Cycle 1
Health 2025-01-16 · Fire 2025-01-16
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Delphos, OH
Meadows Of Delphos The
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
800 Ambose Drive, Delphos, OH
(419) 643-3161
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
54
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
1979-01-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
125 facilities
Chain averages 4 overall / 3 health / 3 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
0.56
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.78
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.53
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.91
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.32
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
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,902
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9885
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.31
Baseline 16.14% · Performance 20.36% · Measure score 2.31 · Achievement 2.31 · Improvement 0
Healthcare-associated infections
5.87
Baseline 6.07% · Performance 6.08% · Measure score 5.87 · Achievement 5.87 · Improvement 0
Total nurse turnover
3.86
Baseline 36.11% · Performance 47.92% · Measure score 3.86 · Achievement 3.86 · Improvement 0
Adjusted total nurse staffing
1.83
Baseline 2.81 hours · Performance 3.50 hours · Measure score 1.83 · Achievement 1.50 · Improvement 1.83
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.39% |
10.72%
2.3 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 3.09% · Lower 95% interval 5.39% |
| Discharge to community | 60.44% |
50.57%
9.9 pts better
|
No Different than the National Rate · Eligible stays 97 · Observed rate 56.7% · Lower 95% interval 48.54% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 86.27% |
95.27%
9 pts worse
|
Numerator 44 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 48.48% |
53.69%
5.2 pts worse
|
Numerator 16 · Denominator 33 |
| Discharge mobility score | 15.15% |
50.94%
35.8 pts worse
|
Numerator 5 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 51 · Adjusted rate 2.42% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 3.17% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 84 |
| Staff flu vaccination coverage | 29.84% |
42%
12.2 pts worse
|
Numerator 37 · Denominator 124 |
| Discharge function score | 36.36% |
56.45%
20.1 pts worse
|
Numerator 12 · Denominator 33 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 90.48% |
96.28%
5.8 pts worse
|
Numerator 19 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 17.14% |
25.2%
8.1 pts worse
|
Numerator 6 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
92.4%
2.4 pts better
|
93.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 88.4% · Q2 92.3% · Q3 100.0% · Q4 100.0% · 4Q avg 94.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
94.5%
0.7 pts better
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.3%
0.6 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 2.6% · Q3 2.8% · Q4 5.4% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.7% |
26.1%
12.4 pts better
|
11.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 13.9% · Q3 17.1% · Q4 14.3% · 4Q avg 13.7% |
| 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 2.3% · Q2 5.3% · Q3 5.9% · Q4 3.1% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.3% |
25.4%
7.9 pts worse
|
19.6%
13.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 35.9% · Q3 37.1% · Q4 36.4% · 4Q avg 33.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
11.5%
6.3 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 7.4% · Q3 6.9% · Q4 3.6% · 4Q avg 5.2% · 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 | 20.8% |
7.7%
13.1 pts worse
|
16.3%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.8% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
6.2%
8.8 pts worse
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 17.9% · Q3 5.9% · Q4 9.4% · 4Q avg 15.0% · 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 | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 21.9% |
21.7%
0.2 pts worse
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 25.0% · Q3 12.5% · Q4 22.9% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 1.6% |
3.7%
2.1 pts better
|
5.1%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.2% · Q4 2.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
78.1%
18.6 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.3% · Q2 96.9% · Q3 98.9% · Q4 96.3% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.9% |
12.5%
4.4 pts worse
|
12.0%
4.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.9% · Observed 17.5% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.2%
0.7 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.7% |
75.6%
11.1 pts better
|
79.7%
7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.4% |
25.1%
2.3 pts worse
|
23.9%
3.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 30.2% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-08-25 · Fire 2022-08-25
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-08-29 · Fire 2019-08-29
3 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
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 2025-01-31
F · Potential for more than minimal harm
2025-01-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-31
F · Potential for more than minimal harm
2025-01-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-31
F · Potential for more than minimal harm
2022-08-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-10
F · Potential for more than minimal harm
2022-08-25
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-10-10
E · Potential for more than minimal harm
2022-08-25
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 2022-10-10
F · Potential for more than minimal harm
2019-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-16
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 2025-01-31
D · Potential for more than minimal harm
2025-01-16
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2025-01-31
E · Potential for more than minimal harm
2022-08-25
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 2022-10-10
E · Potential for more than minimal harm
2022-08-25
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 2022-10-10
D · Potential for more than minimal harm
2022-08-25
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 2022-10-10
D · Potential for more than minimal harm
2022-08-25
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 2022-10-10
D · Potential for more than minimal harm
2022-08-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-10-10
D · Potential for more than minimal harm
2022-08-25
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 2022-10-10
F · Potential for more than minimal harm
2019-08-29
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 2019-10-11
D · Potential for more than minimal harm
2019-08-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-11
Penalties and ownership
What sits behind the stars
Ownership
Trilogy Opco LLC
5% Or Greater Direct Ownership Interest · Organization
American Healthcare Reit Holdings LP
5% Or Greater Indirect Ownership Interest · Organization
American Healthcare Reit Inc
5% Or Greater Indirect Ownership Interest · Organization
Barber, Robin
Corporate Officer · Individual
Barney, Leigh
Corporate Officer · Individual
Bryant, William
Corporate Officer · Individual
Corbin, Kathy
W-2 Managing Employee · Individual
Davis, David
Corporate Officer · Individual
Fightmaster, Lisa
W-2 Managing Employee · Individual
Gahc3 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Gahc4 Trilogy Jv LLC
5% Or Greater Indirect Ownership Interest · Organization
Griffin-American Healthcare Reit Iii, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Griffin-American Healthcare Reit Iv Holdings, LP
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Inc
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Operating Partnership LP
5% Or Greater Indirect Ownership Interest · Organization
Prosky, Danny
Corporate Officer · Individual
Schoenlein, Stephanie
Operational/Managerial Control · Individual
Streiff, Mathieu
Corporate Officer · Individual
Trilogy Health Services LLC
Operational/Managerial Control · Organization
Trilogy Healthcare Holdings Inc
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Holdings Nt-Hci, LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Investors LLC
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Management Services LLC
Operational/Managerial Control · Organization
Trilogy Real Estate Investment Trust
5% Or Greater Indirect Ownership Interest · Organization
Trilogy Reit Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Williamson, Bradley
Corporate Officer · Individual
Nearby options
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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
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