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A middle-range Medicare rating. Review each component and visit in person before deciding.
based on 105 Google reviews
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These current public-data fields deserve follow-up with the facility and the official Medicare record. They are not a clinical risk score or a substitute for an in-person assessment.
The Gardens of St. Francis has a middle-range Medicare overall rating. Strengths include beautiful, clean, and well-maintained facility. Some reviewers note concerns about neglect and lack of supervision in memory care leading to falls and injuries (mentioned by 2 reviewers). Review the health-inspection, staffing, and quality-measure components separately, then visit in person.
The Gardens of St. Francis is widely praised for its beautiful, clean, and well-maintained campus, with many families highlighting the compassionate and attentive staff. However, there are serious, recurring concerns regarding the quality of care in the memory care unit, specifically regarding fall prevention, timely medical intervention, and communication with families during emergencies. While many visitors have positive experiences, families of residents with dementia should exercise caution and conduct thorough due diligence.
Quality Themes
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Concerns
Rating Trends
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Distribution · 112 analyzed
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Key Review Excerpts
“My mom was a resident on the 3rd dementia unit for years they been understaffed and nobody does nothing with them just put the In their chairs and sit our mother has fallen many times unwatched for years she fell again and they covered it up”
“Throughout my husband's healthcare journey he has had occasion to be admitted to six different facilities in the Toledo area. After experiencing these facilities, I find The Gardens of St. Francis to be the best in the areas of cleanliness, care of patient, friendliness of staff, and concern for the patient.”
“The staff was very kind courteous and compassionate. The Activities Director~ Rosanne was always finding ways to keep my mom entertained when she wasn't busy doing therapy.”
Both RN and total nursing hours are below the EveryPlace reference benchmarks. Ask the facility how it staffs each shift for current resident needs.
Reference benchmarks (0.75 RN and 4.1 total nursing hours per resident/day) are comparison targets, not current federal minimum requirements.
Resident outcomes compared with national, state, and local averages · 17 measures
7
measures
8
measures
2
measures
Residents vaccinated for pneumonia
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents whose walking got worse
Residents needing more daily help over time
Residents on antipsychotic medication
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Detailed Medicare record · up to 3-year lookback
This facility shows concerning patterns with recurring problems across medication management, safety hazards, and resident care despite provider corrections. Families have filed complaints that led to federal investigations, including medication errors. The facility repeatedly struggles with medication management, accident prevention, and wound care across multiple years (2020-2024), suggesting systemic issues that persist even after supposed corrections, warranting careful consideration before placement.
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Smoke Deficiencies
Provide properly protected cooking facilities.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Miscellaneous Deficiencies
Have simulated fire drills held at unexpected times.
Miscellaneous Deficiencies
Have restrictions on the use of flammable curtains.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Smoke Deficiencies
Provide properly protected cooking facilities.
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies
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.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Infection Control Deficiencies
Perform COVID19 testing on residents and staff.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Nutrition and Dietary Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Miscellaneous Deficiencies
Have restrictions on the use of flammable curtains.
Federal Penalties
Fine
Feb 1, 2024
$45,250
Payment Denial
Feb 1, 2024
7-day denial
The Gardens of St. Francis
nonprofit
Commonspirit Health
19 facilities nationwide
Chain avg rating: 3.0/5 · Rank 8 of 19
Owners
Sylvania Franciscan Health
Owner · Organization
Commonspirit Health
Owner (parent company) · Organization
Lipsey, Prentice
Individual is an Owner, Partner or Trustee of Any Adp of the Snf
Key personnel
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