18 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Sandusky, OH
1-star overall rating with 2-star inspections with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2025 Hayes Avenue, Sandusky, OH
(419) 627-2273
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
138
Certified beds
Average residents
94
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
1995-01-01
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
RN hours / resident day
0.59
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.39
CMS adjusted RN staffing hours
Adjusted total hours
2.12
CMS adjusted total nurse staffing hours
Case-mix index
2.08
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
13,079
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 19.56% · Performance 23.21% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.79
Baseline 5.39% · Performance 7.30% · Measure score 1.79 · Achievement 1.79 · Improvement 0
Total nurse turnover
0
Baseline 63.85% · Performance 71.09% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.62
Baseline 1.71 hours · Performance 2.58 hours · Measure score 1.62 · Achievement 0 · Improvement 1.62
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.04% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 245 · Observed rate 12.65% · Lower 95% interval 9.12% |
| Discharge to community | 49.14% |
50.57%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 214 · Observed rate 44.39% · Lower 95% interval 43.11% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.62% |
95.27%
2.4 pts better
|
Numerator 123 · Denominator 126 |
| Falls with major injury | 2.38% |
0.77%
1.6 pts worse
|
Numerator 3 · Denominator 126 |
| Discharge self-care score | 62.24% |
53.69%
8.6 pts better
|
Numerator 61 · Denominator 98 |
| Discharge mobility score | 54.08% |
50.94%
3.1 pts better
|
Numerator 53 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 3.97% |
2.29%
1.7 pts worse
|
Numerator 5 · Denominator 126 · Adjusted rate 3.82% |
| Healthcare-associated infections requiring hospitalization | 7.3% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 113 · Observed rate 6.19% · Lower 95% interval 4.64% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 132 |
| Staff flu vaccination coverage | 23.91% |
42%
18.1 pts worse
|
Numerator 33 · Denominator 138 |
| Discharge function score | 62.24% |
56.45%
5.8 pts better
|
Numerator 61 · Denominator 98 |
| Transfer of health information to provider | 84.09% |
95.95%
11.9 pts worse
|
Numerator 37 · Denominator 44 |
| Transfer of health information to patient | 94.64% |
96.28%
1.6 pts worse
|
Numerator 53 · Denominator 56 |
| Resident COVID-19 vaccinations up to date | 9.86% |
25.2%
15.3 pts worse
|
Numerator 7 · Denominator 71 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.9 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.7% |
92.4%
5.3 pts better
|
93.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 95.5% · Q3 100.0% · Q4 98.8% · 4Q avg 97.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 83.5% |
94.5%
11 pts worse
|
95.5%
12 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 83.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.3%
0.4 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.5% · Q3 4.5% · Q4 0.0% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 91.4% |
26.1%
65.3 pts worse
|
11.4%
80 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 74.7% · Q2 94.1% · Q3 97.6% · Q4 100.0% · 4Q avg 91.4% |
| Percentage of long-stay residents who lose too much weight | 10.6% |
6.2%
4.4 pts worse
|
5.4%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 10.1% · Q3 11.0% · Q4 11.8% · 4Q avg 10.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.9% |
25.4%
1.5 pts better
|
19.6%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.1% · Q2 22.2% · Q3 23.0% · Q4 28.6% · 4Q avg 23.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.1% |
11.5%
7.6 pts worse
|
16.7%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 16.1% · Q3 18.2% · Q4 20.0% · 4Q avg 19.1% · 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 | 14.1% |
7.7%
6.4 pts worse
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 18.0% · Q3 17.1% · Q4 12.1% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
6.2%
2.3 pts worse
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 11.8% · Q3 9.2% · Q4 7.0% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.2%
About the same
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.5%
0.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.1% |
21.7%
1.6 pts better
|
19.8%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 30.3% · Q3 18.9% · Q4 16.9% · 4Q avg 20.1% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
3.7%
4.3 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.2% · Q3 9.3% · Q4 9.3% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.9% |
78.1%
0.2 pts worse
|
81.7%
3.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 56.9% · Q2 71.3% · Q3 91.0% · Q4 100.0% · 4Q avg 77.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
12.5%
4.4 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 7.7% · Expected 10.7% · Used in QM five-star |
| 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 · 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 who were assessed and appropriately given the seasonal influenza vaccine | 43.0% |
75.6%
32.6 pts worse
|
79.7%
36.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 43.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.7% |
25.1%
3.4 pts better
|
23.9%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.7% · Observed 20.0% · Expected 22.0% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-13
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-13
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-11-03
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-11-03
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-03
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-03
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-03
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-03
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-11-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-03
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-03
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-11-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-06
Inspection history
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-13
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-13
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-07-13
Health
Dispose of garbage and refuse properly.
Corrected 2025-07-13
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-13
Health
Implement a program that monitors antibiotic use.
Corrected 2025-07-13
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-07-13
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 2025-07-13
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-07-13
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-07-13
Health
Assess the resident when there is a significant change in condition
Corrected 2025-07-13
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 2025-07-13
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-07-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-13
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-07-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-07-13
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-13
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-10-16
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-16
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-03
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-03
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-11-03
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-03
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-03
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 2023-11-03
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-03
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-08-11
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-22
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 2023-07-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-08-06
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 2021-08-06
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-06
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-06
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-08-06
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 2021-08-06
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-08-06
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Nearby options
Sandusky, OH
4-star overall rating with 2-star inspections with abuse icon flag with 10 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
Sandusky, OH
4-star overall rating with 3-star inspections with 2 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
Sandusky, OH
4-star overall rating with 3-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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