | 54.72% |
53.69%
1 pts better
|
Numerator 29 · Denominator 53 |
| Discharge mobility score | 37.74% |
50.94%
13.2 pts worse
|
Numerator 20 · Denominator 53 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 2 · Denominator 62 · Adjusted rate 2.83% |
| Healthcare-associated infections requiring hospitalization | 7.42% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 59 · Observed rate 6.78% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | 11.54% |
42%
30.5 pts worse
|
Numerator 18 · Denominator 156 |
| Discharge function score | 60.38% |
56.45%
3.9 pts better
|
Numerator 32 · Denominator 53 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 71.43% |
96.28%
24.8 pts worse
|
Numerator 30 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 43.33% |
25.2%
18.1 pts better
|
Numerator 13 · Denominator 30 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
92.4%
3.8 pts better
|
93.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 89.5% · Q2 100.0% · Q3 97.4% · Q4 97.6% · 4Q avg 96.2% |
| 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 | 3.8% |
3.3%
0.5 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.3% · Q3 2.6% · Q4 2.4% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.6% |
26.1%
1.5 pts worse
|
11.4%
16.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 29.7% · Q3 27.0% · Q4 26.2% · 4Q avg 27.6% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.2%
2.2 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 9.4% · Q4 2.9% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.0% |
25.4%
13.4 pts better
|
19.6%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 13.3% · Q3 12.5% · Q4 8.8% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.8% |
11.5%
9.7 pts better
|
16.7%
14.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 3.2% · 4Q avg 1.8% · 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 | 16.0% |
7.7%
8.3 pts worse
|
16.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
6.2%
3.5 pts worse
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 18.5% · Q3 3.6% · Q4 3.2% · 4Q avg 9.7% · 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 | 1.9% |
0.5%
1.4 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.6% · Q3 0.0% · Q4 2.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.5% |
21.7%
5.8 pts worse
|
19.8%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 36.0% · Q3 21.9% · Q4 31.0% · 4Q avg 27.5% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
3.7%
0.3 pts worse
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.5% · Q3 2.0% · Q4 4.2% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.9% |
78.1%
0.2 pts worse
|
81.7%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.3% · Q2 80.6% · Q3 84.0% · Q4 74.4% · 4Q avg 77.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.2% |
12.5%
7.3 pts better
|
12.0%
6.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.2% · Observed 4.5% · Expected 9.8% · 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 | 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 | 15.0% |
25.1%
10.1 pts better
|
23.9%
8.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 13.6% · Expected 21.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-02-28 · Fire 2022-02-28
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-09-05 · Fire 2019-09-05
7 health deficiencies
Top issue: Administration (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-27
F · Potential for more than minimal harm
2024-11-07
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 2024-12-27
F · Potential for more than minimal harm
2024-11-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-27
E · Potential for more than minimal harm
2024-11-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-27
E · Potential for more than minimal harm
2022-02-28
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 2022-04-07
E · Potential for more than minimal harm
2022-02-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-07
E · Potential for more than minimal harm
2022-02-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-04-07
E · Potential for more than minimal harm
2022-02-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-04-07
F · Potential for more than minimal harm
2019-09-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-24
F · Potential for more than minimal harm
2019-09-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-09-24
F · Potential for more than minimal harm
2019-09-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-09-24
E · Potential for more than minimal harm
2019-09-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-09-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
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 2026-01-14
D · Potential for more than minimal harm
2025-12-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-14
G · Actual harm
2025-09-02
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 2025-09-03
E · Potential for more than minimal harm
2024-11-07
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 2024-12-20
D · Potential for more than minimal harm
2024-11-07
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 2024-12-20
D · Potential for more than minimal harm
2024-11-07
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-07
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-07
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 2024-12-20
D · Potential for more than minimal harm
2024-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-07
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 2024-12-20
D · Potential for more than minimal harm
2024-11-07
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-07
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 2024-12-20
D · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-07
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-12-20
D · Potential for more than minimal harm
2023-05-26
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-06-14
F · Potential for more than minimal harm
2022-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-07
E · Potential for more than minimal harm
2022-02-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-04-07
D · Potential for more than minimal harm
2022-02-28
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 2022-04-07
D · Potential for more than minimal harm
2022-02-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-04-07
D · Potential for more than minimal harm
2022-02-28
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2022-04-07
D · Potential for more than minimal harm
2022-02-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-04-07
E · Potential for more than minimal harm
2019-09-05
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2019-09-24
D · Potential for more than minimal harm
2019-09-05
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-09-24
D · Potential for more than minimal harm
2019-09-05
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 2019-09-24
D · Potential for more than minimal harm
2019-09-05
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 2019-09-24
D · Potential for more than minimal harm
2019-09-05
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 2019-09-24
C · Minimal harm
2019-09-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-09-24
Penalties and ownership
What sits behind the stars
Ownership
Barth, Phil
Corporate Director · Individual
Davis, Brandi
Corporate Director · Individual
Harris, Kent
Operational/Managerial Control · Individual
Irwin, Terry
Corporate Director · Individual
Johnson, William
Corporate Director · Individual
Ketron, Nicole
Operational/Managerial Control · Individual
Longo, Scott
Corporate Director · Individual
May, Jerry
Corporate Director · Individual
Mckenna, Blythe
Corporate Director · Individual
Mcknight, Matthew
Operational/Managerial Control · Individual
Mcknight, Matthew
Corporate Officer · Individual
Pickens, Roger
Corporate Director · Individual
Poulson, Thomas
Corporate Officer · Individual
Ringle, Michael
Corporate Director · Individual
Sarkel, Ed
Corporate Director · Individual
Susenna, Karen
Corporate Director · Individual
Tidwell, Peggy
Corporate Director · Individual
Nearby options
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Highbanks Care Center
Columbus, OH
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Worthington Christian Village
Columbus, OH
5-star overall rating with 3-star inspections with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Laurels Of Norworth The
Worthington, OH
1-star overall rating with 1-star inspections with $51,871 in total fines with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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