Cycle 1
Health 2023-03-09 · Fire 2023-03-09
15 health deficiencies
Top issue: Resident Rights (3 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Rockford, OH
Colonial Nursing Center Of Rockford
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
201 Buckeye Street, Rockford, OH
(419) 363-2193
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
34
Certified beds
Average residents
29
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Hillstone Healthcare
Operator or chain grouping
Approved since
2002-01-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 3 overall / 3 health / 2 staffing / 5 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
0.47
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.98
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.68
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
44%
Annual nurse turnover · state 50% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 6 · 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 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 39 |
| Staff flu vaccination coverage | 12.5% |
42%
29.5 pts worse
|
Numerator 4 · Denominator 32 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
92.4%
4.8 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.4% · Q3 96.2% · Q4 96.4% · 4Q avg 97.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.6% |
94.5%
2.1 pts better
|
95.5%
1.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
3.3%
2.4 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.3% |
26.1%
16.8 pts better
|
11.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 15.4% · Q3 9.1% · Q4 3.7% · 4Q avg 9.3% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
6.2%
2.1 pts better
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 11.5% · Q3 0.0% · Q4 0.0% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 44.9% |
25.4%
19.5 pts worse
|
19.6%
25.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.9% · Q2 42.3% · Q3 48.0% · Q4 48.0% · 4Q avg 44.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.8% |
11.5%
20.3 pts worse
|
16.7%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.8% · 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 | 15.6% |
7.7%
7.9 pts worse
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.9% |
6.2%
8.7 pts worse
|
14.9%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 28.0% · Q3 0.0% · Q4 4.2% · 4Q avg 14.9% · 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 | 1.9% |
0.5%
1.4 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 3.8% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.6% |
21.7%
12.1 pts better
|
19.8%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 11.5% · Q3 15.0% · Q4 6.8% · 4Q avg 9.6% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
3.7%
3.7 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.4% |
78.1%
7.7 pts worse
|
81.7%
11.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 70.4% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-07-03 · Fire 2019-07-03
9 health deficiencies
Top issue: Infection Control (2 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2018-06-07 · Fire 2018-06-07
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-03-09
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-03-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-03-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-03-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-03-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-03-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-05
F · Potential for more than minimal harm
2023-03-09
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-09
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2023-05-05
E · Potential for more than minimal harm
2023-03-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-13
C · Minimal harm
2023-03-09
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-05-05
F · Potential for more than minimal harm
2019-07-03
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 2019-10-03
F · Potential for more than minimal harm
2019-07-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-09-25
F · Potential for more than minimal harm
2019-07-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-09-25
F · Potential for more than minimal harm
2019-07-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-09-25
F · Potential for more than minimal harm
2019-07-03
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 2019-09-25
F · Potential for more than minimal harm
2019-07-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-09-25
F · Potential for more than minimal harm
2019-07-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-03
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-09-25
E · Potential for more than minimal harm
2019-07-03
K522 · Services Deficiencies
Fire Safety
Have an externally vented heating system.
Corrected 2019-09-25
F · Potential for more than minimal harm
2018-06-07
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2018-07-27
F · Potential for more than minimal harm
2018-06-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2018-07-27
F · Potential for more than minimal harm
2018-06-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-07-27
F · Potential for more than minimal harm
2018-06-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-07-27
F · Potential for more than minimal harm
2018-06-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-07-27
F · Potential for more than minimal harm
2018-06-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-07-27
F · Potential for more than minimal harm
2018-06-07
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2018-07-27
F · Potential for more than minimal harm
2018-06-07
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 2018-07-27
F · Potential for more than minimal harm
2018-06-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-07-27
F · Potential for more than minimal harm
2018-06-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-07-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-31
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 2026-01-05
D · Potential for more than minimal harm
2025-12-31
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2026-01-05
F · Potential for more than minimal harm
2025-04-17
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 2025-05-01
D · Potential for more than minimal harm
2024-09-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-02-22
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-03-06
F · Potential for more than minimal harm
2023-03-09
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-03-09
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 2023-04-13
F · Potential for more than minimal harm
2023-03-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-09
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-09
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-09
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-03-09
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-09
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 2023-04-13
D · Potential for more than minimal harm
2023-03-09
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-09
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 2023-04-13
D · Potential for more than minimal harm
2023-03-09
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 2023-04-13
D · Potential for more than minimal harm
2023-03-09
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-04-13
F · Potential for more than minimal harm
2019-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-07-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-09-25
D · Potential for more than minimal harm
2019-07-03
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 2019-09-25
D · Potential for more than minimal harm
2019-07-03
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 2019-09-25
D · Potential for more than minimal harm
2019-07-03
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 2019-09-25
D · Potential for more than minimal harm
2019-07-03
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 2019-09-25
D · Potential for more than minimal harm
2019-07-03
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-09-25
C · Minimal harm
2019-07-03
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-09-25
F · Potential for more than minimal harm
2018-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-07-27
E · Potential for more than minimal harm
2018-06-07
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 2018-07-27
D · Potential for more than minimal harm
2018-06-07
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2018-07-27
D · Potential for more than minimal harm
2018-06-07
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 2018-07-27
Penalties and ownership
What sits behind the stars
Ownership
Woodward, Melvin
5% Or Greater Direct Ownership Interest · Individual
Kothari, Zahid
5% Or Greater Direct Ownership Interest · Individual
Melton, David
5% Or Greater Direct Ownership Interest · Individual
Kothari, Zahid
Operational/Managerial Control · Individual
Melton, David
Operational/Managerial Control · Individual
Woodward, Melvin
Operational/Managerial Control · Individual
Woodward, Melvin
Corporate Officer · Individual
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#3
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