Christian Care Nursing Center

Based on documentation, staff interview, and the facility policy and procedures, the facility failed to report accurate PBJ (Payroll Based Journal) data as per requirements.Findings included: Review of the PBJ (Payroll Based Journal) FY (fiscal year) Quarter 2 2024 (January 1 to March 31) revealed:no registered nurse (RN) hours on January 1, 2, 3, 9, 13, 14 2024 or March 20 and 31, 2024. no licensed nursing coverage twenty-four hours a day on January 9, 13, 14, 21, 28, 2024, February 4, 11, 17, 25, 2024, and March 2, 3, and 31, 2024. Review of the employee time cards revealed that during the PBJ FY Quarter 2 2024 (January 1 to March 31): there was a registered nurse (RN) coverage for 12 hours on January 1, 2, 3, 9, 13, 14 2024. there was RN coverage for 12 hours on March 20 and 31, 2024. there was licensed nursing coverage twenty-four hours a day on January 9, 13, 14, 21, 28, 2024there was licensed nursing coverage twenty-four hours a day on February 4, 11, 17, 25, 2024.there was licensed nursing coverage twenty-four hours a day on March 2, 3, and 31, 2024. Review of the PBJ FY…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Number of residents sampled:Number of residents cited:TFFT ensure that food handling processes were properly implemented. Based on observations, staff interviews, and policy review, the facility failed to ensure that food items were not expired. The deficient practice could increase the risk of cross-contamination and foodborne illness.Finding includes:During an initial kitchen observation conducted on August 26, 2025 at 7:19 a.m., with the Kitchen Manager (staff # 101), the following food items were found to be expired:-In the dry food storage, 2 bags of Sysco Classic Peanuts with an expiration date of July 31, 2025.-In the walk-in refrigerator, red tomato sauce was stored in a metal container with used-by date of August 21, 2025; a white colored dessert stored in a metal container with used-by date August 22, 2025; dry oats stored in a metal container with used-by date August 10, 2025; and teriyaki sauce stored in a metal container with used-by date August 13, 2025.An interview was conducted on August 26, 2025, at 7:56 a.m., with a Kitchen Manager (staff # 101) who stated that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled:Number of residents cited:TFFT explain in a form and manner including a language that the resident or his/her representative understood Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure the binding arbitration agreement provided for the selection of a neutral arbitrator agreed upon by both parties and a venue agreed upon by both parties. Findings included: Resident (#12) was admitted to the facility on [DATE] with diagnoses that included a seizure disorder, vascular dementia, and cirrhosis of the liver.The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 9 indicating the resident had a moderate cognitive impairment. An arbitration agreement dated August 11, 2027 was signed by resident (#2) and the Administrative Assistant (staff #31). An interview was conducted on August 27, 2025 at 1:47 p.m. with the Administrative Assistant (staff #31), who stated that she reviews the binding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and facility policy review, the facility failed to ensure that there were no expired food items readily available for resident use in the dining room refrigerator. The deficient practice could result in potential foodborne illness. Findings include: On August 26, 2024 at 10:02 a.m. an interview was conducted with the administrator (staff #10)who stated that the kitchen had not been in-use since December 2023; and that, food was brought from the neighboring assisted living facility which was considered their satellite kitchen. The administrator stated that whenever drinks or snacks were requested outside of regular meal times, the items in the dining room refrigerator were available to the residents. An observation of the refrigerator located in the dining room was conducted administrator immediately following the interview. There were five cartons of orange juice with expiration date of August 23, 2024 found inside the refrigerator. In the cabinet beside the refrigerator were twelve peanut butter sandwich crackers without any expiration date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, clinical record reviews, staff interviews, facility documentation and policy and procedures, the facility failed to ensure that the resident environment remained free of accident hazards, by failing to ensure that a shower chair was inspected for safety before use, and that one resident received appropriate transfer assistance (#113). The deficient practice increased the risk for preventable accidents. Findings include: Resident #113 was admitted on [DATE], with diagnoses that included wedge compression fracture of vertebra, fracture of shaft of right arm humerus, difficulty walking and muscle weakness. Review of the admission MDS (minimum data set) dated October 25, 2022 revealed a BIMS (brief interview of mental status) score of 9, indicating moderate cognitive impairment. The assessment revealed that resident required extensive two-plus person physical assistance with transfers. A nurse's notes dated October 27, 2022 at 2:36 p.m. revealed while resident #113 was being transferred from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and policy review, the facility failed to ensure their system of prompt identification of loss or potential diversion of controlled medications was implemented. The resident census was 9. The deficient practice could result in misappropriation of residents' medications. Findings include: -Regarding misappropriation of a medication: Review of the Controlled Count Record revealed no evidence of two nurse reconciliation: -January 29, 2023: 6AM - 6PM - no evidence of off-going nurse verification -January 29, 2023: 6PM - 6 AM - no evidence of on-coming nurse verification. According to a facility investigation, dated January 30, 2023 at approximately 6:30 AM the Director of Nursing (DON/staff #2) was informed that there were missing narcotics by an on-coming registry Registered Nurse (Rn/staff #100). The investigation revealed that a vial of liquid Ativan (lorazepam/anxiolytic) for oral administration ordered for a hospice patient, was missing from the medication refrigerator. The investigation also revealed that the off-going RN (staff #27) had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure that food was properly stored, labeled and dated sanitary conditions. The census was 9. The deficient practice could result in residents acquiring a foodborne illness. Findings include: During a brief kitchen inspection conducted on July 17, 2023 at 8:29 a.m. with the Food Service Director (staff #7), the following were identified in the refrigerator and freezer: -Sweet Street Chocolate Peanut Butter Pie with a received date of 4/12/23, was notably exposed to air and had no use by date. -Brand Villa Frizzoni pepperoni slices was open and exposed to air, with no use by date. -1 large box of blueberries with received date of 2/24/23 was open and exposed to air and did not include an open or use by date. The blueberries were withered and wrinkled in appearance. -Oatmeal Raisin English Bay cookies dated 5/12/23 had no open or use by date. -1 large pepperoni pizza opened and exposed to air, with no open or use by date. -Cooked Meatloaf sealed in aluminum foil dated 6/17/23. -Great Value Vanilla and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to document treatment and care in accordance with professional standards of practice regarding implementation of compression stockings for one resident #263. The deficient practice could result in residents not receiving treatment and care based on their needs. Findings Include: Resident #263 was admitted on [DATE] with diagnosis including unspecified dementia, Alzheimer's disease and essential hypertension. The MDS (minimum data set) dated April 20, 2020 revealed a BIMS (brief interview for mental status) score of 4, suggesting severe cognitive impairment. The dashboard in the electronic health record revealed that resident #263 required one-person physical assistance with dressing. A review of the physician's orders dated January 28, 2020 included an order for compression stockings for edema. Review of the care plan initiated February 5, 2020 included that resident #263 was to have compression…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on concerns identified during the survey, the narcotic log review, and staff interviews, the Quality Assurance and Performance Improvement (QAPI) committee failed to implement and review an appropriate plan of action to correct the deficiency of incomplete narcotic count documentation. The deficient practice could result in narcotic medications not being accurately accounted for. Findings include: A review of the narcotic logs was conducted on July 20, 2023 at 9:05 a.m. The review revealed that there were multiple missing signatures for the narcotic count log for the months of January 2023, February 2023, March 2023, April 2023, May 2023, and June 2023. The total count of missing signatures was 139. The breakdown by month, revealed the following: January: north medication cart: missing 15 signatures January: south medication cart: missing 14 signatures February: north medication cart: missing 2 signatures February: south medication cart: missing 13 signatures March: north medication cart: missing 21 signatures March: south medication cart: missing 9 signatures April: north…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.