Cycle 1
Health 2023-06-01 · Fire 2023-06-01
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Leipsic, OH
Meadows Of Leipsic
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
901 East Main Street, Leipsic, OH
(419) 943-2103
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
52
Certified beds
Average residents
42
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Trilogy Health Services
Operator or chain grouping
Approved since
2002-12-19
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
0.81
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.48
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.81
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,865
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9865
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.11
Baseline 21.92% · Performance 19.67% · Measure score 4.11 · Achievement 3.81 · Improvement 4.11
Healthcare-associated infections
2.80
Baseline 7.07% · Performance 7.00% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Total nurse turnover
4.51
Baseline 54.55% · Performance 45.24% · Measure score 4.51 · Achievement 4.51 · Improvement 2.63
Adjusted total nurse staffing
1.18
Baseline 2.39 hours · Performance 2.96 hours · Measure score 1.18 · Achievement 0 · Improvement 1.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.36% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 5% · Lower 95% interval 6.18% |
| Discharge to community | 65.33% |
50.57%
14.8 pts better
|
Better than the National Rate · Eligible stays 70 · Observed rate 67.14% · Lower 95% interval 55.26% |
| Medicare spending per beneficiary | 1.33 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 52.27% |
95.27%
43 pts worse
|
Numerator 23 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 47.22% |
53.69%
6.5 pts worse
|
Numerator 17 · Denominator 36 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 12 · Denominator 36 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 44 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 5.88% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 2.13% |
8.2%
6.1 pts worse
|
Numerator 2 · Denominator 94 |
| Staff flu vaccination coverage | 15.08% |
42%
26.9 pts worse
|
Numerator 19 · Denominator 126 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 18 · Denominator 36 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 26.92% |
25.2%
1.7 pts better
|
Numerator 7 · Denominator 26 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.8
1.1 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 1.0 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.8
1.2 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.8% |
92.4%
1.6 pts worse
|
93.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 91.9% · Q2 88.9% · Q3 94.1% · Q4 88.6% · 4Q avg 90.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.3%
2.6 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.8% |
26.1%
12.3 pts better
|
11.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 12.5% · Q3 6.5% · Q4 18.8% · 4Q avg 13.8% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
6.2%
1.3 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 9.7% · Q3 0.0% · Q4 6.9% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
25.4%
1.2 pts worse
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 21.9% · Q3 26.7% · Q4 27.6% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.6% |
11.5%
1.1 pts worse
|
16.7%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 10.0% · Q3 16.0% · Q4 8.0% · 4Q avg 12.6% · 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 | 9.0% |
7.7%
1.3 pts worse
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
6.2%
2.1 pts worse
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 9.4% · Q3 10.0% · Q4 0.0% · 4Q avg 8.3% · 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 | 0.0% |
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 | 26.9% |
21.7%
5.2 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.8% · Q2 38.8% · Q3 17.0% · Q4 20.4% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
3.7%
3.2 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 81.6% |
78.1%
3.5 pts better
|
81.7%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 87.5% · Q3 83.3% · Q4 74.0% · 4Q avg 81.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.3% |
12.5%
8.2 pts better
|
12.0%
7.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.3% · Observed 4.3% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.8% |
75.6%
12.2 pts better
|
79.7%
8.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.7% |
25.1%
6.4 pts better
|
23.9%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 17.0% · Expected 21.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-03 · Fire 2021-05-03
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-02-28 · Fire 2019-02-28
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-06-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-13
F · Potential for more than minimal harm
2023-06-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-13
E · Potential for more than minimal harm
2023-06-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-06-13
F · Potential for more than minimal harm
2021-05-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-06-01
F · Potential for more than minimal harm
2021-05-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-01
E · Potential for more than minimal harm
2021-05-03
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 2021-06-01
E · Potential for more than minimal harm
2021-05-03
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-06-01
E · Potential for more than minimal harm
2019-02-28
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2019-03-27
E · Potential for more than minimal harm
2019-02-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-03-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2023-06-01
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 2023-06-12
D · Potential for more than minimal harm
2023-06-01
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 2023-06-12
D · Potential for more than minimal harm
2023-06-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-06-01
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-06-12
F · Potential for more than minimal harm
2021-05-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-05-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-05-03
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 2021-06-01
D · Potential for more than minimal harm
2021-05-03
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 2021-06-01
D · Potential for more than minimal harm
2021-05-03
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-06-01
F · Potential for more than minimal harm
2019-02-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-27
F · Potential for more than minimal harm
2019-02-28
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-03-27
D · Potential for more than minimal harm
2019-02-28
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 2019-03-27
D · Potential for more than minimal harm
2019-02-28
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 2019-03-27
D · Potential for more than minimal harm
2019-02-28
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 2019-03-27
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
Barney, Leigh
Corporate Officer · Individual
Bryant, William
Corporate Officer · Individual
Bufford, Randall
Corporate Officer · Individual
Conner, Gregory
Corporate Officer · Individual
Continental Merger Sub LLC
5% Or Greater Indirect Ownership Interest · Organization
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
Keybank National Association
5% Or Greater Mortgage Interest · Organization
Mehaffey, Todd
Corporate Officer · Individual
Northstar Healthcare Income Inc
5% Or Greater Indirect Ownership Interest · Organization
Northstar Healthcare Income Operating Partnership LP
5% Or Greater Indirect Ownership Interest · Organization
Pietrowski, Cristina
Corporate Officer · Individual
Prosky, Danny
Corporate Officer · Individual
Siefker, Madison
Operational/Managerial Control · Individual
Streiff, Mathieu
Corporate Officer · Individual
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
Nearby options
Other facilities in reach
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Autumn Court
Ottawa, OH
5-star overall rating with 4-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Meadows Of Ottawa The
Ottawa, OH
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Vancrest Health Care Ctr Of Ho
Holgate, OH
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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