Cycle 1
Health 2024-07-18 · Fire 2024-07-18
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Ashland, OH
Good Shepherd The
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
622 Center St, Ashland, OH
(419) 289-3523
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
108
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
1.04
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.44
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.32
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.88
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.21
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.75
Higher values indicate more complex resident acuity
RN turnover
15%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,915
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.97
Composite VBP score used to determine payment impact.
Payment multiplier
1.0004
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.46
Baseline 20.32% · Performance 19.83% · Measure score 3.46 · Achievement 3.46 · Improvement 0.99
Healthcare-associated infections
4.03
Baseline 6.84% · Performance 6.63% · Measure score 4.03 · Achievement 4.03 · Improvement 0.66
Total nurse turnover
8.34
Baseline 37.33% · Performance 29.58% · Measure score 8.34 · Achievement 8.34 · Improvement 5.71
Adjusted total nurse staffing
2.95
Baseline 4.13 hours · Performance 3.92 hours · Measure score 2.95 · Achievement 2.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.64% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 15.19% · Lower 95% interval 7.96% |
| Discharge to community | 49.25% |
50.57%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 40.91% · Lower 95% interval 38.18% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 32 |
| Discharge self-care score | 43.48% |
53.69%
10.2 pts worse
|
Numerator 10 · Denominator 23 |
| Discharge mobility score | 39.13% |
50.94%
11.8 pts worse
|
Numerator 9 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 2.45% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 5.41% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 1.69% |
8.2%
6.5 pts worse
|
Numerator 4 · Denominator 236 |
| Staff flu vaccination coverage | 57.98% |
42%
16 pts better
|
Numerator 138 · Denominator 238 |
| Discharge function score | 43.48% |
56.45%
13 pts worse
|
Numerator 10 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.4%
7.6 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
94.5%
4.6 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.0% |
3.3%
5.7 pts worse
|
3.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 12.4% · Q3 8.7% · Q4 7.3% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
26.1%
21.8 pts better
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.2% · Q3 6.0% · Q4 1.1% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 5.8% |
6.2%
0.4 pts better
|
5.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.8% · Q3 9.3% · Q4 6.8% · 4Q avg 5.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.3% |
25.4%
8.9 pts worse
|
19.6%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 37.5% · Q3 40.8% · Q4 32.4% · 4Q avg 34.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.2% |
11.5%
7.7 pts worse
|
16.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 21.1% · Q3 19.6% · Q4 14.0% · 4Q avg 19.2% · 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 | 9.6% |
7.7%
1.9 pts worse
|
16.3%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 9.6% · Q3 9.4% · Q4 2.5% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
6.2%
0.1 pts worse
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 7.0% · Q3 10.9% · Q4 1.5% · 4Q avg 6.3% · 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 | 0.2% |
0.5%
0.3 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.2% |
21.7%
2.5 pts worse
|
19.8%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 22.0% · Q3 25.5% · Q4 20.5% · 4Q avg 24.2% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
3.7%
1.3 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.3% · Q3 2.0% · Q4 3.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
78.1%
21.9 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.0% |
12.5%
5.5 pts worse
|
12.0%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 18.6% · Expected 11.6% · 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 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.5% |
75.6%
8.9 pts better
|
79.7%
4.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
25.1%
1.3 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 27.9% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-03 · Fire 2022-03-03
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2019-04-05 · Fire 2019-04-05
14 health deficiencies
Top issue: Quality of Life and Care (5 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
2024-07-18
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 2024-08-16
E · Potential for more than minimal harm
2024-07-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-07-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-07-18
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2024-08-16
E · Potential for more than minimal harm
2024-07-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-16
E · Potential for more than minimal harm
2022-03-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-07-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
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 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-08-16
D · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-16
G · Actual harm
2023-11-27
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 2023-11-24
F · Potential for more than minimal harm
2022-03-03
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 2022-04-08
D · Potential for more than minimal harm
2022-03-03
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 2022-04-08
D · Potential for more than minimal harm
2022-03-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-03-03
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-04-08
C · Minimal harm
2022-03-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-04-01
B · Minimal harm
2022-03-03
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 2022-04-01
E · Potential for more than minimal harm
2019-04-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-05-17
E · Potential for more than minimal harm
2019-04-05
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 2019-05-17
D · Potential for more than minimal harm
2019-04-05
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 2019-05-17
D · Potential for more than minimal harm
2019-04-05
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-04-05
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 2019-05-17
D · Potential for more than minimal harm
2019-04-05
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 2019-05-17
D · Potential for more than minimal harm
2019-04-05
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 2019-05-17
D · Potential for more than minimal harm
2019-04-05
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-04-05
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 2019-05-17
D · Potential for more than minimal harm
2019-04-05
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-04-05
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2019-05-17
D · Potential for more than minimal harm
2019-04-05
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 2019-05-17
D · Potential for more than minimal harm
2019-04-05
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 2019-05-17
Penalties and ownership
What sits behind the stars
Ownership
Lutheran Social Services Of Central Ohio
5% Or Greater Direct Ownership Interest · Organization
Abraham, Joseph
Operational/Managerial Control · Individual
Applegate, Alicia
Operational/Managerial Control · Individual
Bogner, Kristy
Operational/Managerial Control · Individual
Dubbe, Heather
Operational/Managerial Control · Individual
Dunn, Robert
Corporate Director · Individual
Fratianne, Julia
Operational/Managerial Control · Individual
Fratianne, Julia
Corporate Officer · Individual
Kendall, Earl
Corporate Director · Individual
Kerr, Ronald
Corporate Director · Individual
Kerr, Sarah
Operational/Managerial Control · Individual
Lustig, Rachel
Operational/Managerial Control · Individual
Lustig, Rachel
Corporate Officer · Individual
Manser, Marlene
Corporate Director · Individual
Martin-Terry, Wanda
Corporate Director · Individual
Mcclendon, Aaron
Corporate Director · Individual
Mcquate, Eric
Operational/Managerial Control · Individual
Meek, Violet
Corporate Director · Individual
Meslow, Andrew
Corporate Director · Individual
Miller, Kimberly
Operational/Managerial Control · Individual
Miller, Kimberly
Corporate Officer · Individual
Mitchell, Deborah
Corporate Director · Individual
Prillerman, Sheila
Corporate Director · Individual
Riggins, Brandon
Corporate Director · Individual
Savage, Theressa
Operational/Managerial Control · Individual
Smith, Anna
Operational/Managerial Control · Individual
Spring, Lori
Operational/Managerial Control · Individual
Steinbrenner, Adam
Corporate Director · Individual
Stucky, Erin
Operational/Managerial Control · Individual
Suiter, Brian
Corporate Director · Individual
Tavallaee, Mehrdad
Operational/Managerial Control · Individual
Tunis Pheister, Erin
Corporate Director · Individual
Uhler, Julie
Operational/Managerial Control · Individual
White, Lorie
Operational/Managerial Control · Individual
Wolverton, Chad
Operational/Managerial Control · Individual
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#3
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