Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Christian Heights Nursing And Rehabilitation Cente during CMS and state inspections, most recent first.
A nurse misappropriated a resident’s metoprolol succinate ER 25 mg by removing it from that resident’s medication card and giving it to another resident who was out of the dose. The nurse stated this was normal practice, while the DON and Administrator stated borrowing medication from one resident for another was not approved.
Medication storage and controlled substance handling were deficient when the facility kept a resident’s oral Ativan in a medication cart drawer despite the carton labeling requiring refrigeration, and the medication storage room lacked a separately locked, permanently affixed compartment for controlled drugs. The DON stated the Ativan was kept on the cart because it did not require refrigeration, while an RN was unsure whether the liquid Ativan needed cold storage after opening; the Administrator stated medication should be refrigerated as specified on the storage instructions.
The facility failed to follow food safety standards, with improperly sealed and labeled food items, and inadequate temperature control for cold foods. Observations revealed uncovered and undated food, posing contamination risks. Staff interviews highlighted a lack of adherence to policies, compromising resident safety.
The facility failed to provide a functional, sanitary, and comfortable environment for residents, with issues such as broken tiles, peeling paint, and unsanitary conditions observed in multiple rooms. Residents expressed dissatisfaction, and the Maintenance Director acknowledged slow repairs due to funding constraints. Despite a cleaning schedule, the facility struggled to maintain cleanliness, as evidenced by dust, debris, and unsanitary conditions.
Misappropriation of Resident Medication During Pass
Penalty
Summary
The facility failed to protect residents from misappropriation of property when a nurse removed metoprolol succinate ER 25 mg from one resident’s medication card and gave it to another resident who was out of the medication. During medication administration on Hall 2, RN1 locked the cart, went to Hall 1 to obtain the medication cart keys from KMA3, then pulled the tablet from another resident’s card and placed it into the medication cup for the resident on Hall 2. The resident whose medication was taken, R38, had diagnoses including COPD, chronic pain syndrome, dysphagia, and essential hypertension. The resident who received the borrowed dose, R30, had diagnoses including COPD, schizophreniform disorder, anxiety disorder, and essential hypertension. RN1 stated that if someone was out of a medication, it was normal practice to get it from another resident, and that when the resident who loaned the medicine ran out, she would borrow medication from another resident. The DON stated that borrowing medication from another resident was not normal practice and that if a resident was out of a medication, staff should check the Pyxis, not administer the dose if unavailable, document it as not given, notify the physician, and use the refill function in the MAR. The Administrator also stated that borrowing medication from one resident for another was not approved by the facility.
Medication Storage and Controlled Substance Handling Deficiency
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles when the facility failed to keep a controlled substance in a separately locked, permanently affixed compartment and failed to store a medication under the temperature specified on its label. During observation of the medication storage room, the facility’s only medication storage area contained the Pixis system and three unlocked refrigerators. Although temperature logs for the refrigerators were reviewed and showed no concerns, there was no controlled substance affixed lock box inside the refrigerators, and no controlled drugs were found stored there. R29 had been prescribed Ativan for new comfort measures. The DON stated R29’s Ativan was kept on the medication cart because it did not require refrigeration, but observation of Hall 2’s Medication Cart 1 controlled substance drawer showed a zip-lock bag with a bright pink label stating “Refrigerate,” containing a single 30 mL bottle of oral Ativan in its carton. The carton label directed storage between 2 and 8 degrees Celsius. RN 1 stated she was uncertain whether the oral liquid Ativan required cold storage after opening, and the Administrator later stated medication should be refrigerated as specified on the storage instructions.
Food Safety and Temperature Control Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Food items in the kitchen were not properly sealed or covered, leading to potential contamination. Opened food items lacked necessary labeling, such as received, opened, and use-by dates, which are crucial for maintaining food safety. Additionally, the kitchen environment was not conducive to safe food preparation, with uncovered cookies left out under discolored vents, and cheese slices and shredded mozzarella cheese improperly stored in the refrigerator. Further inspection revealed issues in the dry pantry storage area, where Freezer 3 was soiled with food particles, and a box of frozen beef patties was left unsealed and undated. A bulk box of rice was also found uncovered, exposing it to possible contamination. Interviews with staff confirmed awareness of the facility's food safety policies, yet these were not being consistently followed, posing a risk of bacterial growth and cross-contamination. The facility also failed to maintain proper temperature control for cold food items during meal service. Cold foods, such as mayonnaise-based salads, were found to be above the required 41 degrees Fahrenheit, which could lead to bacterial growth. Staff interviews revealed a lack of awareness regarding the correct temperature for cold foods, indicating a need for further training. The failure to maintain appropriate food temperatures and adhere to labeling and storage policies compromised the safety and quality of food served to residents.
Facility Fails to Maintain Sanitary and Comfortable Environment
Penalty
Summary
The facility failed to maintain a functional, sanitary, and comfortable environment for 20 out of 57 residents. Observations revealed numerous issues, including broken and missing floor tiles, peeling paint, holes in walls, and unsanitary conditions in resident rooms. Specific rooms had chipped paint, gouge marks, and stains on floors, while others had strong odors of urine and food particles on the floor. Additionally, some rooms had broken tiles, crumbling walls, and discolored caulking around sinks. Interviews with residents indicated dissatisfaction with the condition of their living spaces, as they expressed a desire for repairs to be made. The facility's Maintenance Director acknowledged the issues, stating that repairs were being made slowly due to funding constraints and a preference to complete all repairs in one room before moving to another. The Maintenance Director also mentioned ongoing problems with a toilet that frequently became clogged, requiring daily attention. The Environmental Services Director provided a cleaning schedule, indicating that each room was scheduled for a monthly deep clean. However, the presence of dust, debris, and unsanitary conditions suggested that these measures were insufficient. The facility's Administrator expressed an expectation for a clean, comfortable, and homelike environment, but the observations and interviews highlighted significant deficiencies in meeting this standard.
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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 Pembroke
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Western State Nursing Facility | 7.9 mi | ★★★★★ | 3 | 0 |
| Christian Health Center | 9.8 mi | ★★★★★ | 7 | 0 |
| Elkton Nursing And Rehabilitation Center | 11.4 mi | ★★★★★ | 0 | 0 |
| Bradford Heights Nursing & Rehabilitation | 11.5 mi | ★★★★★ | 15 | 0 |
| Brigadier General Wendell H Gilbert Tn State Veter | 14.2 mi | ★★★★★ | 1 | 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.