Cycle 1
Health 2024-06-13 · Fire 2024-06-13
48 health deficiencies
Top issue: Quality of Life and Care (17 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Toledo, OH
Franciscan Care Ctr Sylvania
1-star overall rating with 1-star inspections with Special Focus status with $337,580 in total fines with 48 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
4111 Holland Sylvania Rd, Toledo, OH
(419) 882-6582
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
96
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
1993-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.56
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.36
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
2.83
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.41
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
1.88
CMS adjusted total nurse staffing hours
Case-mix index
2.06
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,617
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.81
Baseline 23.22% · Performance 19.93% · Measure score 4.81 · Achievement 3.24 · Improvement 4.81
Healthcare-associated infections
0
Baseline 6.12% · Performance 8.01% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 3.18 hours · Performance 2.91 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.04% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 13.89% · Lower 95% interval 7.22% |
| Discharge to community | 55.85% |
50.57%
5.3 pts better
|
No Different than the National Rate · Eligible stays 62 · Observed rate 46.77% · Lower 95% interval 42.98% |
| Medicare spending per beneficiary | 1.17 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.43% |
95.27%
1.2 pts better
|
Numerator 54 · Denominator 56 |
| Falls with major injury | 1.79% |
0.77%
1 pts worse
|
Numerator 1 · Denominator 56 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 24 · Denominator 32 |
| Discharge mobility score | 59.38% |
50.94%
8.4 pts better
|
Numerator 19 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 56 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.01% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 11.9% · Lower 95% interval 4.67% |
| Staff COVID-19 vaccination coverage | 1.64% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 122 |
| Staff flu vaccination coverage | 27.62% |
42%
14.4 pts worse
|
Numerator 29 · Denominator 105 |
| Discharge function score | 71.88% |
56.45%
15.4 pts better
|
Numerator 23 · Denominator 32 |
| Transfer of health information to provider | 91.3% |
95.95%
4.7 pts worse
|
Numerator 21 · Denominator 23 |
| Transfer of health information to patient | 85.71% |
96.28%
10.6 pts worse
|
Numerator 18 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 17.65% |
25.2%
7.6 pts worse
|
Numerator 6 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.2% |
92.4%
19.2 pts worse
|
93.4%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 79.6% · Q3 69.1% · Q4 61.0% · 4Q avg 73.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 72.1% |
94.5%
22.4 pts worse
|
95.5%
23.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 72.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.3%
0.7 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.7% · Q3 3.6% · Q4 1.7% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 53.0% |
26.1%
26.9 pts worse
|
11.4%
41.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 50.0% · Q3 54.0% · Q4 81.6% · 4Q avg 53.0% |
| 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 · Q1 2.1% · Q2 15.2% · Q3 17.3% · Q4 9.3% · 4Q avg 11.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
25.4%
10.1 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.7% · Q3 9.6% · Q4 18.5% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
11.5%
2.4 pts worse
|
16.7%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 11.9% · Q3 15.6% · Q4 16.7% · 4Q avg 13.9% · 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 | 20.6% |
7.7%
12.9 pts worse
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.7% |
6.2%
10.5 pts worse
|
14.9%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 30.4% · Q3 17.0% · Q4 13.0% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.2%
0.3 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
0.5%
0.4 pts worse
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.8% · Q4 1.7% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.8% |
21.7%
1.1 pts worse
|
19.8%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 30.6% · Q3 17.4% · Q4 25.1% · 4Q avg 22.8% |
| 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 6.3% · Q2 5.6% · Q3 3.1% · Q4 3.1% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.5% |
78.1%
32.6 pts worse
|
81.7%
36.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.0% · Q2 54.2% · Q3 37.2% · Q4 18.1% · 4Q avg 45.5% |
| 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 16.7% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.2%
1.6 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.1% · Q3 2.5% · Q4 2.9% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 29.3% |
75.6%
46.3 pts worse
|
79.7%
50.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 29.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.1% |
25.1%
1 pts worse
|
23.9%
2.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.1% · Observed 35.2% · Expected 32.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-16 · Fire 2022-06-16
13 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-07-25 · Fire 2019-07-25
25 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-13
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-06-13
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-06-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-06-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-06-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-06-13
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-06-13
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 2024-09-05
E · Potential for more than minimal harm
2024-06-13
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-06-13
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-06-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-05
E · Potential for more than minimal harm
2024-06-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-05
F · Potential for more than minimal harm
2022-06-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-29
F · Potential for more than minimal harm
2022-06-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-16
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 2022-07-29
E · Potential for more than minimal harm
2022-06-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-07-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-22
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 2026-01-06
E · Potential for more than minimal harm
2025-12-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-06
G · Actual harm
2025-11-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-11-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-11-20
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 2025-12-04
J · Immediate jeopardy
2025-11-13
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 2025-12-04
F · Potential for more than minimal harm
2025-11-13
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 2025-12-04
F · Potential for more than minimal harm
2025-11-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-12-04
E · Potential for more than minimal harm
2025-11-13
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 2025-12-04
E · Potential for more than minimal harm
2025-11-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-12-04
E · Potential for more than minimal harm
2025-11-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-04
E · Potential for more than minimal harm
2025-11-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-11-13
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 2025-12-04
D · Potential for more than minimal harm
2025-11-13
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-11-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-11-13
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-12-04
D · Potential for more than minimal harm
2025-11-13
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-12-04
F · Potential for more than minimal harm
2025-04-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-03
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-05-14
E · Potential for more than minimal harm
2025-04-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-03
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-03
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 2025-05-14
D · Potential for more than minimal harm
2025-04-03
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 2025-05-14
D · Potential for more than minimal harm
2025-04-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-03
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-14
D · Potential for more than minimal harm
2025-01-17
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-08-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-06-13
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 2024-09-05
E · Potential for more than minimal harm
2024-06-13
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 2024-09-05
E · Potential for more than minimal harm
2024-06-13
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 2024-09-05
D · Potential for more than minimal harm
2024-06-13
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 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
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 2024-09-05
D · Potential for more than minimal harm
2024-06-13
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 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
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 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-06-13
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 2024-09-05
D · Potential for more than minimal harm
2024-06-13
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-03-25
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-05
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 2024-04-12
D · Potential for more than minimal harm
2024-03-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-04-12
D · Potential for more than minimal harm
2023-12-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-12-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-12-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-12-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-12-11
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-12-27
G · Actual harm
2023-11-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-10-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-10-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-27
D · Potential for more than minimal harm
2023-07-27
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 2023-08-25
C · Minimal harm
2023-07-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-08-25
C · Minimal harm
2023-07-27
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 2023-08-25
D · Potential for more than minimal harm
2023-03-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-02
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-02
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-03-24
E · Potential for more than minimal harm
2022-06-16
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-16
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-29
D · Potential for more than minimal harm
2022-06-16
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 2022-07-29
D · Potential for more than minimal harm
2022-06-16
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 2022-07-29
D · Potential for more than minimal harm
2022-06-16
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 2022-07-29
F · Potential for more than minimal harm
2019-07-25
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-08-16
F · Potential for more than minimal harm
2019-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-16
E · Potential for more than minimal harm
2019-07-25
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 2019-08-16
E · Potential for more than minimal harm
2019-07-25
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 2019-08-16
D · Potential for more than minimal harm
2019-07-25
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-25
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 2019-08-16
D · Potential for more than minimal harm
2019-07-25
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 2019-08-16
D · Potential for more than minimal harm
2019-07-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-25
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 2019-08-16
Penalties and ownership
What sits behind the stars
$337,580
2025-11-13
Fine
Fine · fine $337,580
Fine
$0
2023-10-05
Payment Denial
Payment Denial · denial start 2023-12-01 · 26 days
26 day denial
Ownership
Chi Living Communities
5% Or Greater Direct Ownership Interest · Organization
Boehme, Laurie
Operational/Managerial Control · Individual
Cecil, Caitlin
Corporate Director · Individual
Chi Living Communities
Operational/Managerial Control · Organization
Commonspirit Health
5% Or Greater Indirect Ownership Interest · Organization
Finn, Christina
Corporate Director · Individual
Grubbs, Stacey
Corporate Director · Individual
Hackett, Dionne
Operational/Managerial Control · Individual
Hazard, Ted
Corporate Director · Individual
Howard, Casey
Operational/Managerial Control · Individual
Iffland, Alisa
Operational/Managerial Control · Individual
Iffland, Alisa
Corporate Officer · Individual
Lipsey, Prentice
Corporate Officer · Individual
Longhin-Howard, Joan
Operational/Managerial Control · Individual
Mckinney, Marissa
Operational/Managerial Control · Individual
Munroe, Kyle
Corporate Director · Individual
Murriel, Shelly
Corporate Director · Individual
Nagel, Jennifer
Corporate Director · Individual
Rehmer, Heather
Operational/Managerial Control · Individual
Rehmer, Heather
Corporate Officer · Individual
Snodgrass, Barbara
Corporate Director · Individual
Soukup-Mcfarland, Dianne
Operational/Managerial Control · Individual
Sylvania Franciscan Health
5% Or Greater Indirect Ownership Interest · Organization
Tyler, Shawn
Operational/Managerial Control · Individual
Wine, Matthew
Corporate Director · Individual
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