Cycle 1
Health 2025-04-10 · Fire 2025-04-10
2 health deficiencies
Top issue: Environmental (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Tiffin, OH
St Francis Senior Ministries
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
182 St Francis Ave, Tiffin, OH
(419) 447-2723
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
50
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-01-06
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
0.38
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.22
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
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,880
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.45
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
5.04
Baseline 17.89% · Performance 19.10% · Measure score 5.04 · Achievement 5.04 · Improvement 0
Healthcare-associated infections
1.57
Baseline 5.67% · Performance 7.36% · Measure score 1.57 · Achievement 1.57 · Improvement 0
Total nurse turnover
3.58
Baseline 38.89% · Performance 49.06% · Measure score 3.58 · Achievement 3.58 · Improvement 0
Adjusted total nurse staffing
2.39
Baseline 3.86 hours · Performance 3.76 hours · Measure score 2.39 · Achievement 2.39 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.24% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 12.99% · Lower 95% interval 8.24% |
| Discharge to community | 44.3% |
50.57%
6.3 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 34.78% · Lower 95% interval 32.35% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 45 · Denominator 45 |
| Falls with major injury | 4.44% |
0.77%
3.7 pts worse
|
Numerator 2 · Denominator 45 |
| Discharge self-care score | 57.69% |
53.69%
4 pts better
|
Numerator 15 · Denominator 26 |
| Discharge mobility score | 34.62% |
50.94%
16.3 pts worse
|
Numerator 9 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 45 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.37% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.92% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 70.64% |
42%
28.6 pts better
|
Numerator 77 · Denominator 109 |
| Discharge function score | 57.69% |
56.45%
1.2 pts better
|
Numerator 15 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · 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 | 34.48% |
25.2%
9.3 pts better
|
Numerator 10 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.5 · 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 | 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 | 8.2% |
3.3%
4.9 pts worse
|
3.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 10.9% · Q3 10.4% · Q4 11.1% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.1% |
26.1%
15 pts better
|
11.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 9.5% · Q3 12.5% · Q4 15.0% · 4Q avg 11.1% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
6.2%
0.8 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.7% · Q3 9.8% · Q4 10.3% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
25.4%
8.2 pts better
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 17.9% · Q3 17.1% · Q4 17.9% · 4Q avg 17.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.1% |
11.5%
0.4 pts better
|
16.7%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 11.8% · Q3 6.9% · Q4 10.0% · 4Q avg 11.1% · 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 | 8.4% |
7.7%
0.7 pts worse
|
16.3%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 0.0% · Q3 0.0% · Q4 8.4% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.4% |
6.2%
2.2 pts worse
|
14.9%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 0.0% · Q3 2.5% · Q4 7.7% · 4Q avg 8.4% · 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 | 24.3% |
21.7%
2.6 pts worse
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 20.9% · Q3 20.6% · Q4 25.5% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
3.7%
2.3 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.9% · Q3 0.0% · Q4 1.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.4% |
78.1%
6.3 pts better
|
81.7%
2.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.4% · Q2 88.9% · Q3 82.8% · Q4 80.0% · 4Q avg 84.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
12.5%
0.8 pts better
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 14.9% · Expected 14.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.2%
1 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 4.8% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
75.6%
18.8 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.0% |
25.1%
3.1 pts better
|
23.9%
1.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 27.7% · Expected 29.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-16 · Fire 2023-03-16
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-09-19 · Fire 2019-09-19
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-10
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-10
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-10
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-10
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-10
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-10
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-14
E · Potential for more than minimal harm
2025-04-10
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 2025-05-14
F · Potential for more than minimal harm
2023-03-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-17
F · Potential for more than minimal harm
2023-03-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-17
F · Potential for more than minimal harm
2023-03-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-17
F · Potential for more than minimal harm
2023-03-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-03-16
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 2023-04-17
E · Potential for more than minimal harm
2023-03-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-04-17
F · Potential for more than minimal harm
2019-09-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-01
E · Potential for more than minimal harm
2019-09-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-11-01
E · Potential for more than minimal harm
2019-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-01
E · Potential for more than minimal harm
2019-09-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-11-01
C · Minimal harm
2019-09-19
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-11-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-10
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 2025-05-14
D · Potential for more than minimal harm
2025-04-10
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-05-14
F · Potential for more than minimal harm
2023-03-16
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-03-16
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 2023-04-17
E · Potential for more than minimal harm
2023-03-16
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-03-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-16
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 2023-04-17
D · Potential for more than minimal harm
2023-03-16
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 2023-04-17
D · Potential for more than minimal harm
2023-03-16
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 2023-04-17
D · Potential for more than minimal harm
2023-03-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-17
D · Potential for more than minimal harm
2023-03-16
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 2023-04-17
E · Potential for more than minimal harm
2019-09-19
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 2019-11-01
E · Potential for more than minimal harm
2019-09-19
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 2019-11-01
D · Potential for more than minimal harm
2019-09-19
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-19
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 2019-11-01
D · Potential for more than minimal harm
2019-09-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-19
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 2019-11-01
D · Potential for more than minimal harm
2019-09-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-11-01
D · Potential for more than minimal harm
2019-09-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-11-01
C · Minimal harm
2019-09-19
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2019-11-01
Penalties and ownership
What sits behind the stars
Ownership
Csj Initiatives Inc
5% Or Greater Direct Ownership Interest · Organization
Aldridge, Sara
Corporate Director · Individual
Anderson, Eleanor
Corporate Director · Individual
Arnone, Myra
Corporate Director · Individual
Csj Initiatives Inc
Operational/Managerial Control · Organization
Dariano, Kelli
Corporate Director · Individual
Fabrizio, Dominic
Corporate Director · Individual
Fabrizio, Dominic
Corporate Officer · Individual
Falter, Brian
Corporate Director · Individual
Gannon, Denise
Corporate Director · Individual
Griffin, Jill
Corporate Director · Individual
Kucera, Jan
Corporate Director · Individual
Mack, Shellie
Corporate Director · Individual
O'brien, Marguerite
Corporate Director · Individual
O'brien, Marguerite
Corporate Officer · Individual
Slater, William
Corporate Officer · Individual
Stoll, Gabriel
W-2 Managing Employee · Individual
Webb, Tyler
Corporate Director · Individual
Webb, Tyler
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Autumnwood Care Center
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2-star overall rating with 2-star inspections with 13 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
The Willows At Tiffin
Tiffin, OH
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
St Catherine's C C Of Fostoria
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3-star overall rating with 3-star inspections with $14,433 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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