The Gardens of St. Francis
930 South Wynn Road · Oregon, OH · 43616 · 4196984331
60 certified beds Non profit - Corporation Chain: Commonspirit Health Part of a CCRC
- Inspection results have improved across recent cycles.
Red flags
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
No standard inspection in over 2 years
The inspection record here is older than usual — conditions may have changed since.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.68 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.60 | 0.55–0.75 |
| Weekend hours / resident-day | 3.23 | ≈ weekday level |
| Nursing turnover / year | 50% | median 45% |
| Fines (3-yr window) | 1 · $45,250 |
Inspection citations (39 in the current record)
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Potential for harm · D March 7, 2024 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 8, 2024 · Pharmacy Service
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Actual harm · G February 1, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 8, 2024 · Quality of Life and Care
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Potential for harm · D February 1, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 8, 2024 · Resident Rights
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Potential for harm · D February 1, 2024
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected March 8, 2024 · Resident Rights
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Potential for harm · D February 1, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 8, 2024 · Quality of Life and Care
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Potential for harm · D February 1, 2024
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 March 8, 2024 · Quality of Life and Care
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Potential for harm · D February 1, 2024
Provide safe, appropriate pain management for a resident who requires such services.
Corrected March 8, 2024 · Quality of Life and Care
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Potential for harm · D February 1, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 8, 2024 · Pharmacy Service
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Potential for harm · D February 1, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected March 8, 2024 · Pharmacy Service
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Potential for harm · D February 1, 2024
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 March 8, 2024 · Pharmacy Service
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Actual harm · G October 11, 2023 · found via complaint
Ensure that residents are free from significant medication errors.
Corrected September 30, 2023 · Pharmacy Service
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Potential for harm · D September 8, 2021
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected October 15, 2021 · Resident Rights
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Potential for harm · D September 8, 2021
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected October 15, 2021 · Resident Rights
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Potential for harm · D September 8, 2021
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected October 15, 2021 · Resident Rights
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Potential for harm · E September 8, 2021
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.
Corrected October 15, 2021 · Resident Rights
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Potential for harm · D September 8, 2021
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected October 15, 2021 · Resident Rights
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Potential for harm · D September 8, 2021
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 October 15, 2021 · Resident Rights
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Potential for harm · D September 8, 2021
Ensure each resident receives an accurate assessment.
Corrected October 15, 2021 · Resident Assessment and Care Planning
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Potential for harm · E September 8, 2021
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected October 15, 2021 · Resident Assessment and Care Planning
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Potential for harm · D September 8, 2021
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected October 15, 2021 · Resident Assessment and Care Planning
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Potential for harm · D September 8, 2021
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected October 15, 2021 · Quality of Life and Care
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Potential for harm · E September 8, 2021
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 15, 2021 · Quality of Life and Care
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Potential for harm · D September 8, 2021
Assist a resident in gaining access to vision and hearing services.
Corrected October 15, 2021 · Quality of Life and Care
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Potential for harm · D September 8, 2021
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected October 15, 2021 · Quality of Life and Care
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Potential for harm · D September 8, 2021
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 15, 2021 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| February 1, 2024 | Fine | $45,250 |
| February 1, 2024 | Payment Denial | 7 days |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 366312 · certified since May 9, 2005. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.