Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avenue At Medina during CMS and state inspections, most recent first.
The facility failed to safeguard resident medications and ensure professional standards of practice when an LPN diverted multiple non‑narcotic medications belonging to several residents, many with impaired cognition and complex medical conditions. Pharmacy and law enforcement investigations found numerous patient‑specific blister packs, pill bottles, and a transdermal patch in the LPN’s possession that had been removed from the facility without detection or reporting. Although an investigator met with the Administrator and DON and confirmed that the medications were tied to current and former residents, the Administrator did not submit a self‑reported incident, and the DON reported limited knowledge of the situation. This occurred despite a written policy requiring reporting and thorough investigation of misappropriation of resident property, including diversion of medications.
Inaccurate MDS coding affected three residents. One resident was incorrectly coded as receiving insulin when the record showed a one-time antibiotic injection, another was coded as receiving a hypnotic despite no such order or use during the look-back period, and a third resident’s annual MDS failed to reflect a fall with major injury documented in the medical record. The residents had diagnoses including major depressive disorder, anxiety disorder, hypotension, and Alzheimer's disease.
Failure to obtain ordered urine laboratory tests for a resident with major depressive disorder, anxiety disorder, and hypotension. After the resident had amber urine and an abnormal dipstick, the physician ordered a UA and C&S, but the tests were not completed as ordered. The DON later stated the order was discontinued after the hematuria stopped, and the Regional Nurse confirmed the UA C&S was never completed.
A resident with severe cognitive impairment and diagnoses including Alzheimer’s disease had POA consent for the COVID vaccine, witnessed by two nurses, but the vaccine was not given. An MDS nurse confirmed there was no documented evidence of administration or refusal.
Two residents experienced falls without comprehensive post-fall assessments or individualized interventions. One resident, with a history of joint replacement and Parkinsonism, fell after activating the call light, but only a 'call not fall' sign was placed. Another resident, with severe cognitive impairment, had multiple falls without proper documentation or follow-up assessments. The facility's failure to conduct timely assessments and update care plans contributed to the deficiency.
A resident with spinal stenosis and functional quadriplegia experienced significant pain that was not effectively managed by the facility. Despite having a care plan, the facility failed to conduct timely pain assessments or notify the physician when interventions were ineffective. Staff interviews revealed inconsistencies in pain management practices, and the facility's policy on pain management was not adequately followed.
The facility failed to ensure proper infection control measures, as staff did not use PPE or follow hand hygiene protocols for two residents on contact precautions. A resident with possible C-Diff lacked appropriate signage, leading to staff entering without PPE. Another staff member handled soiled linens without gloves and entered a resident's room without washing hands. These deficiencies risked infection transmission.
A facility failed to ensure a resident's pressure ulcer dressing was maintained as ordered. The resident, with severe cognitive impairment and a left heel DTI, was observed without the required dressing, despite records indicating treatment was completed. An LPN confirmed the dressing was missing, suggesting it may have come off, contrary to the facility's skin care policy.
A facility failed to provide a resident with the required fluids on their meal tray, as specified in the meal ticket. The resident, with severe cognitive impairment and specific dietary needs, did not receive the necessary two-handled spouted sippy cup and nectar thick water during breakfast, as confirmed by the Activity Director.
Failure to Safeguard and Report Diversion of Resident Medications
Penalty
Summary
The deficiency involves the facility’s failure to safeguard resident medications and ensure services met professional standards of quality when an LPN diverted non‑narcotic medications belonging to multiple residents without the knowledge of facility administration. Record review showed that ten residents, most with impaired cognition and multiple medical diagnoses, had prescribed medications documented on their MARs, including hydroxyzine for anxiety, several antibiotics (Macrobid, cephalexin, cefadroxil) for treatment or prophylaxis, Levsin as needed, prednisone daily, and a scopolamine patch. These medications were ordered and recorded as being administered over various time frames, but were later found in the possession of the LPN outside the facility. A State Board of Pharmacy investigation, initiated after notification from local law enforcement, determined that the LPN had 31 blister packs of various medications, two pill bottles containing white powder, and one transdermal patch, all identified as patient‑specific medications belonging to approximately 20 residents, including the ten residents cited in the deficiency. The medications were able to be removed from the facility without anyone noticing or reporting the theft. An email from the Pharmacy Board to the DON on the date of the investigation stated that a former employee was found in possession of numerous patient‑specific medications and that these medications had been removed from the facility without detection or reporting to the Board of Pharmacy. Interviews with facility leadership showed that administration did not recognize or act upon the diversion as a reportable incident involving misappropriation of resident property. The Administrator stated that when the Pharmacy Board investigator came to the facility, she was not given resident names or specific medications and therefore did not complete a self‑reported incident to the State agency, and she left the meeting believing the diversion had occurred at another facility. The DON, hired after the diversion period, reported she had been kept in the dark about the investigation and could not provide adequate information. These actions and inactions occurred despite a facility policy on Abuse Prohibition, revised in 2022, which required that allegations of misappropriation of resident property, including diversion of resident medications, be reported and thoroughly investigated.
Inaccurate MDS Coding for Medications and Fall History
Penalty
Summary
The facility failed to code resident Minimum Data Set (MDS) assessments accurately for three residents reviewed. Resident #2 was admitted with diagnoses including major depressive disorder, anxiety disorder, and hypotension. In the admission MDS, he was coded as receiving one shot injection and one dose of insulin, but the medical record showed no insulin orders. MDS Nurse #139 stated that the injection was actually a one-time antibiotic dose that had been marked as insulin in error. Resident #8 was admitted and later readmitted with diagnoses including major depressive disorder, anxiety disorder, and Alzheimer's disease. The admission MDS coded her as receiving a hypnotic, but the medical record did not show an order for a hypnotic medication, and MDS Nurse #139 verified that she did not receive a hypnotic during the look-back period. Resident #43 was admitted with diagnoses including major depressive disorder, pruritus, and Alzheimer's disease. Her annual MDS did not reflect a fall with major injury in Section J, although the medical record showed she sustained a fall on 12/05/26, and MDS Nurse #139 verified that the annual MDS should have reflected that fall with major injury.
Failure to Obtain Ordered Urine Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory tests were obtained per physician's order for one resident. Resident #2 was admitted with diagnoses including major depressive disorder, anxiety disorder, and hypotension, and the admission MDS showed the resident was moderately cognitively impaired and required moderate assistance with ADLs. After the resident presented with amber-colored urine and an abnormal urine dipstick result, the physician was notified and ordered a UA and C&S for 02/09/26. The medical record showed the UA C&S were ordered for 02/09/26 but were not completed until 02/10/26, and later the DON stated she spoke with the physician on 02/11/26 to discontinue the UA C&S order because the hematuria stopped, so it was not completed. The Regional Nurse stated the order for UA C&S was never completed, and the DON stated there was no policy for obtaining labs.
Failure to Administer and Document Consented COVID-19 Vaccine
Penalty
Summary
The facility did not ensure that residents received COVID immunizations as requested and did not properly document the resident’s vaccination status. Resident #43 was admitted with diagnoses including major depressive disorder, pruritus, and Alzheimer’s disease, and the annual MDS showed she was severely cognitively impaired and required substantial assistance with ADLs. The medical record included a COVID consent form showing the resident’s POA verbally consented to the COVID vaccine, witnessed by two nurses, but further review showed the resident did not receive the vaccine. An MDS nurse confirmed that the resident consented to the COVID vaccine and that there was no documented evidence that the vaccine was administered or that the resident refused it.
Deficiencies in Fall Management and Documentation
Penalty
Summary
The facility failed to ensure comprehensive post-fall assessments were completed for two residents, leading to deficiencies in fall management. Resident #58, who had a history of joint replacement surgery, Parkinsonism, and other conditions, was at risk for falls due to gait and balance problems. Despite this, after a fall on 11/30/24, there was no evidence of post-fall assessments, fall risk assessments, or pain assessments being completed. The resident had activated the call light before the fall, but the intervention implemented was merely placing a 'call not fall' sign in view, which was inadequate given the circumstances. Resident #66, who had severe cognitive impairment and required substantial assistance for daily activities, experienced multiple falls without proper documentation or follow-up assessments. On 10/11/24, the resident was found on the floor with a bruise on the elbow, but the incident was not documented in the incident log until the following day. Subsequent falls on 10/13/24 and 10/18/24 also lacked 72-hour post-fall assessments, and there was no documentation of a fall on 10/18/24 in the incident log. The facility's failure to conduct timely assessments and update care plans after these incidents contributed to the deficiency. The Director of Nursing (DON) acknowledged the lapses in documentation and assessment, noting that sometimes nurses completed incident reports but failed to transfer the documentation to the resident's progress notes. The facility's policy required immediate assessment and intervention after a fall, but this was not consistently followed. The lack of comprehensive post-fall assessments and individualized interventions for residents at risk for falls highlights significant gaps in the facility's fall management practices.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide timely and comprehensive pain management for a resident with a history of spinal stenosis, functional quadriplegia, and type two diabetes mellitus. The resident, who was cognitively intact, frequently experienced pain that affected sleep and participation in therapy. Despite having a care plan that included interventions for pain management, the facility did not conduct a timely pain assessment or notify the physician when pain interventions were ineffective. Over a period of several days, the resident reported significant pain levels, ranging from six to eight on a scale of ten, and expressed that the pain was not normal for him. The resident's Medication Administration Record (MAR) showed that oxycodone was administered but was often ineffective, and there was no documentation of a comprehensive pain assessment or physician notification. Nonpharmacological interventions were attempted, but the resident continued to experience pain, and the facility staff did not contact the medical director over the weekend when the resident's pain persisted. Interviews with facility staff revealed inconsistencies in pain management practices. Licensed Practical Nurses (LPNs) and a Certified Nursing Assistant (CNA) acknowledged the resident's pain but did not consistently document or communicate the severity of the pain to the medical director. The facility's policy on pain management required assessments and interventions in line with professional standards, but these were not adequately followed, leading to a deficiency in the resident's care.
Infection Control Deficiencies in PPE and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place, particularly concerning the use of personal protective equipment (PPE) and hand hygiene. Resident #58, who was on contact precautions due to a possible C-Diff infection, did not have appropriate signage indicating contact isolation. A Registered Nurse Unit Manager (RN/UM) entered the resident's room without donning an isolation gown or gloves and assisted the resident without following proper hand hygiene protocols. The RN/UM was unaware of the resident's contact precautions, and there was no contact precaution sign by the door, only an Enhanced Barrier Precautions (EBP) sign. Additionally, the facility's staff failed to adhere to hand hygiene protocols in another instance involving Resident #30. A Certified Nursing Assistant (CNA) was observed carrying soiled linens without gloves, and a reusable chux pad with fecal material fell to the floor. The CNA picked up the soiled pad with bare hands and continued to handle it without washing hands or using hand sanitizer. The CNA then entered Resident #30's room to assist with incontinence care without performing hand hygiene, only doing so after surveyor intervention. The facility's policies on isolation and handwashing were not followed, leading to potential risks of infection transmission. The lack of proper signage and adherence to PPE and hand hygiene protocols were significant deficiencies observed during the survey. These failures affected two residents directly and had the potential to impact others on transmission-based precautions.
Failure to Maintain Pressure Ulcer Dressing
Penalty
Summary
The facility failed to ensure that a resident's pressure ulcer wound care dressing was in place as ordered. The resident, who was admitted with diagnoses including Parkinsonism, unspecified fall, and anemia, exhibited severe cognitive impairment. The resident had a deep tissue injury (DTI) on the left heel, first identified on July 11, 2024, which was being treated with skin prep and foam dressing as per physician orders. Despite the treatment being documented as completed in the medication and treatment administration records, an observation on July 24, 2024, revealed that the dressing was not in place on the resident's left heel. During an interview, the LPN Unit Manager confirmed that the dressing was not in place as ordered and speculated that it might have come off at some point. The facility's Pressure Ulcer Prevention and Interventions policy, revised in January 2023, outlines the need for preventative skin measures and routine skin assessments, which were not adhered to in this instance. This deficiency was investigated under Complaint Numbers OH00155381 and OH00155223.
Failure to Provide Required Fluids on Meal Tray
Penalty
Summary
The facility failed to provide fluids on a resident's meal tray as specified in the meal ticket, affecting one of three residents reviewed for meals and fluids. The resident, who was admitted with Alzheimer's disease, generalized anxiety, and a contracture of the left hand, exhibited severe cognitive impairment according to a recent assessment. Physician orders indicated the resident required a two-handled mug with straws at meals and a regular diet with mechanical soft texture and nectar thick liquids. However, during a breakfast observation, the resident's meal tray lacked the required two-handled spouted sippy cup and nectar thick water, as confirmed by the Activity Director.
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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) |
|---|---|---|---|---|
| Samaritan Care Center And Villa | 0.2 mi | ★★★★★ | 4 | 0 |
| Medina Center For Rehabilitation And Nursing | 0.3 mi | ★★★★★ | 1 | 0 |
| Medina Bsd Opco Llc | 1.3 mi | ★★★★★ | 0 | 0 |
| Champion Creek Health And Rehabilitation | 2 mi | — | 0 | 0 |
| Western Reserve Masonic Comm | 2.6 mi | ★★★★★ | 0 | 0 |
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