Above 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 July 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.
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.
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 | ★★★★★ | 1 | 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 July 2026) and official state health department websites.