Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 0 |
| Allen Oaks Nursing And Rehab Center | 15 mi | — | 0 | 0 |
| Savoy Care Center | 20.5 mi | — | 3 | 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.