Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at St Frances Nsg & Rehab Center during CMS and state inspections, most recent first.
Failure to Initiate Grievance for Missing Resident Money: A resident with intact cognition reported missing cash from his room and told the Admin and DON, but no grievance was documented or completed despite the facility policy covering theft of property and requiring prompt investigation and resolution. The DON said the Admin handled missing item issues, and the Admin acknowledged he knew about the missing money, replaced the funds when they could not be located, and admitted a grievance was not initiated even though it should have been.
A resident with severe cognitive impairment, vision loss, and communication deficits required substantial to maximal assistance with bathing and grooming, but repeated observations showed thick facial hair on the face, chin, and upper lip over multiple days. A CNA confirmed the resident should have been shaved previously, and the Corporate RN stated it was unacceptable for the non-interviewable female resident to have thick facial hair.
Planned menus were not followed for 2 residents on mechanical soft diets when their lunch trays did not include cornbread or the ordered bread substitute. One resident had a BIMS score of 99 and the other had a BIMS score of 9, and both were observed without the planned menu item or the substitute. An S5DM confirmed the trays were missing both the cornbread and the additional mashed potatoes that were supposed to replace it.
Improper storage and dating of open food items were observed in the pantry and refrigerator. Surveyors found vanilla wafers left open to air, a gallon of mayonnaise opened without an open date, and multiple cereal containers with inaccurate open dates. S5DM confirmed the cereal dates were not updated when refilled and that the wafers and mayonnaise were not properly sealed or dated.
Inaccurate ADL Documentation in Resident Record: A resident with severe cognitive impairment and extensive ADL needs had care documented in the chart by staff who did not actually provide the care. Multiple CNAs reported they lacked working login access to the EHR, so other CNAs entered ADL documentation on their behalf. An LPN/CNA sup and the DON were aware of the ongoing login issues, and a CNA confirmed she charted ADL care for an agency CNA without verifying the care was actually delivered.
A resident with moderate cognitive impairment and a history of exit-seeking behavior eloped from the facility unnoticed, despite wearing a wanderguard bracelet. The alarm sounded, but the LPN on duty did not conduct a census check, assuming the alarm was triggered by a staff member or another resident. The facility only became aware of the elopement when a family member called to inform them that the resident had arrived at their home.
A resident with cognitive impairment and a history of exit-seeking behaviors eloped from the facility after exiting through the front door, triggering an alarm. An LPN failed to conduct a census check, assuming the alarm was set off by a staff member or another resident. The facility was only alerted to the elopement when the resident's family member called to report the resident's arrival at their home.
A resident with multiple health issues, including dementia and osteoporosis, sustained a right humerus fracture of unknown origin. The facility's policy required reporting such incidents within two hours due to the serious nature of the injury. However, the administrator failed to report the incident within the mandated timeframe, despite an immediate investigation being initiated by the DON.
Failure to Initiate Grievance for Missing Resident Money
Penalty
Summary
The facility failed to follow its grievance policy for a resident who reported missing personal property, specifically missing money. The facility policy stated that grievances or complaints regarding theft of property and other concerns could be filed without fear of reprisal, and that upon receipt of a grievance the grievance official would ensure prompt investigation and resolution. Review of the grievance logs from November 2025 through April 2026 showed no documented grievance initiated or completed for the resident related to the missing money. The resident had been admitted with diagnoses including Type 2 DM with hyperglycemia, hypertensive heart disease with HF, hyperlipidemia, PVD, and dementia, and a quarterly MDS showed a BIMS score of 15 indicating intact cognition. During interview, the resident stated that $220 had been stolen from his room about two weeks earlier, that he had informed the Admin and DON, and that he had not been told the findings of any investigation and his money was not replaced. The DON confirmed awareness of the report but stated she did not handle missing item investigations and that the Admin was responsible for initiating the grievance. The Admin stated he knew the resident had reported missing money about one month earlier, replaced the money because it could not be located, and acknowledged that a grievance was not initiated even though it should have been; he also confirmed awareness of the more recent allegation and again acknowledged that a grievance was not initiated.
Failure to Maintain Grooming for a Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming. Facility policy stated that a resident unable to perform ADLs would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #64 had diagnoses including unspecified vision loss, unspecified intellectual disabilities, and communication deficit, and the Significant Change MDS dated 04/10/2026 showed a BIMS score of 4, indicating severe cognitive impairment. The resident required substantial to maximal assistance with showering/bathing and all personal hygiene/grooming. Observations on 05/04/2026, 05/05/2026, and 05/05/2026 showed the female resident sitting in the day room, wheelchair, and dining room with facial hair on the bilateral sides of the face, chin, upper lip, and later full facial hair on the bilateral cheeks, lip, and chin. The facial hair was described as more than sparse and approximately as long as a grain of rice. During interview, the CNA confirmed the resident's face was very hairy with thick facial hair and should have been shaved previously, and the Corporate RN stated it was unacceptable for the non-interviewable resident to have thick facial hair.
Planned Menu Not Followed for Mechanical Soft Diets
Penalty
Summary
The facility failed to follow the planned menus for residents receiving mechanically altered diets by not providing bread or a bread substitute at lunch for 2 residents. Resident #68 had a quarterly MDS dated 03/25/2026 showing a BIMS score of 99, indicating an assessment could not be completed, and required a mechanically altered diet. Resident #69 had a quarterly MDS dated 03/19/2026 showing a BIMS score of 9, indicating moderate cognitive impairment, and also required a mechanically altered diet. During observation of their lunch trays on 05/04/2026, both residents were prescribed mechanical soft diets but did not receive cornbread or a substitute. An interview with S5DM confirmed that residents on mechanical soft diets were not served cornbread and were supposed to receive an additional scoop of mashed potatoes as a substitute, but neither resident received the cornbread or the substitute.
Improper Storage and Dating of Open Food Items
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety by leaving open food items improperly sealed and by failing to label opened items with an open date. During an observation of the pantry and refrigerator, surveyors found one package of vanilla wafers open to air, one gallon of mayonnaise opened without a date showing when it was opened, and three plastic cereal containers with open dates that were inaccurate, including two labeled 04/14/2025 and one labeled 11/20/2025 and 02/25/2025. The facility’s policy on dry food storage stated that containers should be kept tightly closed from insects, rodents, and dust. S5DM stated the cereal was used daily and the containers were refilled frequently, and confirmed the cereal dates were inaccurate, the vanilla wafers should have been sealed properly, and the mayonnaise should have had an opening date.
Inaccurate ADL Documentation in Resident Record
Penalty
Summary
The facility failed to ensure a resident’s medical record was accurately documented in accordance with accepted professional standards and practices when activities of daily living (ADL) care provided to Resident #2 were documented by staff who did not actually perform the care. Resident #2 was admitted on 05/06/2024 and re-entered on 03/27/2025 with diagnoses including displaced intertrochanteric fracture of the right femur, type 2 diabetes, severe protein calorie malnutrition, dementia, viral hepatitis C, and cirrhosis of the liver. The resident’s MDS with an ARD of 02/02/2026 showed a BIMS score of 6, indicating severe cognitive impairment, and that the resident required substantial to maximum assistance with ADLs. During interviews, multiple CNAs reported they had been unable to access the electronic documentation system because their login credentials were not functioning or had not been provided for weeks to months. An agency CNA stated she could not document the ADL care she provided and relied on other CNAs to complete the charting. Several staff members confirmed that CNAs with login access were documenting care on behalf of agency CNAs who did not have access, even when they had not personally provided the care. A CNA with functioning credentials stated she documented ADL care for an agency CNA on 05/04/2026 without verifying that the care had actually been provided. The DON acknowledged awareness that staff were documenting care for agency CNAs who lacked access, and the Corporate RN and DON confirmed that records were not accurate when the person documenting the care did not actually provide it.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident, who was at high risk for elopement, from leaving the premises unnoticed. The resident, who had moderate cognitive impairment and a history of exit-seeking behavior, was wearing a wanderguard bracelet. Despite this, the resident managed to exit the facility through the front door without staff knowledge. The alarm sounded, but the LPN on duty did not alert other staff to perform a census check when no resident was observed outside. The facility only became aware of the resident's elopement when a family member called to inform them that the resident had arrived at their home. The resident's medical records indicated a history of Alzheimer's Disease, Unspecified Dementia, and Schizophrenia, with a BIMS score indicating moderate cognitive impairment. The resident was assessed as being at high risk for elopement and was supposed to be monitored with hourly visual checks and a wanderguard. However, the LPN on duty did not conduct a census check after the alarm sounded, assuming it was triggered by a staff member or another resident with the door code. Interviews with staff revealed that the LPN did not follow the facility's policy of conducting a census check when the alarm was triggered without an identifiable cause. The facility's administrator and DON confirmed that a census check should have been initiated immediately. The failure to do so resulted in the resident leaving the facility and walking to a family member's home, highlighting a lapse in the facility's supervision and response protocols.
Resident Elopement Due to Inadequate Response to Alarm
Penalty
Summary
The facility failed to effectively administer its resources to ensure the safety and well-being of its residents, particularly in the case of a resident who was at risk for elopement. This resident, who was moderately cognitively impaired and had a history of exit-seeking behaviors, managed to leave the facility unnoticed despite wearing a wanderguard bracelet. The incident occurred when the resident exited through the front door, triggering an alarm that went unaddressed by the staff in terms of conducting a necessary census check. The deficiency was further compounded by the actions of an LPN who, upon hearing the alarm, failed to alert other staff members or initiate a census check to account for all residents. The LPN assumed the alarm was triggered by a staff member or another resident with a door code, leading to a delay in realizing the resident's absence. The facility only became aware of the elopement when the resident's family member called to inform them that the resident had walked to her home. Interviews with facility staff, including the Administrator and the DON, revealed that there was a lack of awareness and adherence to the facility's elopement policy, which required immediate census checks when an alarm sounded without an identifiable cause. The facility's policies were not effectively communicated or enforced, resulting in a situation where the safety protocols were not followed, leading to the resident's unsupervised departure from the facility.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an injury of unknown source involving a resident within the required timeframe. The resident, who was unable to communicate due to a BIMS score of 99, was found with a skin tear and bruising on the right upper arm. An x-ray revealed a right humerus fracture, which was considered a serious bodily injury. The facility's policy mandates that such incidents be reported to the State Survey Agency within two hours if they involve serious bodily injury. However, the administrator did not report the incident within this timeframe. The resident had multiple diagnoses, including osteoporosis, dementia, and schizoaffective disorder, and was dependent on staff for daily activities. The Director of Nursing (DON) was informed of the injury and initiated an investigation, but the cause of the injury remained undetermined. Despite the facility's immediate investigation, the administrator acknowledged the failure to report the incident as per the policy, which constitutes a deficiency in adhering to federal and state regulations for reporting suspected abuse or injuries of unknown origin.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oberlin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kinder Retirement And Rehabilitation Center | 9.9 mi | ★★★★★ | 0 | 0 |
| Maison D'acadiens Care Center | 13.4 mi | ★★★★★ | 8 | 0 |
| Allen Oaks Nursing And Rehab Center | 15 mi | ★★★★★ | 1 | 0 |
| Savoy Care Center | 20.5 mi | ★★★★★ | 10 | 0 |
| Oak Lane Wellness & Rehabilitative Center | 21.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.