Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
WESTERVILLE POST ACUTE
WESTERVILLE, OH · 130 certified beds · Last Life Safety survey June 30, 2025
CMS Certification Number 365611 · first certified December 1983
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- New ownershipOwnership changed December 1, 2024 (change of ownership)from LEGACY WESTERVILLE OPERATING COMPANY, LLC
Position within OH
6 citations — more than 7% of the 922 certified nursing homes in OH. Compared within OH rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 3 citations; the earlier surveys in the window averaged 1.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens February 2027 — about 5 months from now. This facility’s last Life Safety survey was June 2025. Facilities in OH are typically surveyed 20–32 months after the last one (median 26), measured over 889 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 6 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
How that compares
Compared with the median facility in OH, and nationally. Surveyors differ markedly between states, so the OH figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 6 |
| Median facility in OH | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 5, 2021 | 0 |
| October 10, 2023 | 3 |
| June 30, 2025 | 3 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0331 | Construct fire resistant interior walls. | 1 | 2023-10-10 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2023-10-10 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-06-30 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2025-06-30 |
| K-0381 | Provide outside doors or windows in every resident room. | 1 | 2023-10-10 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2025-06-30 |
What the citations cover
- Smoke Deficiencies 3
- Miscellaneous Deficiencies 2
- Services Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 3 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 30, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 15, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 15, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 15, 2025) |
October 10, 2023 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (December 14, 2023) |
| K-0381 | Provide outside doors or windows in every resident room. | Deficient, Provider has date of correction (December 14, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (December 14, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.