Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 Samaritan Care Center And Villa during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to label and date multiple refrigerated food items, including cooked vegetables, soups, beverages, cheeses, meats, salads, desserts, and baked goods. During an observation with the Dietary Manager, numerous containers and packages in the refrigerator were discovered without any date markings, and the Dietary Manager acknowledged that staff from the previous shift had not labeled or dated the food. Review of the facility’s food safety policy showed that all opened or prepared foods must be clearly date-marked by the person opening or preparing them, and that the Dietary Manager or designee must perform weekly spot checks for compliance. This noncompliance affected food items that could be served to all residents.
The facility did not maintain appropriate hot water temperatures in several resident rooms, as evidenced by resident reports of cold sink water and temperature checks showing water at 101–104°F after running for several minutes. One resident stated her room water had not been hot since admission and that she had previously informed staff. Review of tap water temperature logs over multiple months showed repeated low readings in multiple rooms on the same hall, indicating an ongoing failure to ensure safe, comfortable water temperatures for residents.
The facility failed to provide safe assistance during care and transfers for two high fall-risk residents, leading to falls. One resident with severe cognitive impairment, COPD, dementia, abnormal gait, and muscle weakness, who was dependent for mobility and transfers, was left unattended on her side in an elevated bed while a CNA left the room to obtain supplies after moving the bedside floor mat away; the resident turned and fell from the bed, sustaining a forehead laceration requiring sutures. Another resident with hemiplegia, dysphagia, muscle weakness, CHF, obesity, and moderate cognitive impairment, who was dependent for chair-to-bed transfers, was transferred using a sit-to-stand lift by a single CNA instead of the required assistance, causing the resident to slide out of the device, though without injury. In both cases, facility documentation identified improper supervision and failure to follow safe transfer techniques as the root causes of the falls.
Surveyors found that the facility failed to honor documented food preferences and allergy restrictions for two residents. One resident, with multiple behavioral and medical diagnoses, was served rice despite a recorded dislike and reported frequently receiving tomato-based items that upset her stomach. Another resident, with COPD and an allergy to raw onions, was served sautéed peppers and onions even after dietary staff verbally reminded each other to avoid onions, and the resident reported repeatedly receiving onions, mayonnaise, and sour cream despite stating he did not want them.
Surveyors found that food stored in both a shared nutrition refrigerator and in personal room refrigerators was not consistently labeled, dated, or disposed of when expired. Expired and unlabeled items, including nutritional shakes, yogurts, salads, and other food products, were observed in both common and personal refrigerators. These deficiencies were confirmed by the ADON during inspection and were not in accordance with facility policy.
A resident with severe cognitive impairment and multiple medical conditions developed new skin abrasions, but the facility failed to notify the resident's responsible party of this change in condition. Despite ongoing guardianship proceedings and facility policy requiring notification, the next of kin was not informed, and communication with the family was reported as inadequate.
Two residents did not have complete care plans addressing all their assessed needs. One resident with PTSD did not have a care plan for this diagnosis despite exhibiting related behaviors, and another resident with significant physical and cognitive needs did not have an activities care plan, even though their preferences and interests were documented. Staff confirmed these omissions during interviews.
A resident with a chronic wound requiring enhanced barrier precautions did not receive proper infection prevention measures during high-contact care activities. Staff provided bed bath, dressing, and transfer assistance without consistently using gowns as required by facility policy and physician orders, resulting in a failure to maintain appropriate infection control protocols.
A resident with multiple chronic conditions received Macrobid for UTI prophylaxis on a non-standard schedule due to a misinterpreted physician order. Despite discrepancies noted by pharmacy staff and the facility's policy requiring medication review, the antibiotic was administered inappropriately over several months without clarification.
Multiple residents experienced ongoing gnat infestations in their rooms, bathrooms, and common areas, with staff and dietary personnel also reporting insect activity in food service equipment. Despite attempts by housekeeping and maintenance to address the issue with chemicals and traps, the infestation persisted, and pest control service reports did not document fly activity during inspections.
Failure to Label and Date Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in food labeling and dating practices in the facility’s kitchen refrigerator, which had the potential to affect all 38 residents. During an observation and interview with the Dietary Manager, multiple food items were found in the refrigerator without any labels or dates, including two containers of mushrooms, a plastic container of cooked vegetable mix, peaches, potato soup, a pitcher of tea, a pitcher of lemonade, a plastic package of cheese slices, a plastic container of cooked steak for Philly cheese steak, a plastic container of chicken salad, a plastic container of Jell-O, a container of muffins, a bag of shredded cheese, and a plastic container of chili. The Dietary Manager confirmed these items were not labeled or dated and stated she had not worked the previous night and that the night staff had failed to label or date the food. Review of the facility’s 2025 “Date Marking for Food Safety” policy showed that all opened or prepared foods must be clearly marked with the date of opening and the date by which they must be consumed or discarded, and that the individual opening or preparing the food is responsible for date marking at that time, with the Dietary Manager or designee required to spot check the refrigerator weekly for compliance and document accordingly. This failure to follow the facility’s date-marking policy for multiple refrigerated food items constituted the basis of the cited deficiency.
Failure to Maintain Appropriate Resident Tap Water Temperatures
Penalty
Summary
The facility failed to maintain resident tap water at appropriate temperatures, resulting in persistently cool water in certain resident rooms. One resident reported during interview that the water in his bathroom sink was cold, and another resident stated that the water in her room had not been hot since her admission in September 2025 and that she had previously informed staff about the issue. During an interview and observation with the Maintenance Director on February 11, 2026, water temperatures measured after running for three minutes were 101°F in an occupied room and 102°F in an unoccupied room on the same hall. Review of the facility’s Tap Water Temperature Checks from July 2025 through January 2026 showed that in August 2025 the water temperature in one room was 101°F, and in January 2026 water temperatures in three rooms on the same hall were recorded at 101°F, 103°F, and 104°F. These findings demonstrate that the facility did not ensure water temperatures were maintained at appropriate levels for residents on the 100 Hall. This deficiency represents non-compliance investigated under Complaint Number 2722647 and affected one identified resident, with the potential to affect all six residents on the 100 Hall.
Failure to Provide Safe Assistance During Transfers and Bed Care Resulting in Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents at high risk for falls were provided safe assistance during care, resulting in falls. One resident with COPD, emphysema, dementia, abnormal gait and posture, muscle weakness, and severe cognitive impairment was assessed as dependent for bed mobility, transfers, and mobility, and identified as high risk for falls. Her care plan included use of a bedside floor mat and placement in supervised areas during restlessness. Despite these needs and interventions, the resident experienced multiple falls, including a witnessed fall in which she was left unattended on her side in bed with the bed elevated while a CNA left the room to obtain a clean brief, after having moved the bedside floor mat away to dry. During this incident, the CNA changed the resident’s brief, placed it on the bedside floor mat, then cleaned and moved the mat aside to dry. The CNA then left the bedside to get a clean brief while the resident remained on her side in bed with the bed elevated and without the floor mat in place. The resident turned and fell out of bed, sustaining a 4 cm laceration to the right forehead that required sutures. Facility documentation of the fall investigation identified that the resident had been left unattended inappropriately and that the root cause of the fall was the CNA leaving the resident on her right side with the bed elevated. A second resident, with diagnoses including cerebral infarction with hemiplegia, dysphagia, muscle weakness, CHF, osteoarthritis, obesity, hypotension, hypertension, and moderate cognitive impairment, was also assessed as dependent for chair-to-bed transfers and at high risk for falls. Her care plan included anticipating and meeting needs, ensuring the call light was within reach, encouraging non-slip footwear, and keeping commonly used items within reach. Despite this, a CNA used a sit-to-stand lift alone to transfer the resident, contrary to the required assistance and technique, resulting in the resident sliding out of the sit-to-stand device. The fall investigation identified that the sit-to-stand lift had been operated by only one person, and this was documented as the root cause of the fall, although the resident did not sustain injuries.
Failure to Honor Resident Food Preferences and Allergy Restrictions
Penalty
Summary
The deficiency involves the facility’s failure to provide food that met documented resident preferences and allergies for two residents out of three reviewed for food preferences, in a census of 38. For one resident admitted with multiple diagnoses including post-traumatic stress disorder, alcohol use, major depressive disorder, generalized anxiety disorder, history of traumatic brain injury, convulsions, anemia, essential hypertension, vitamin D deficiency, and insomnia, the food preference and allergy sheet documented numerous dislikes, including any type of tomato products and rice. During observation of the lunch tray line, this resident was plated rice despite the tray card indicating rice as a disliked item, which was confirmed by the Dietary Manager and another staff member. In interview, the resident reported that tomatoes upset her stomach and that she often receives tomato-based soups or spaghetti sauce, which she does not eat when they are served. For a second resident admitted with diagnoses including chronic obstructive pulmonary disease, emphysema, acute chronic respiratory failure, anxiety disorder, essential hypertension, and major depressive disorder, the food preference and allergy sheet documented an allergy to raw onions and dislikes of tomatoes or tomato products and yogurt. During observation of the lunch tray line, the Dietary Manager reminded a staff member not to give this resident sautéed peppers and onions, and the resident’s tray card showed an allergy to raw onions. Despite this, the plated meal for the resident included sautéed peppers and onions, which was confirmed by the Dietary Manager and the staff member. In interview, the resident stated he keeps receiving onions despite telling staff multiple times he did not want them and also reported repeatedly receiving mayonnaise and sour cream, which he does not like. This deficiency was investigated under Complaint Number 2722647.
Failure to Properly Label, Date, and Dispose of Expired Food in Resident Refrigerators
Penalty
Summary
The facility failed to ensure that food stored in both a designated nutrition refrigerator for resident use and in personal refrigerators in residents' rooms was properly labeled, dated, and that expired items were disposed of in a timely manner. During an observation with the Assistant Director of Nursing, multiple expired, unlabeled, and undated food items were found in the shared nutrition refrigerator, including a nutritional shake past its use-by date, an unlabeled and stale breadstick with red sauce, an unidentified liquid with separated particles, a visibly wilted and moldy side salad, several yogurts past their use-by dates, and a partially eaten baked potato with mold. These findings were confirmed by the ADON at the time of observation. Further inspection of five residents' personal refrigerators revealed additional concerns, such as expired cream cheese spread, protein shake, yogurts, rice pudding, and an opened, undated jar of pickles past its use-by date. The facility's policy requires all food brought in by family or visitors to be labeled with content and date, and for prepared food to be consumed within three days or discarded. The failure to follow these procedures was confirmed during the observations, affecting three of five residents reviewed for personal refrigerators and potentially impacting all residents using facility refrigeration for personal food items.
Failure to Notify Responsible Party of Change in Resident Condition
Penalty
Summary
The facility failed to notify the responsible party of a resident's change in condition. Specifically, a resident with multiple complex medical diagnoses, including diabetes with a foot ulcer, cognitive impairment, and a history of traumatic brain injury, was found to have new skin abrasions. Although the facility's records indicated that management and the physician were updated, the documentation stated the resident was his own responsible party, despite a severely impaired cognition score (BIMS of 2) and ongoing guardianship proceedings. Interviews revealed that the resident's spouse was not always informed of changes in the resident's care, and communication from the facility was described as inadequate. Facility policy required notification of a representative in cases where the resident was not competent or was in the process of obtaining guardianship. However, in this instance, the next of kin was not notified of the change in condition, contrary to policy and regulatory requirements.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with diagnoses including bipolar disorder, acute respiratory failure, PTSD, anxiety, and type II diabetes, the care plan addressed mood and behavior issues but did not include interventions for the resident's PTSD, despite this diagnosis being present in the medical record. Observations and staff interviews confirmed the resident exhibited behaviors such as yelling, crying, and distress related to past events, and that redirection and spending time with the resident were effective, yet no care plan for PTSD was in place. For another resident with acute respiratory failure, hemiplegia, hemiparesis, and general anxiety disorder, the care plan did not address activities, even though assessments indicated the resident's preferences for reading, music, and being around pets, as well as a tendency to prefer self-directed leisure activities. The Activities Director confirmed that an activities care plan was never developed for this resident following admission. These omissions were identified through medical record review and staff interviews, and were not in accordance with the facility's policy requiring comprehensive, person-centered care plans for all residents.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to maintain infection prevention protocols for a resident who required enhanced barrier precautions due to a chronic wound. The resident, who had multiple diagnoses including diabetes with a foot ulcer, malnutrition, cognitive impairment, and an above-knee amputation, had a physician order requiring the use of gown and gloves during high-contact care activities. Observations revealed that a CNA provided bed bath and dressing care, and assisted with transferring the resident using a hoyer lift, while only wearing gloves and a mask, but not a gown as required. The CNA stated she believed gowns were only necessary if wounds were seeping, which was not the case for this resident at the time. An LPN wore a gown and gloves for wound care but removed the gown in the room after the resident refused care. Interviews with staff confirmed that gowns were not consistently used during all high-contact care activities, contrary to facility policy, which requires gowns and gloves for such activities for residents with wounds, regardless of wound drainage. The Director of Nursing acknowledged the requirement for gowns and gloves during high-contact care and indicated a need for staff re-education. Review of facility policy confirmed the expectation for PPE use during specified care activities for residents on enhanced barrier precautions.
Failure to Ensure Appropriate Antibiotic Prescribing and Administration
Penalty
Summary
The facility failed to ensure that antibiotics were appropriately prescribed and administered with the correct indication, dose, and duration for a resident. The resident, who had multiple diagnoses including chronic obstructive pulmonary disease, anxiety, type II diabetes, atrial fibrillation, and peripheral vascular disease, was admitted with a hospital discharge order for Macrobid 100 mg. The facility's physician order specified Macrobid 100 mg to be given twice daily every ten days for urinary tract infection prophylaxis. Review of the Medication Administration Record showed that this regimen was followed from November 2024 through June 2025. Interviews with clinical staff revealed discrepancies and confusion regarding the intended dosing schedule. The Certified Nurse Practitioner stated he would not have written such an order, and pharmacists noted the order did not match standard therapeutic regimens or FDA-approved dosages for UTI prophylaxis. The pharmacists also indicated that the order should have been clarified, but no such recommendation was made during monthly pharmacy reviews. The facility's policy required staff to compare the MAR to the medication and consult drug references if unfamiliar, but this was not followed, resulting in the continued administration of an inappropriate antibiotic regimen.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent gnat infestation affecting multiple residents and areas within the building. Observations revealed that several residents had tiny flying insects swarming around their faces, meals, and bathrooms, with one resident reporting the issue had persisted for weeks. Staff interviews confirmed awareness of the problem, with housekeepers and maintenance staff attempting to address the infestation using chemicals, traps, and homemade remedies. Despite these efforts, the presence of gnats continued in resident rooms, bathrooms, the shower area, and even in the dietary meal cart, as noted by both staff and residents. Documentation review showed that pest control service reports did not identify fly activity during their inspection, and maintenance requests had been made regarding fly infestations. Staff interviews indicated uncertainty about the pest control company's involvement in addressing the issue, and the problem was reported to have been ongoing since at least April. The deficiency affected at least seven residents directly and had the potential to impact all residents in the facility.
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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 Medina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avenue At Medina | 0.2 mi | ★★★★★ | 11 | 0 |
| Medina Center For Rehabilitation And Nursing | 0.5 mi | ★★★★★ | 1 | 0 |
| Medina Bsd Opco Llc | 1.4 mi | ★★★★★ | 14 | 1 |
| Champion Creek Health And Rehabilitation | 2.2 mi | — | 0 | 0 |
| Western Reserve Masonic Comm | 2.4 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.