Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Independence House during CMS and state inspections, most recent first.
A resident with diabetes, PVD, CHF, and chronic non-pressure ulcers to the right heel, midfoot, and bilateral lower extremities did not consistently receive ordered wound treatments, and the facility did not perform required ongoing wound assessments. The care plan and physician orders called for scheduled cleansing, application of triple antibiotic ointment or betadine, and appropriate dressings to multiple wound sites, along with weekly documentation of wound measurements and characteristics. Review of the TAR showed several missed and undocumented treatments, and there was no evidence of facility-completed wound monitoring or skin/wound grids for several weeks, despite multiple prior visits to an outside wound clinic. Facility leadership confirmed the absence of wound assessment documentation and the missing treatment initials on the TAR.
The facility failed to complete thorough fall investigations and post-fall monitoring for two residents at risk for falls due to deconditioning and multiple comorbidities. In one case, a cognitively intact resident with vascular disease, diabetes, CHF, and foot ulcers was found on the floor after sliding from a recliner; the incident report lacked documentation of environmental, situational, and physiological factors, neurological checks for the unwitnessed fall were not initiated, required 72-hour monitoring was missed on night shifts, and the fall risk assessment was not updated until several days later. In another case, a cognitively intact, wheelchair-dependent resident with dementia, DVT, and general weakness was found on the floor with the wheelchair tipped over after an unwitnessed fall, and the neurological check section on the post-fall form was crossed off with no monitoring documented, despite facility expectations and policy requiring such assessments after unwitnessed falls.
A resident with multiple complex wounds and comorbidities did not consistently receive or have documented the ordered wound care due to failures in following and transcribing MD orders. In December, several ordered treatments to the coccyx, sacrum, mid-thoracic back, back incision, bilateral heels, and right heel were not signed off on the TAR, despite specific orders for cleansing solutions, topical agents, and dressings. After a hospital visit in early January, new orders for sacral packing with Dakin’s, daily iodine and mepilex to bilateral heels, and routine back incision dressing checks and changes were not fully entered into the physician orders, resulting in missing sacral treatment orders for several days, lack of documented back incision monitoring, and heel care orders that were either not signed off or initiated only after discharge. The Administrator confirmed these transcription gaps and unsigned treatments, which conflicted with the facility’s wound treatment management policy.
A resident with multiple complex diagnoses and intact cognition had hospital discharge orders for ergocalciferol 50,000 units weekly, but this was incorrectly transcribed as 5,000 units weekly, and the resident received three doses weekly. Additionally, ordered daily weights with parameters for MD notification were not obtained on multiple days, and ordered doses of cyclobenzaprine and gabapentin were not administered or signed off for an evening shift. These actions did not follow the facility’s own medication administration policy requiring medications and monitoring to be carried out as ordered by the physician and documented on the MAR.
A facility failed to update a resident's care plan to reflect a change in code status from full code to DNRCC, despite documentation in physician orders and a DNR order form. The resident, with intact cognition and diagnoses including end stage renal disease, changed their code status, but the care plan was not revised accordingly. An LPN confirmed the oversight, which was against the facility's policy for updating care plans after significant changes.
A resident with impaired cognition experienced a failure in obtaining and documenting physician orders for wound care. Despite a new skin issue being reported, the facility did not have orders for a dressing change, and the treatment administration record lacked documentation. An LPN applied a dressing without verifying orders or applying the prescribed antibacterial ointment. The DON confirmed that orders were received but not entered, highlighting a lapse in ensuring proper wound care procedures.
Failure to Complete Ordered Wound Treatments and Ongoing Wound Assessments
Penalty
Summary
The deficiency involves the facility’s failure to provide wound treatments according to physician orders and to conduct ongoing assessments of non-pressure wounds for a resident with multiple chronic conditions. The resident was admitted with diagnoses including Type II diabetes mellitus with foot ulcers, CHF, hypertension, PVD, and non-pressure chronic ulcers of the right heel and midfoot. The care plan, revised in April 2026, required detailed and ongoing wound assessments, including documentation of wound location, drainage, peri-wound condition, pain, edema, size, depth, tissue type, exudate, granulation, infection, necrosis, gangrene, and weekly measurements of each area of skin breakdown. Physician orders in February 2026 directed specific wound care to the right heel and bilateral lower leg wounds on scheduled days, and April 2026 orders required daily betadine treatment and bandage to the right fourth toe until healed. Review of the Treatment Administration Records showed missing documentation indicating that ordered treatments were not completed on multiple specified dates for the right heel, bilateral lower legs, and right fourth toe. Additionally, although the resident was followed by a community wound clinic with multiple visits between December 2025 and March 2026, the facility’s own records contained no evidence of wound monitoring or completion of required skin and wound grids from the last wound clinic visit on March 11, 2026, through April 28, 2026. Interviews with the Regional Clinical Nurse and the DON confirmed that no facility wound grids were completed beyond those from the wound clinic and verified the missing initials on the TAR, indicating the treatments were not done. These failures were inconsistent with the facility’s policies requiring weekly pressure and non-pressure wound grids and ongoing assessment to monitor the effectiveness of wound treatments.
Incomplete Fall Investigations and Missed Post-Fall Neurological Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and thorough fall investigations and post-fall monitoring for two residents. One resident with diagnoses including peripheral vascular disease, diabetes with foot ulcers, CHF, hypertension, and a non-pressure chronic ulcer of the right heel and midfoot was cognitively intact and care planned for fall risk due to deconditioning, with interventions such as anticipating needs, ensuring call light and appropriate footwear, and following fall protocol. After this resident was found sitting on the floor in front of a recliner, having reportedly slid from the chair and denying injury, the incident report for the fall was left incomplete, with no documentation in the sections for predisposing environmental, situational, or physiological factors, and only vital signs, a brief statement of findings, and notifications recorded. For this same resident, the Post Fall Monitoring Form showed that the section for initiation of neurological checks following the unwitnessed fall was crossed off, and there was no documentation of immediate neurological monitoring. The required 72-hour post-fall monitoring, to be completed every eight hours for six shifts, was not done on the midnight shifts on two specified dates. Additionally, the resident’s fall risk assessment, which facility policy required to be completed after any fall, was not updated until eight days after the fall. Interviews with the DON and Regional Clinical Nurse confirmed that neurological checks should have been implemented for this unwitnessed fall, that the incident report was not fully completed, that post-fall assessments were missed on specified shifts, and that the fall risk assessment should have been completed immediately after the fall. A second resident, with diagnoses including difficulty in walking, DVT of the right lower leg, dementia, general weakness, diabetes, and wheelchair dependence, was also cognitively intact and care planned for falls due to deconditioning, with interventions such as Dycem to the chair, appropriate footwear, call light in reach, items within reach, and a custom wheelchair. This resident experienced an unwitnessed fall in which the resident was found sitting upright on the floor, leaning against the bed with shoes on, and the wheelchair tipped over on its side. The Post Fall Monitoring Form again showed the neurological check section crossed off with no documentation of immediate neurological monitoring. Interviews with the Administrator confirmed that the facility’s expectation was to initiate neurological checks for any unwitnessed fall, that this resident’s fall was unwitnessed, and that neurological checks were not completed despite this expectation. Facility policies on falls and fall prevention required assessment after any fall, monitoring for 72 hours, and detailed documentation and review, which were not followed in these cases.
Failure to Follow and Transcribe Physician Wound Care Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and provide ordered wound care for a cognitively intact resident with multiple complex medical conditions, including atrial fibrillation, heart failure, osteomyelitis, type 2 diabetes, and several pressure and non-pressure wounds. Record review showed multiple physician orders for wound treatments to the coccyx, sacrum, mid-thoracic back, back incision, bilateral heels, and right heel over December, including specific cleansing solutions, topical agents (such as Santyl and miconazole), dressings (calcium alginate, silicone border foam, ABD pads, mepilex), and treatment frequencies. The December treatment administration record (TAR) revealed that several of these ordered treatments were not signed off on multiple dates, including coccyx treatment, sacral wound care, mid-thoracic back wound care, miconazole powder applications, right heel dressing changes, back incision care, and bilateral heel protection. Wound documentation from mid-December indicated that the mid-thoracic, sacral, and bilateral heel wounds were improving from admission, but the missing documentation on the TAR showed that ordered treatments were not consistently documented as provided. Further review of the after-visit summary dated early January showed new orders to pack the coccyx wound with Dakin’s-soaked kerlix and apply sacral foam, to paint bilateral heels with iodine and cover with mepilex daily, and to check the back incision dressing at least once per shift and change it on postoperative day three and as needed thereafter. However, these orders were not fully transcribed into the physician orders: there was no order entered for monitoring the back incision every shift or for changing the postoperative dressing on the specified postoperative day, and no sacral wound treatment order was present from the time of the after-visit summary until several days later. Heel inspection orders were present but not signed off on at least one date in January, and an order to paint the left heel with betadine and cover with mepilex was not started until after the resident’s discharge. During interview, the Administrator confirmed that the discharge orders for sacral packing, bilateral heel care, and back incision monitoring and dressing changes were not fully entered into the physician orders, that an order for the back incision dressing placed under “other” did not appear on the physician order list, and that there were gaps in sacral and heel treatment orders and multiple wound treatments not signed off in December, contrary to the facility’s wound treatment management policy requiring wound care in accordance with physician orders and prompt physician notification when orders are absent.
Failure to Follow Physician Medication and Monitoring Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders were followed as written for one resident. The resident was admitted with multiple diagnoses, including atrial fibrillation, psoas muscle abscess, heart failure, chronic gout, bacteremia, osteomyelitis of the lumbar vertebra, neoplasm of uncertain behavior of cerebral meninges, type 2 diabetes, a non-pressure chronic ulcer of the right foot with fat layer exposed, and hypertension, and was documented as cognitively intact. Hospital discharge orders dated 12/05/25 included ergocalciferol 50,000 units by mouth weekly. However, when the orders were transcribed into the facility’s physician orders on 12/05/25, ergocalciferol was entered as 5,000 units by mouth weekly on Monday for vitamin D deficiency, resulting in a discrepancy from the hospital discharge paperwork. Further review of the physician orders and MAR for December 2025 showed additional failures to follow ordered treatments. Daily weights ordered to be taken first thing in the morning, with instructions to notify the physician if weight increased three pounds in 24 hours or five pounds in one week, were not obtained on multiple dates throughout the month. Cyclobenzaprine 5 mg twice daily, ordered as a muscle relaxant until 12/15/25, was not administered on the evening of 12/05/25, and gabapentin 400 mg by mouth four times daily was not signed off as administered on the evening of 12/05/25. During interview, the Administrator confirmed that daily weights were not obtained on the identified dates, that the ergocalciferol order had been transcribed incorrectly and the resident received three doses weekly since admission, and that cyclobenzaprine and gabapentin were not signed off for the evening shift on 12/05/25. The facility’s medication administration policy requires medications to be administered as ordered by the physician and documented on the MAR after administration.
Failure to Update Care Plan for Code Status Change
Penalty
Summary
The facility failed to revise a resident's care plan to reflect a change in advanced directive orders. Resident #12, who had diagnoses including end stage renal disease, polyneuropathy, and hypertension, was admitted with intact cognition. The resident's care plan, initially indicating a full code status, was not updated after the resident changed their code status to Do Not Resuscitate Comfort Care (DNRCC) on 08/14/24. This change was documented in the physician orders and a DNR order form dated 08/15/24. However, the care plan, last revised on 10/26/23, did not reflect this significant change. An interview with an LPN confirmed the care plan had not been updated to reflect the resident's new code status, contrary to the facility's policy requiring updates for significant changes in resident condition.
Failure to Obtain and Document Physician Orders for Wound Care
Penalty
Summary
The facility failed to timely obtain physician orders for a wound dressing change and complete wound dressing changes as ordered for Resident #23, who was admitted with diagnoses including hypertension, chronic obstructive pulmonary disease, and depression. The resident had impaired cognition as per the quarterly Minimum Data Set assessment. On 08/22/24, a nursing progress note indicated that the resident was reported to have been bitten by something, resulting in a raised reddened area on the left forearm. A verbal order for Benadryl was given by the physician. However, on 09/02/24, a nurse's note revealed a new skin issue on the left forearm, and the physician was notified, but no response was documented. Subsequent wound assessments noted drainage and a skin tear on the left forearm. Observations on 09/03/24 revealed that the resident had a gauze dressing on the left forearm without a physician's order or documentation in the treatment administration record. A physician order for antibacterial ointment was later obtained on 09/03/24. On 09/04/24, an LPN removed an undated dressing and applied a new one without checking for a physician order or applying the ordered antibacterial ointment. The LPN later verified the absence of a dressing order and the omission of the ointment application. The Director of Nursing confirmed that a nurse had received wound care orders but failed to enter them, and emphasized the need for nurses to ensure orders are in place and documented before changing wound dressings.
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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 Fostoria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Shepherd Home | 1.6 mi | ★★★★★ | 1 | 0 |
| St Catherine's C C Of Fostoria | 1.7 mi | ★★★★★ | 16 | 0 |
| The Manor At Greendale | 11.4 mi | ★★★★★ | 0 | 0 |
| The Willows At Tiffin | 12.1 mi | ★★★★★ | 0 | 0 |
| Briar Hill Health Campus | 12.5 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.