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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Ridge Skilled Nursing And Rehab during CMS and state inspections, most recent first.
Kitchen sanitation and food storage failures were observed throughout the facility. Staff found unlabeled and undated food items in refrigerators, missing thermometer and temperature log documentation, and a three-compartment sink that was not registering sanitizer. Staff also observed improper food handling during pureed food preparation and dishwashing, along with heavy debris buildup in kitchen ceiling vents and soiled resident refrigerators containing expired or improperly stored items.
The facility failed to keep kitchen garbage sealed when three garbage cans that were not in active use were observed uncovered during repeated kitchen observations. The Administrator verified the cans should have been covered, and the facility policy required garbage containers to have tight-fitting lids and remain covered when stored or not in continuous use. The issue was cited as non-compliance affecting residents who received food from the kitchen.
Essential kitchen equipment was not kept in good working condition. A large kitchen refrigerator had standing water on the bottom shelf and water dripping from the top onto covered food, and a resident refrigerator freezer had heavy ice buildup with a splintered gasket that did not attach well. The ADON and Maintenance Director both verified the equipment problems, and the MD stated the refrigerator was not working properly and needed repaired.
Dining room dignity was not maintained for two residents who needed help with eating. One resident with severely impaired cognition and partial to moderate eating assistance needs, and another resident with dementia, Parkinson’s disease, and severely impaired cognition, were served meals while staff left plates, cups, utensils, and other items on the trays and assisted them while standing or sitting beside them. An LPN and a CNA both described this as normal practice, and the ED confirmed staff were supposed to remove all items from the tray and place the empty tray on the cart.
A resident with multiple medical conditions, including malnutrition, was readmitted from the hospital with an order for Nutren 2.0 tube feeding. The facility did not enter the tube feeding order into the medical record or provide the prescribed nutrition, as the ordered formula was not available and no alternative was used, despite facility policy allowing for basic formulary products until specialized products could be delivered.
The facility failed to maintain food safety and sanitation standards, affecting all 47 residents. Observations revealed a black and gray fuzzy substance on a kitchen dehumidifier, a black substance on the kitchen floor, and improper storage of raw bratwurst in the freezer. Additionally, a fly was found on an uncovered piece of cake on a food cart. These issues were confirmed by the Dietary Supervisor and an LPN.
A resident's privacy was compromised due to an incomplete privacy curtain in their shared room, leaving a two-foot gap that exposed them to their roommate. The resident, who was cognitively intact and had a complex medical history, expressed dissatisfaction with the lack of privacy. The DON confirmed the deficiency, which violated the facility's dignity policy requiring protection of resident privacy.
Two residents did not receive their prescribed diabetes medications due to unavailability, and the facility failed to notify their providers and families. One resident with heart failure and diabetes did not receive Ozempic, while another with multiple conditions missed doses of Trulicity. Documentation lacked evidence of required notifications, contrary to facility policy.
The facility failed to develop comprehensive care plans for two residents, one with multiple medical conditions including heart failure and diabetes, and another with hearing impairment. The care plans did not address these critical health issues, as confirmed by the DON.
The facility failed to administer prescribed Ozempic injections to a resident due to an error in the electronic ordering process, resulting in the medication being unavailable from the pharmacy. Despite the facility's policy requiring contact with the pharmacy and documentation when medications are unavailable, this was not done until the ADON intervened.
The facility failed to post required signage for two residents under transmission-based and enhanced barrier precautions. One resident with C-diff had no signage despite having a PPE bin outside the room, and another resident with a JP tube post-surgery also lacked signage, contrary to facility policies.
Kitchen sanitation and food storage failures
Penalty
Summary
The facility failed to maintain kitchen sanitation and to provide meals in a sanitary manner. During an initial kitchen tour, an opened undated package of donuts, an unwrapped plate of food with no date or label, two large pans of undated and unlabeled gelatin dessert, and a plate of sliced tomatoes without a date were observed in the reach-in refrigerator. The refrigerator and deep freezer had no thermometers inside, and the upright freezer had a heavy buildup of white frost on the shelves and interior surfaces. Six wrapped sandwiches were dated 06/22/25. Review of records showed missing temperature documentation for three refrigerators and freezers on multiple dates in June 2026, and the three-compartment sink sanitation logs had no documentation from 06/05/26 through 06/29/26. When tested with the Administrator present, the three-compartment sink registered no sanitizing indication, and the Administrator verified there was no documentation that it had been tested since 06/04/26. The dishwasher log also showed missing documentation from 06/18/26 through 06/30/26, and the posted directions indicated the dishwasher was a low-temperature machine requiring a rinse cycle temperature of 120 degrees Fahrenheit and a chlorine sanitizer level of 50 to 100 PPM. Staff observations showed unsafe food handling and cleaning practices. One staff member preparing pureed foods reassembled a blender blade into the bowl with bare hands and then continued pureeing food. Another staff member loaded dirty pans into the dishwasher and removed clean pans without sanitizing or changing gloves between tasks. Additional observations found eight kitchen ceiling vents with heavy gray debris over food preparation areas. In resident refrigerators, one contained thickened juice dated 06/15/26 and a brown substance coating the back of the refrigerator and pooling into the drawers, while another contained unlabeled staff lunch bags, uncovered food without labels or dates, and protein sandwiches with missing temperature log entries. Facility policies reviewed addressed dish machine temperatures, pot sink sanitizer testing, food brought in by family members, and daily refrigeration temperature recording.
Uncovered Kitchen Garbage Containers
Penalty
Summary
The facility failed to ensure kitchen garbage was sealed. During an initial kitchen tour, three garbage cans that were not actively in use were observed uncovered. The Administrator verified that the three kitchen garbage cans were not actively in use and should have been covered. On two later observations, three garbage cans that were not actively in use were again verified as uncovered. Review of the facility policy titled Garbage and Rubbish Disposal stated that all garbage containers shall be provided with tight fitting lids and must be kept covered when stored or not in continuous use. The deficiency was cited as non-compliance under Complaint Number 3053748 and was identified as affecting 47 of 47 residents who received food from the kitchen.
Kitchen Refrigeration Not Maintained in Working Condition
Penalty
Summary
Essential kitchen equipment was not maintained in good working condition. During an initial kitchen tour and a later observation, the large three-door refrigerator had one quarter to one half inch of standing water on the bottom shelf and water dripping from the top, and bags of food were wet from the dripping water. On the 200 unit, a resident refrigerator freezer had a heavy one half inch build-up of white ice on the top and side surfaces, and the gasket around the freezer was splintered and did not attach well to the compartment. An ADON verified the freezer gasket was in disrepair and did not attach well, and the Maintenance Director verified the kitchen refrigerator had standing water in the bottom, water dripping from inside the top onto covered food, and that the refrigerator was not working properly and needed repaired. The facility policy stated maintenance would attempt repairs and use outside contractors if unable to complete them.
Dining Room Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure residents were treated with dignity during meals for two residents who required assistance with eating. Resident #37 had diagnoses including anxiety disorder, contracture of the left hand, chronic pain, and degeneration of the nervous system, and his MDS quarterly assessment showed severely impaired cognition and partial to moderate assistance needed for eating. Resident #49 had diagnoses including anxiety disorder, dementia, and Parkinson’s Disease, and her MDS comprehensive assessment showed severely impaired cognition and partial assistance needed for eating. During observation in the main dining room, nine residents were waiting for meals while a CNA and an LPN assisted with positioning and meal service. The CNA distributed meals by placing trays in front of residents and removing plates, cups, utensils, and other items from the trays, then returning to retrieve the next tray. Resident #49 was served by placing the tray in front of her, and the LPN sat beside her, opened her drink, inserted a straw, and began feeding her. The CNA placed a tray in front of Resident #37 and, while standing next to him, began feeding him; she then served two additional residents before returning to Resident #37 and continuing to feed him. The LPN stated she was there to assist and was unsure whether all residents needing feeding assistance were served meals on trays. The CNA stated she normally sits when assisting a resident with eating and confirmed it was normal for her to leave plates, cups, napkins, and flatware on the trays for residents who required feeding assistance. The Executive Director confirmed staff were to serve all residents in the same fashion by removing all items from the tray and placing the empty tray on the cart in the corner of the dining room.
Failure to Implement Tube Feeding Orders Upon Readmission
Penalty
Summary
The facility failed to implement tube feeding orders for a resident upon readmission from the hospital. The resident, who had diagnoses including COPD, major depressive disorder, anxiety disorder, and mild protein-calorie malnutrition, was readmitted with a hospital order for Nutren 2.0 tube feeding at a specified rate. However, there was no corresponding physician order for tube feeding entered into the resident's medical record upon return, and the Medication Administration Record did not document any tube feeding administration during the relevant period. The care plan identified the resident as being at moderate nutritional risk and included interventions to provide enteral feedings as ordered. Despite this, the Director of Nursing confirmed that tube feeding was not provided from the time of readmission because the facility did not have the prescribed formula available. Facility policy indicated that staff could use products from a basic formulary until specialized products could be delivered, but this was not done, resulting in the resident not receiving the ordered nutritional support.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain food items, a kitchen dehumidifier, and the kitchen flooring in a manner that prevents foodborne illness, affecting all 47 residents. During an observation of the kitchen, a black substance and a gray fuzzy substance were found on the dehumidifier, and a black substance was built up on the kitchen floor. Additionally, a frozen pack of raw bratwurst was improperly stored on a Styrofoam tray covered with plastic wrap in the freezer, placed next to a bag of frozen asparagus. These observations were confirmed by the Dietary Supervisor. Further inspection of the room tray food cart revealed that residents were served meals where the cake was left uncovered, allowing a fly to sit on it. This was verified by an LPN, who confirmed that the cakes were uncovered and a fly was present on a piece of cake. The facility's dietary policy, which was undated, stated that food should be prepared and served in a manner that meets the individual needs of each resident, indicating a failure to adhere to this policy.
Inadequate Privacy Curtain Compromises Resident's Privacy
Penalty
Summary
The facility failed to ensure adequate privacy for a resident, identified as Resident #20, by not providing a complete privacy curtain in their shared room. The deficiency was observed during a survey on November 12, 2024, when it was noted that the privacy curtain between Resident #20 and their roommate did not cover the entire track, leaving a gap approximately two feet wide. This gap compromised the resident's privacy, as they were partially viewable to their roommate. Resident #20, who was cognitively intact, expressed dissatisfaction with the situation, stating that the incomplete curtain did not provide sufficient privacy. Resident #20 had a complex medical history, including type two diabetes mellitus, congestive heart failure, hypothyroidism, hypertension, major depressive disorder, anxiety disorder, chronic kidney disease, insomnia, rheumatoid arthritis, cellulitis of the right lower limb, acute respiratory failure with hypoxia, and unspecified psychosis. The Director of Nursing confirmed the deficiency during an interview on November 13, 2024, acknowledging the gap in the privacy curtain. The facility's dignity policy, dated August 2009, mandates that staff promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment procedures, which was not adhered to in this instance.
Failure to Notify Provider and Family of Medication Unavailability
Penalty
Summary
The facility failed to ensure proper notification to the provider and family when medications were unavailable for administration as ordered, affecting two residents. Resident #42, who was admitted with diagnoses including acute on chronic diastolic heart failure, stage three chronic kidney disease, and type two diabetes, did not receive her prescribed Ozempic medication on multiple occasions. There was no documentation in the medical record indicating that the resident's family or provider was notified about the unavailability of the medication. Interviews with the resident and her daughter revealed uncertainty about the current status of the medication order, as they had not been informed of any discontinuation. Similarly, Resident #20, with a complex medical history including type two diabetes mellitus, congestive heart failure, and other conditions, did not receive her prescribed Trulicity medication on specified dates due to its unavailability at the facility. The Medication Administration Record and progress notes lacked documentation of any notification to the resident's physician regarding the missed doses. Interviews with the resident and the Director of Nursing confirmed the medication was not administered as ordered, and there was no record of physician notification. The facility's policy required notification of the physician and resident representative in cases of medication omission, which was not adhered to in these instances.
Deficiency in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and implemented for residents, affecting two out of eight residents reviewed. Resident #42, admitted with diagnoses including acute on chronic diastolic heart failure, stage three chronic kidney disease, and type two diabetes, did not have care plans addressing these medical conditions. The Director of Nursing (DON) confirmed the care plan's incompleteness during an interview. Resident #20, with multiple diagnoses such as type two diabetes, congestive heart failure, and hearing impairment, also lacked a care plan for hearing impairment. Despite being listed as having hearing impairment on the MDS, the care plan did not address this issue. The DON verified the absence of a care plan for hearing impairment, confirming the deficiency in the facility's care planning process.
Medication Administration Deficiency Due to Ordering Error
Penalty
Summary
The facility failed to ensure that medications were available and administered as ordered, affecting two residents out of five sampled for medication administration. Specifically, Resident #42, who was admitted with diagnoses including acute on chronic diastolic heart failure, stage three chronic kidney disease, and type two diabetes, did not receive the prescribed Ozempic injections for diabetes management. The medication was not administered on multiple occasions from September to November 2024 due to its unavailability from the pharmacy. Interviews and record reviews revealed that the failure to administer the medication was due to an error in the electronic ordering process. The Assistant Director of Nursing (ADON) confirmed that no nurse had contacted the pharmacy to resolve the issue until the ADON intervened. The facility's policy required that when medications with an active order were unavailable, the pharmacy should be contacted, and an explanatory note should be documented in the electronic health record. However, this procedure was not followed, leading to the deficiency.
Failure to Post Infection Control Signage
Penalty
Summary
The facility failed to ensure appropriate signage was posted for residents under transmission-based and enhanced barrier precautions, affecting two residents. Resident #201, who was admitted with diagnoses including chronic heart failure and diabetes, had physician orders for isolation precautions due to C-diff. However, during an observation, it was noted that there was no signage indicating transmission-based precautions outside the resident's room, despite the presence of a PPE bin. The Director of Nursing confirmed the absence of signage, which was against the facility's policy requiring a sign to be placed on the door or doorframe when isolation precautions are implemented. Similarly, Resident #6, who was readmitted with conditions such as insomnia and diabetes, was observed to have an infection control cart outside their room but lacked the necessary signage for Enhanced Barrier Precautions (EBP) due to a recent surgery with a JP tube. The Director of Nursing confirmed the resident was on EBP, and the facility's policy required signage to identify residents under such precautions. The absence of signage for both residents indicates a failure to adhere to the facility's infection control policies.
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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 Morrow
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedarview Care Center | 6.3 mi | ★★★★★ | 9 | 0 |
| Cedars Of Lebanon Care Center | 7.1 mi | ★★★★★ | 0 | 0 |
| Embassy Of Lebanon | 7.3 mi | ★★★★★ | 8 | 0 |
| Otterbein At Maineville | 7.4 mi | ★★★★★ | 1 | 0 |
| Continental Manor Nurs And Rehabilitation Center | 8.6 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 August 2026) and official state health department websites.