Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Meadows At Osborn Park during CMS and state inspections, most recent first.
An LPN and RN observed multiple medication storage and security failures, including food kept in a med refrigerator without dates or labels, a tuberculin vial left in use beyond the 30-day discard period, and insulin pens for a resident that were not properly dated. Staff also left med carts unlocked and unattended, allowing access to medications.
A resident who required a mechanical lift with 2 staff per MD order was observed being transferred by 1 CNA alone, and the CNA confirmed this happened when staffing was short. The facility also had worn, frayed slings with unreadable tags, a sling with holes, and disposable slings that were being laundered and used with the wrong lift type, despite manufacturer instructions requiring inspection and proper sling-lift compatibility.
Incorrect pureed food portions were served to residents ordered on pureed diets. Menu review showed meatloaf was to be served in a three-ounce portion, but dietary staff were observed portioning pureed meatloaf with a scoop that resulted in four-ounce servings. The DON confirmed the menu portion should have remained three ounces even when the food was mechanically altered, and seven residents were identified as being on pureed diets.
Failure to Provide Routine Showers/Bathing: A resident with Parkinson's disease, impaired cognition, and dependence on staff for bathing did not receive routine showers as scheduled. Records showed the resident was supposed to be bathed twice weekly, but after one shower and one refusal, there was no documentation that bathing was offered on two other scheduled days before the next shower occurred. The resident stated he was lucky to get one shower a week and had to ask staff for one, while the RN confirmed the facility standard was twice-weekly showers or per resident preference.
Soiled Wheelchair Harness: A resident with MS, paraplegia, weakness, and urinary incontinence had a visibly soiled wheelchair safety harness. The resident stated it was embarrassing, and CNA and COTA observations later verified the harness remained soiled. The resident had intact cognition and required substantial to maximal assistance with personal hygiene.
Advance directive records were inconsistent for a resident with epilepsy, mild cognitive impairment, and chronic diastolic HF. The EMR listed the resident as DNR-CC, while the paper chart stated Full Code, and the care plan had no advance directive documentation. Staff interviews confirmed the conflicting records and showed uncertainty about who was responsible for updating the paper chart.
Failure to provide catheter securement was identified for a resident with an indwelling urinary catheter and diagnoses including obstructive and reflux uropathy. The resident stated she was allergic to the adhesive in the catheter securement devices and had not had a non-adhesive securement device for about two months; a CNA confirmed the catheter was not secured. CDC guidance reviewed by surveyors stated a catheter securement device should be used to anchor the catheter.
Oxygen Not Administered Per Physician Orders: The facility failed to administer oxygen per physician orders for two residents. One resident with CHF, COPD, and OSA was receiving O2 at 1.5 L NC instead of the ordered 1 L NC, and another resident with interstitial lung disease and COPD was receiving O2 below 2 L NC instead of the ordered 3 L NC to keep O2 sat above 96%. An LPN verified both observations, and the facility policy required oxygen to be given per MD orders.
A resident with Alzheimer's disease and lack of coordination used a bed rail, but the record did not show that alternatives to bed rails had been attempted. The resident's side rail assessment and MDS indicated cognitive impairment and need for supervision to moderate assistance with ADLs and mobility, and an observation found her resting in bed against the rail. The DON confirmed quarterly bed rail safety assessments were not documented, alternatives were not attempted, and the facility had no policy or procedure for safe bed rail use.
Controlled substance records did not match the actual lorazepam supply for a resident with generalized anxiety disorder and moderately impaired cognition. During cart observation, the controlled substance book showed 14 tablets while the medication card contained 13 tablets, and an LPN confirmed the discrepancy.
Staff failed to follow EBP for two residents with orders for targeted gown and glove use during high-contact care. A resident with MS and a history of E. coli/ESBL and another resident with traumatic amputation, osteomyelitis, and vascular dementia both had room signs indicating EBP, yet CNAs and an LPN provided dressing, brief changes, toileting assistance, and topical care without gowns; the staff later confirmed the omissions, and one CNA said she did not know EBP were needed for dressing care.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Medication Storage, Labeling, and Security Failures
Penalty
Summary
The facility failed to store and manage medications safely by allowing food items to be kept in the medication storage refrigerator and by leaving a tuberculin purified protein derivative diluted/aplisol vial in use beyond the 30-day discard timeframe. During observation of the medication storage room, an opened 16-ounce container of Marzetti ranch vegetable dip and an unopened Hillshire Farms snacking tray were found in the refrigerator without dates or labels identifying ownership. The same refrigerator also contained a one mL vial of Tuberculin Purified Protein Derivative Diluted/aplisol that had been opened on 11/11/25, was approximately one-half used, and had a manufacturer expiration date of February 2027. Staff interviews confirmed the food items were in the medication refrigerator and were not supposed to be stored there. The RN verified that the tuberculin vial should be discarded 30 days after opening. Review of the manufacturer insert and facility policies showed that Tuberculin Purified Protein Derivative Diluted/aplisol must remain refrigerated and be discarded 30 days after opening, and that medications should be segregated from foods such as fruit juices, applesauce, employee lunches, and activity refreshments. The facility also failed to properly date insulin pens for a resident. On the medication cart for rooms 201-222, a NovoLOG insulin flex pen for Resident #54 was marked opened on 04/21/26 and was approximately one-half used, while a Lantus insulin pen for the same resident was opened and approximately one-half used but had no opening date. The manufacturer inserts and facility policy stated both insulin pens must be discarded 28 days after opening. In addition, staff left medication carts unsecured: one LPN stepped away from a cart without locking it, and another medication cart at the 100-hall nurse station was observed unlocked and unattended, with the LPN confirming the medications were accessible to anyone.
Unsafe mechanical lift transfers and worn sling use
Penalty
Summary
The facility failed to ensure residents were transferred safely according to physician orders and failed to ensure staff monitored mechanical lift slings for signs of damage. Resident #65 had diagnoses including multiple sclerosis, paraplegia, muscle wasting and atrophy, and weakness, and was dependent on staff for transfers. His care plan and physician orders required transfer with a mechanical lift and two staff members, but on observation a CNA transferred him from his wheelchair to bed without another staff member present. The CNA confirmed she independently completed the transfer and stated that this occurred when the facility was short-staffed. The resident also confirmed he had been transferred by one staff member. The facility also failed to monitor the condition and use of mechanical lift slings. The Maintenance Director stated he did not monitor sling integrity and was unaware of where disposable slings in the facility came from. Observation in the laundry room revealed four slings that were frayed and worn, with two unreadable tags, and two disposable slings hanging on the clean side of the laundry room. The Laundry Supervisor stated there was no documentation for monitoring sling integrity and that laundry staff and CNAs were responsible for checking them. The Dietary and Environmental Manager also verified the slings were worn, frayed, and had faded or unreadable tags. Further observation showed Resident #65's sling had two holes near the head where the loops attached. A CNA demonstrated that disposable slings were being used with the facility's mechanical lift even though the sling had a clip and was meant for hospital lifts, and she described placing the lift's metal rod through the fabric portion of the sling. The EZ Way representative stated disposable slings were not to be laundered and should be discarded if washed, and that other brands of slings should not be used with EZ Way lifts. The report also noted that residents identified by the facility as requiring mechanical lifts included 39 residents.
Incorrect Pureed Food Portions Served
Penalty
Summary
The facility failed to serve the correct food portions of pureed foods to residents ordered on pureed diets. Review of the spring menu showed lunch on 06/23/26 included three ounces of meatloaf, and observation in the dietary area found a staff member preparing pureed meatloaf and initially planning to portion it with a half-filled two-and-a-half-ounce scoop. A subsequent observation showed the staff member using a full four-ounce scoop to portion the pureed meatloaf into bowls. The Dietary Manager confirmed that portion sizes were dictated by the seasonal menu, were the same regardless of mechanical alteration, and that the pureed meatloaf portion should have been three ounces. Record review showed residents #22, #32, #45, #60, #72, #74, and #104 were on a pureed diet.
Failure to Provide Routine Showers/Bathing
Penalty
Summary
The facility failed to provide routine showers/bathing for a resident who was dependent on staff for bathing assistance. Resident #64 was admitted with diagnoses including Parkinson's disease, major depressive disorder, weakness, anxiety, and muscle weakness. The quarterly MDS showed moderately impaired cognition and need for partial or moderate assistance with tub or shower transfers and bathing. The care plan identified an ADL self-care performance deficit related to impaired balance, limited mobility, and Parkinson's disease, with interventions stating the resident required moderate assistance from one to two staff members for bathing. Review of the shower sheets and EMR showed the resident was scheduled to receive showers on Tuesdays and Thursdays, but after receiving a shower on 06/04/26 and refusing one on 06/09/26, the resident did not receive another shower until 06/18/26. There was no documentation that bathing was offered on 06/11/26 or 06/16/26. The resident stated he was lucky to receive one shower a week and wanted at least two showers a week, and said he had to tell staff when he wanted a shower or they would not offer one. RN #315 verified the facility standard was for residents to receive showers twice a week or per resident preference, and the DON verified the shower pattern and stated she was unaware why the resident did not receive a shower during that time.
Soiled Wheelchair Harness
Penalty
Summary
The facility failed to ensure Resident #65 was treated with dignity when his wheelchair safety harness was visibly soiled. Resident #65 was admitted on 10/24/18 and had diagnoses including multiple sclerosis, paraplegia, muscle wasting and atrophy, weakness, and urinary incontinence. The quarterly MDS assessment noted intact cognition and that he required substantial or maximal assistance from staff for personal hygiene. His care plan identified an ADL self-care performance deficit related to multiple sclerosis, hemiplegia, and impaired balance, with interventions including a vest to encourage upright posture and square seating in the chair. During observation and interview on 06/22/26, Resident #65 stated that the soiled safety harness bothered him and was embarrassing. The harness was again observed to be visibly soiled on 06/23/26, 06/24/26, and 06/25/26, with CNA #390 and COTA #395 both verifying the condition. The facility policy titled Resident Rights and Facility Responsibilities stated that residents must be treated with respect and dignity and cared for in a manner and environment that promotes maintenance or enhancement of quality of life, recognizing each resident's individuality.
Advance Directive Records Were Inconsistent
Penalty
Summary
The facility failed to ensure Resident #86’s advance directives were accurate in both the paper chart and the EMR. Resident #86 was admitted with diagnoses including epilepsy, mild cognitive impairment, and chronic diastolic heart failure, and the annual MDS indicated moderately impaired cognition. The care plan contained no documentation regarding advance directives, while the EMR physician orders listed the resident as DNR-CC for advance directives. At the same time, the resident’s paper chart contained a document stating Full Code. During interview, an RN stated that in an emergency she would check the closest chart, whether paper or EMR, to determine the resident’s advance directives, and verified the conflicting DNR-CC and Full Code information. The RN stated updating the paper chart was a group responsibility, while the DSS stated she did not update the paper charts and that this was the responsibility of the nurses on the unit. The facility policy titled Advanced Directives stated staff would review and revise the advance directive if requested by the resident or responsible party.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
Failure to provide a resident with an indwelling urinary catheter with a means to secure the catheter was identified for Resident #107. The resident was admitted with diagnoses including obstructive and reflux uropathy, had intact cognition per the quarterly MDS, and required an indwelling catheter. The care plan documented the catheter was related to immobility and obstructive uropathy and included a goal of remaining free from catheter-related trauma through the review date. During observation and concurrent interview, Resident #107 stated she did not have a catheter securement device and reported she was allergic to the adhesive in the devices the facility had used. She stated the facility had not provided a non-adhesive catheter securement device and that she had not had a securement device for approximately two months. A CNA later verified the resident did not have a catheter securement device. CDC guidance reviewed by surveyors stated that a catheter securement device should be used to anchor the catheter to maintain unobstructed urine flow and prevent tugging and pulling.
Oxygen Not Administered Per Physician Orders
Penalty
Summary
The facility failed to ensure oxygen was administered according to physician orders for two residents. Resident #60 had diagnoses including systolic congestive heart failure, chronic pulmonary edema, COPD, and obstructive sleep apnea, and the care plan directed staff to administer oxygen via nasal cannula as ordered. The physician order specified oxygen at one liter via nasal cannula every shift, but during observation the resident’s oxygen was being administered at one and a half liters via nasal cannula, which was verified by an LPN. Resident #94 had diagnoses including interstitial pulmonary disease, COPD, dementia, parkinsonism, anxiety, and major depressive disorder, and the care plan directed staff to administer oxygen via nasal cannula as ordered. The physician order specified oxygen at three liters via nasal cannula to maintain oxygen saturation above 96%, but during observation the resident’s oxygen was being administered below two liters via nasal cannula, which was verified by an LPN. The facility policy titled Oxygen Therapy stated oxygen should be administered per physician orders.
Bed Rail Safety Assessment and Monitoring Deficiency
Penalty
Summary
The facility failed to ensure alternatives to bed rails were attempted and failed to provide ongoing monitoring and supervision for a resident who used a bed rail. Resident #1 was admitted with diagnoses including Alzheimer's disease and lack of coordination. Her side rail acknowledgement, signed by her representative on admission, stated the facility would not allow side rails unless there was a documented medical reason. A side rail assessment completed during the admission indicated the side rails did not enable her to turn and reposition independently, were not essential to prevent skin breakdown, were not used as an assistive device, and did not restrict her movement. Review of the quarterly MDS showed Resident #1 was cognitively impaired, did not exhibit behaviors or refusals of care, and required supervision to moderate assistance with ADLs and mobility. Her medical record did not contain documentation that alternatives to bed rails had been attempted. During observation, she was resting in bed against her bed rail. The DON confirmed there were no quarterly bed rail safety assessments documented, no documentation supporting attempts at alternatives to bed rails, and no facility policy or procedure regarding the safe use of bed rails.
Controlled Substance Count Did Not Match On-Hand Lorazepam
Penalty
Summary
The facility failed to ensure accurate accountability of controlled substances by maintaining controlled substance records that reconciled with the actual quantity of medication on hand. For Resident #87, who was admitted with generalized anxiety disorder and had moderately impaired cognition on the quarterly MDS, the physician ordered lorazepam 1 mg by mouth twice daily for anxiety and/or agitation. During observation of the medication storage cart for rooms 101-112, the controlled substance book count for Resident #87's lorazepam showed 14 tablets, while the medication card contained 13 tablets. An interview with the LPN at the time of observation confirmed the discrepancy between the controlled substance book count and the tablets present in the medication card.
Failure to Use EBP During High-Contact Care
Penalty
Summary
The facility failed to ensure staff used Enhanced Barrier Precautions (EBP) during high-contact resident care activities for residents with physician orders for EBP. Resident #51 had diagnoses including multiple sclerosis, generalized muscle weakness, and anxiety disorder, and was assessed as moderately cognitively impaired and dependent on staff for all functional abilities. A physician order dated 07/31/21 directed EBP every shift for a history of E. coli and ESBL. During observation, a sign outside the room indicated the resident was in EBP and that staff must clean their hands and wear gloves and a gown for high-contact care activities, including dressing, bathing, transferring, changing linens, hygiene, brief changes, toileting assistance, device care, and wound care. Despite this, CNA #500 entered the room to dress the resident and change her brief without a gown, and LPN #343 entered to assist with toileting, dressing, and applying topical cream to the resident’s labia without a gown. Both staff members later verified they provided this care without wearing gowns. Resident #74 had diagnoses including complete traumatic amputation of the right great toe, acute osteomyelitis, and vascular dementia, and had a physician order for EBP every shift for CDC guidelines. A sign outside the room indicated the resident was in EBP and that staff must clean their hands and wear gloves and a gown for high-contact care activities. However, CNA #332 entered the room to dress the resident and change her brief without first donning a gown, and CNA #366 later entered to assist with dressing and brief changes without a gown. Both CNAs verified they provided the care without gowns, and CNA #332 stated she did not realize EBP were necessary for dressing a resident and was not aware the resident was ordered to be in EBP. The facility policy and CDC guidance reviewed by surveyors described EBP as requiring gown and glove use during high-contact resident care activities for residents with MDROs or those at increased risk, including residents with wounds or indwelling medical devices.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
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Illustrative
What surveyors actually found near you
We read the 190 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Huron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkvue Health Care Center | 1.4 mi | ★★★★★ | 11 | 0 |
| Admirals Pointe Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| Ohio Veterans Home | 2.9 mi | ★★★★★ | 12 | 0 |
| Concord Care And Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Providence Care Center | 4.2 mi | ★★★★★ | 8 | 2 |
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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 October 2026) and official state health department websites.