Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Friends Extended Care Center during CMS and state inspections, most recent first.
The facility failed to keep documentation of routine water system maintenance and Legionella-related activities. Records did not show that faucets in unoccupied rooms were flushed weekly or after rooms were unoccupied for more than 3 days, even though the written water control procedures required routine flushing, annual Legionella and ice machine testing, weekly whirlpool flushing, and annual cleaning or replacement of shower hoses and faucet aerators. The DOBS stated staff did flush faucets in unoccupied rooms, but there was no documentation identifying which rooms were completed, and the facility had been flushing unoccupied rooms weekly instead of every 3 days as written.
Kitchen stove fire due to accumulated debris. During lunch prep, flames were observed coming from under a gas stove burner while multiple burners were in use, and the DES extinguished the fire with a fire extinguisher. Staff said grease and debris had built up under the burners, and an earlier fire had occurred under the middle burners about a week before. The DOD stated there was no cleaning policy or cleaning log, and routine weekend cleaning did not include removing burner covers to clean beneath the burners.
Failure to document wound measurements and descriptions for a resident with buttocks/coccyx wounds. The record showed repeated references to cellulitis, an open sacral area, bruising, and later stage 3 pressure ulcers, but multiple nursing and skin notes lacked measurements and wound details. An LPN confirmed no measurements were documented on admission and that the wound NP did not assess the resident until later, when stage 3 pressure ulcers to the right buttocks and coccyx were documented.
Missing Documentation for Water System Maintenance and Legionella Procedures
Penalty
Summary
The facility failed to maintain documentation of all routine activities related to maintenance, testing, and treatment of water systems. Review of Legionella documentation showed no record supporting that maintenance flushed faucets in unoccupied rooms weekly or when rooms were unoccupied for more than three days. The facility’s written Monitoring Waterborne Organisms: Legionnaire’s Disease and Water Control Measures for Legionnaire’s Disease procedures stated that records of routine and special activities related to water systems would be completed, that Legionella testing and ice machine testing would occur annually, that rooms unoccupied for more than three days would have all fixtures flushed hot and cold for 15 minutes, that the whirlpool tub would be flushed every Wednesday, and that shower hoses and faucet aerated outlets would be cleansed or replaced annually. During interview, the Director of Building Services stated maintenance staff went to unoccupied rooms weekly and ran water from faucets as part of Legionella procedures, but there was no documentation showing which rooms were flushed. The Director also confirmed the procedure required unoccupied rooms to have all fixtures flushed every three days, while the facility had only done this weekly.
Kitchen Stove Fire Due to Accumulated Debris
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe, working condition when flames were observed coming from under the lower left burner on the gas stove during lunch preparation. Four of the six burners were in use at the time, and the Director of Environmental Services extinguished the fire with a fire extinguisher after the Dietary staff member called out that the stove was on fire. The census was 49 residents, and the deficiency was identified based on observation and staff interviews. During interview, the Dietary staff member stated the fire was caused by grease and other debris that had accumulated under the burners and said the stove had previously caught fire about a week earlier under the middle burners, which had been reported to the Director of Dietary. She stated she believed the stove should have been cleaned then, but was unsure whether that occurred. She also stated she had stopped using the middle burners after that earlier fire and was using the left and right burners instead. The Director of Dietary stated there was no policy for cleaning the stove and no log to document when it was cleaned, and that weekend cleaning had been limited to wiping burner covers and placing the under tray in the 3-sink sanitizer without removing the covers to clean beneath the burners where the fire originated.
Failure to Document Wound Measurements and Descriptions
Penalty
Summary
The facility failed to assess and document wound descriptions, including measurements, for a resident admitted with diagnoses including NSTEMI, acute on chronic combined systolic and diastolic CHF, acute respiratory failure with hypoxia, cellulitis of the buttock, and hypertension. The record showed the resident was cognitively intact and required partial assistance with toileting hygiene, bathing, bed mobility, and ambulation. Although the admission MDS later reflected a stage 3 pressure ulcer, the Skin Observation Tool on admission documented cellulitis to the right buttocks with no measurements, and the Continuity of Care Document from the hospital noted sepsis secondary to cellulitis involving the buttocks with no abscess. Skilled daily notes and nursing documentation repeatedly referenced cellulitis, a sacral wound, a surgical opening to the right wrist, bruising to the arms and forearm, and an open area to the coccyx, but several entries did not include wound measurements. The record further showed that a weekly skin assessment documented only pre-existing wounds without measurements, and a nursing note later stated no skin issues were noted. A skin note eventually documented an open area on the buttocks measuring 1.5 cm x 1.0 cm x 0.3 cm, and the wound NP later documented a stage 3 pressure wound to the right buttocks and a stage 3 pressure wound to the coccyx with measurements and tissue descriptions. During interview, the Director of Admission/LPN confirmed there were no wound measurements documented on admission for the buttocks wound, that no measurements were documented until the skin note on 02/02/26, and that the resident was not seen by the wound NP until 02/05/26 when the stage 3 pressure ulcers were identified. Observation of wound care on 02/18/26 showed the coccyx wound measured approximately 0.5 cm x 0.5 cm x 0.1 cm and the right buttocks wound measured approximately 1.5 cm x 1.0 cm x 0.2 cm with pink granulation tissue present. The facility wound care policy stated the facility would document wound type, date, time, wound bed color, size, and drainage.
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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 Yellow Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Community At Fairborn | 5.1 mi | ★★★★★ | 0 | 0 |
| Dayspring Of Miami Valley Hlth Care Center & Rehab | 5.9 mi | ★★★★★ | 0 | 0 |
| Wright Rehabilitation And Healthcare Center | 6.1 mi | ★★★★★ | 10 | 0 |
| Atrium Nursing And Rehabilitation | 6.8 mi | ★★★★★ | 8 | 0 |
| Alpine Nursing And Rehabilitation Center | 6.9 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.