Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Christian Care Center Of Medina during CMS and state inspections, most recent first.
Unlabeled and Unsecured Medications on Medication Cart: An LPN was observed with multiple unlabeled and unsecured medication cups on the 200 Hall med cart, including numerous prescription and supplement medications such as Depakote, Bupropion, Levothyroxine, Eliquis, Plavix, and others. One additional unlabeled cup containing Cyclobenzaprine was also found in a drawer. The LPN stated meds were pulled at the start of the shift, and the DON stated medications should be administered after removal from the packs and not returned to the cart.
Unlabeled, undated, and expired food items were found stored in the kitchen, including boiled eggs, pureed foods, beets, tomato sauce, chicken base, and cooked lasagna past their use-by dates. Surveyors also observed undated items such as a brownish liquid identified by the CDM as nectar thick tea and an undated peeled onion, while dietary staff acknowledged food should be labeled, dated, and discarded after 3 days.
The facility failed to complete timely baseline care plans for two residents. One resident, admitted with multiple diagnoses including dementia and depression, did not have a care plan completed within 48 hours. Another resident, with conditions such as Alzheimer's and diabetes, lacked a care plan addressing anticoagulant therapy. Both the LPN and DON confirmed these deficiencies.
A resident experienced a fall resulting in a fracture, and the facility failed to notify the physician immediately and reassess the resident's pain in a timely manner. The resident, who was cognitively intact and required assistance with daily activities, fell while returning to bed, leading to a fracture. The facility's policies on fall prevention and pain management were not followed, as the physician was notified hours later, and pain reassessment was delayed significantly after medication administration.
The facility failed to follow physician orders for oxygen therapy for two residents. One resident with chronic respiratory issues had their oxygen set below the prescribed rate, while another resident with COPD had their oxygen set above the prescribed rate. Both discrepancies were confirmed by the DON and an LPN.
A resident received Ozempic injections more frequently than prescribed, with the MAR showing multiple doses per week instead of the weekly schedule. An LPN confirmed administering the injections as per the MAR, and the DON acknowledged the error, stating the Thursday order should have been discontinued.
The facility failed to document the necessary physician rationale for extending PRN psychotropic medications beyond 14 days for two residents with anxiety and dementia-related diagnoses. The facility's policy requires such documentation, but it was not provided, as confirmed by the DON.
Two medication administration errors were identified in an LTC facility, resulting in a 7.14% error rate. An LPN crushed an extended-release potassium chloride tablet for a resident, contrary to guidelines, while another LPN administered sevelamer carbonate to a resident before a meal instead of with it, as prescribed.
Two LPNs in a LTC facility committed medication administration errors, resulting in a 7.14% error rate. One LPN crushed an extended-release potassium chloride tablet, while another administered Sevelamer Carbonate before a meal instead of with it, as per physician's orders. The DON confirmed these actions as errors.
The facility failed to securely store medications, as evidenced by two incidents where medications were left unsecured in residents' rooms. In one case, a resident had Tylenol left on their overbed table, and in another, an LPN left medications unattended on a bedside table. Both residents were cognitively intact, and the facility's policy requires medications to be stored in a locked box.
Two LPNs at the facility failed to adhere to infection control practices. One LPN did not use PPE during medication administration and enteral feeding for a resident with a PEG tube and failed to clean a pulse oximeter. Another LPN improperly disposed of a used lancet in a trash can instead of a sharps container. The DON confirmed these actions were errors in infection control.
Unlabeled and Unsecured Medications on Medication Cart
Penalty
Summary
The facility failed to ensure medications were properly stored when multiple medication cups on the 200 Hall medication cart were left unsecured and unlabeled during medication administration observation. The facility policy titled, Storage of Medications, stated that all drugs and biologicals are to be stored in a safe, secure, and orderly manner, and the policy titled, Administering Oral Medications, directed staff to select the drug from the unit dose drawer or stock supply, check the label against the MAR, and prepare the correct dose before administration. During observation on the 200 Hall Medication Cart, an LPN had numerous unlabeled and unsecured medication cups containing a wide variety of medications. The cups included medications such as Depakote, Magnesium Oxide, Docusate Sodium, Acidophilus, Omeprazole, Paroxetine, Bupropion, Ferrous Sulfate, Vitamin D3, Carvedilol, Celecoxib, Plavix, Furosemide, Potassium Chloride, Spironolactone, Levothyroxine, Quetiapine, Eliquis, Sertraline, Famotidine, Fluoxetine, Losartan, and others. One additional unlabeled and unsecured medication cup containing Cyclobenzaprine was also stored in a drawer of the medication cart. The LPN stated that all medications were pulled when she arrived that morning and that medications should be administered after each one was pulled. The DON stated that all medications should be administered after removing them from the packs and should not be replaced in the medication cart. The deficiency was based on the presence of multiple unsecured and unlabeled medication cups on the cart during the observation.
Unlabeled, Undated, and Expired Food Stored in Kitchen
Penalty
Summary
Food was not stored, prepared, and served under sanitary conditions because multiple food items in the kitchen were found unlabeled, undated, or expired. Facility policy required foods stored in the refrigerator or freezer to be covered, labeled, and dated, and required open food items to have a label identifying the contents, the date received, the date opened, and a use-by date. During kitchen observations, surveyors found boiled eggs, pureed sausage, pureed eggs, beets, tomato sauce, chicken base, and cooked lasagna with use-by dates that had already passed, along with several items that were not labeled or dated at all, including two half sheet pans of red jelly-like substance and an undated peeled onion wrapped in plastic wrap. Additional observations showed an unlabeled, undated glass containing a brownish liquid on a shelf in the reach-in cooler, which the Certified Dietary Manager identified as nectar thick tea and began placing on a tray with other items to be served to residents. The walk-in refrigerator also contained four pans of cooked lasagna dated 12/16/2025, and dietary staff stated the lasagna should be discarded after 3 days. The Certified Dietary Manager later acknowledged that food should be labeled and dated with a use-by date and discarded after 3 days, yet an opened container of chicken base with a use-by date of 1/8/2026 remained in the refrigerator when observed again.
Failure to Complete Timely Baseline Care Plans for Two Residents
Penalty
Summary
The facility failed to develop an accurate baseline care plan within 48 hours of admission for two residents. Resident #47, who was admitted with diagnoses including ESBL, UTI, dementia, and depression, did not have a completed baseline care plan within the required timeframe. The resident was severely cognitively impaired, as indicated by a BIMS score of 3, and was on antidepressants and psychotropic medication. The LPN and DON confirmed that the care plan was not completed in a timely manner, acknowledging that it should have been done within 48 hours of admission. Similarly, Resident #412, admitted with conditions such as Alzheimer's disease, atherosclerotic heart disease, and diabetes, did not have a baseline care plan that included the use of anticoagulant therapy, despite physician's orders for Eliquis to treat atrial fibrillation. The DON confirmed that the baseline care plan failed to reflect the use of anticoagulant therapy, indicating a lapse in the facility's care planning process for this resident.
Failure to Notify Physician and Reassess Pain After Resident Fall
Penalty
Summary
The facility failed to timely notify the physician and reassess pain for a resident who experienced a fall resulting in a fracture. The facility's Fall Prevention Program policy requires immediate notification of the medical director and transfer to the emergency room for evaluation when a fall occurs. However, the physician was not notified until several hours after the incident. The resident, who was cognitively intact and required assistance with activities of daily living, fell while returning to bed from the restroom, resulting in a fracture of the left ankle. Additionally, the facility did not adhere to its Pain Management policy, which mandates reassessment of pain at established intervals. The resident's pain was not reassessed within the required timeframe after the administration of pain medication. The Medication Administration Record showed multiple instances where the resident's pain was not reassessed promptly, with significant delays between the administration of medication and the reassessment of pain levels. The Director of Nursing confirmed that pain should have been reassessed within one hour after administration and that the physician should have been notified immediately of the fall.
Failure to Follow Physician Orders for Oxygen Therapy
Penalty
Summary
The facility failed to adhere to physician orders and properly monitor the oxygen flow rate for two residents requiring respiratory therapy. Resident #59, who was admitted with chronic respiratory failure, pulmonary hypertension, pneumonia, and interstitial pulmonary disease, had a physician order for oxygen at 4 liters per minute via nasal cannula. However, observations on multiple occasions revealed the oxygen was set at 3.5 liters per minute. The Director of Nursing confirmed that the oxygen concentrator should have been set at the prescribed 4 liters per minute, indicating a failure to follow physician orders. Similarly, Resident #412, diagnosed with Alzheimer's, anxiety disorder, and chronic obstructive pulmonary disease, had a physician order for oxygen at 2 liters per minute. Observations showed the oxygen was set at 5 liters per minute, contrary to the physician's order. A Licensed Practical Nurse confirmed the discrepancy, and the Director of Nursing reiterated that physician orders should be followed. These findings highlight the facility's failure to provide safe and appropriate respiratory care as per the established physician orders.
Excessive Dosage of Ozempic Administered to Resident
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary medications in excessive dosages. Specifically, Resident #33, who was cognitively intact and had diagnoses including Diabetes, Morbid Obesity, Chronic Obstructive Pulmonary Disease, and Hypertension, received Ozempic injections more frequently than prescribed. The physician's order indicated that Ozempic should be administered weekly, but the Medication Administration Records (MAR) for January, February, and March 2025 showed that the resident received the injections more than once a week. During interviews, LPN B acknowledged administering the injections according to the MAR, which included both Thursday and Saturday doses in the same week. The Director of Nurses (DON) confirmed that the Ozempic injections should be given weekly and acknowledged that the resident received multiple doses during some weeks. The DON also confirmed that the Thursday order should have been discontinued to prevent duplicate dosing.
Failure to Document PRN Psychotropic Medication Duration
Penalty
Summary
The facility failed to ensure that residents' medication regimens were free of unnecessary medications, specifically regarding the use of PRN psychotropic medications. The facility's policy on psychotropic medications, revised in November 2022, mandates that PRN orders for such drugs should only be used when necessary to treat a diagnosed specific condition and should be limited to a duration of 14 days unless extended with documented rationale by the attending physician. However, the facility did not provide the required physician documentation to extend the PRN psychotropic medication beyond 14 days for two residents. Resident #19, who was admitted with diagnoses including anxiety, depression, dementia, and Alzheimer's disease, had a PRN order for Xanax to be administered twice daily for anxiety disorder. The facility failed to provide documentation to justify the continuation of this medication beyond the 14-day limit. Similarly, Resident #412, admitted with similar diagnoses, had a PRN order for Lorazepam for anxiety disorder, but the facility did not document the duration of this medication. The Director of Nursing confirmed that PRN psychotropic medications should have a stop date after 14 days, which was not adhered to in these cases.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with two errors observed out of 28 opportunities, resulting in a 7.14% error rate. One incident involved LPN F, who administered medications to a resident with a history of thrombocytopenia, dementia, anxiety disorder, hypertension, and heart failure. The LPN crushed an extended-release potassium chloride tablet, which should not be crushed according to facility policy and pharmaceutical guidelines, and mixed it with pudding before administering it to the resident. This action constituted a medication error as it compromised the drug's intended release mechanism. Another incident involved LPN C, who administered sevelamer carbonate to a resident with atrioventricular block, end-stage renal disease, cardiac arrhythmia, anemia, and diabetes mellitus. The medication was prescribed to be taken with meals, but the LPN instructed the resident to take it before the meal, which was not in accordance with the physician's order. The Director of Nursing confirmed that administering the medication at the incorrect time was a deviation from the prescribed order, resulting in a medication error.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered with a medication error rate of less than 5%, resulting in a 7.14% error rate. Two specific incidents were observed involving Licensed Practical Nurses (LPNs) F and C. LPN F crushed an extended-release potassium chloride tablet and administered it to a resident mixed in pudding, which is against the facility's policy and the medication's intended use. This action was confirmed as a medication error by the Director of Nursing (DON), as extended-release medications should not be crushed. Another incident involved LPN C, who administered Sevelamer Carbonate tablets to a resident before a meal, contrary to the physician's order to take the medication with meals. The resident questioned the timing, but the nurse instructed them to take it before the meal, leading to a medication error. The DON confirmed that administering medication at the scheduled time with meals is crucial and that the nurse's action did not follow the physician's order.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure medications were properly and securely stored, as evidenced by two separate incidents involving residents. In the first incident, a resident with a cognitive status indicating intact mental faculties was found to have Tylenol left unsecured in a basket on their overbed table throughout the day. The facility's policy requires that self-administered medications be stored in a safe place not accessible to other residents, and the medication should only be left in a resident's room if it is in a locked box and the resident has orders to self-administer. An LPN confirmed that the medication should not have been left unsecured in the resident's room. In the second incident, an LPN left medications unsecured and unattended at the bedside of another resident during medication administration. The resident, who was also cognitively intact, was in their wheelchair and able to move around the room. The LPN placed the medications on the bedside table and then left the room, leaving the medications within reach of the resident. The Director of Nursing confirmed that medications should not be left unsecured and unattended in a resident's room, and they must be kept in a locked box to prevent access by other residents.
Infection Control Deficiencies in PPE Use and Sharps Disposal
Penalty
Summary
The facility failed to maintain infection prevention and control practices, as evidenced by the actions of two LPNs. LPN A did not adhere to the facility's policy on using personal protective equipment (PPE) during medication administration and enteral feeding through a PEG tube for a resident with dysphagia and a gastrostomy. LPN A administered medications and feeding without wearing PPE and failed to clean a pulse oximeter before and after use, instead storing it in a pocket. The Director of Nursing (DON) confirmed these actions were errors in infection control. Additionally, LPN C did not properly dispose of a used lancet after performing a blood glucose check on a resident with multiple diagnoses, including atrioventricular block and diabetes mellitus. Instead of placing the lancet in a sharps container, LPN C disposed of it in a trash can on the medication cart. The DON confirmed that the appropriate disposal method for a used lancet is in a sharps box, not a trash can.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 41 citations issued within 25 miles in the last 12 months — including the 1 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Medina
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maplewood Health Care Center | 6.2 mi | ★★★★★ | 3 | 0 |
| Northbrooke Post Acute | 6.5 mi | ★★★★★ | 0 | 0 |
| W D Bill Manning Tennessee State Veterans Home | 7.5 mi | ★★★★★ | 0 | 0 |
| Avondale Health And Rehabilitation Center, Llc | 8.9 mi | ★★★★★ | 0 | 0 |
| West Tennessee Post Acute | 9.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Christian Care Center Of Medina.
100% money-back within 48 hours.
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.