Christian Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure the Level 1 PASRR (Pre-admission Screening and Resident Review; an assessment used to identify residents with a Serious Mental Illness [SMI] or intellectual disabilities were not inappropriately placed in a nursing facility for long term care) was accurate for 1 of 5 residents (Resident 62). The facility failed to identify a SMI or that there was a suspicion of SMI upon admission for a resident with depression. This failure placed residents at risk for psychological decline and unmet psychosocial needs.Findings included.Review of a facility policy titled, PASRR, revised date 05/2026, documented social service staff review the PASRR screen as part of their intake process. Should they identify or credibly suspect SMI, they will complete a new Level I.Resident 62 was admitted to the facility on [DATE].Review of Resident 62's hospital PASRR Level I assessment, dated 02/05/2025, documented no history of SMI.Review of the hospital Discharge summary,…

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 observation, interview and record review, the facility failed to manage and reconcile controlled medications in 1 of 3 medication storage rooms (Baker Hall/Medicare unit) reviewed. This failure allowed for the potential risk of diversion of resident's medications. Findings included . Review of facility policy titled Medication Storage in the Facility, dated 05/09/2018, documented under Controlled Substance Storage: B. Schedule II - V medications and other medications subject to abuse or diversion arestored in a permanently affixed, double locked compartment separate from all other medications per state regulation. C. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. E. At each shift change, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses and is documented. During an observation and interview on 06/10/2026 at 1:10 PM, Staff E, Nurse Manager/Registered Nurse (RN) opened the door for the…

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 <DENTAL> <RESIDENT 47> Resident 47 admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other mental functions), high blood pressure, and dysphasia (difficulty swallowing). Review of Resident 47's Annual MDS assessment dated [DATE] showed they had no obvious or likely cavity, no broken natural teeth, no facial pain or discomfort, and no inflamed or bleeding gums or difficulty chewing. In an observation on 05/20/2025 at 2:45 PM, Resident 47 gums and teeth appeared to be black in color, with debris in their teeth, and they were missing teeth. Review of Resident 47's dental status assessment dated [DATE] showed the resident had obvious or likely cavities. Review of dental hygienist notes dated 03/26/2024 showed Resident 47 had broken teeth. Review of Resident 47's Significant Change MDS dated [DATE] showed the resident had no obvious or likely cavity, no broken natural teeth, no facial pain or discomfort, and no inflamed or bleeding gums…

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 observation, interview and record review, the facility failed to properly label and/or discard undated, opened ophthalmic medications (drugs specifically formulated for application to the eye). This failure placed the residents at risk of receiving compromised or ineffective medications. Findings included . Review of a facility policy titled, Medication Storage in the Facility, dated 05/09/2018, documented the facility would ensure all medications were stored safely, securely, and properly, following manufacturer's recommendations. Ophthalmic medications, once opened, required an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Review of the updated package insert document for Refresh Tear eye drops, showed to discard the medication 90 days after opening. Review of the updated package insert document for Latanoprost Ophthalmic Solution, showed to discard an opened bottle after six weeks. Review of the updated package insert document for Timolol eye drops, showed to discard an opened bottle with any remaining solution…

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 observation, interview and record review, the facility failed to prepare food under safe and sanitary conditions in the facility kitchen. The failure to ensure hand hygiene when changing gloves and using food-contact sanitizer to clean gloves, placed residents at risk for cross-contamination and foodborne illnesses. Findings included . In an observation on 05/21/2025 at 11:27 AM, Staff Q, Dietary Staff removed gloves and then put on new gloves without washing their hands. A few minutes later, observed the same staff, Staff Q with gloved hands reach in their left side pocket for a marker, then took their left-hand glove off and placed a new glove on without washing their hands. Then observed Staff Q use the washcloth that came from the red bucket under the sink to wipe their gloves from food debris then continued placing food on the plates without their changing gloves. In an interview on 05/22/2025 at 1:15 PM, Staff P, Chef stated that they change gloves as needed, if they see the gloves were visibly soiled or if they touched their face. Staff P added that they wash their…

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 interview and record review the facility failed to ensure a system in which resident's records were complete, accurate, accessible and systematically organized for 4 of 7 residents (Residents 29, 47, 83 and 84) reviewed. This failure included inaccessible hospice visit documentation, hospice plan of care, and incomplete documentation of meal intakes which placed residents at risk for unmet needs, unrecognized changes in condition and adverse outcomes. Findings included . Review of the facility policy titled, Documentation in Medical Record reviewed in (no month and day) 2025 documented each resident's medical record shall contain an accurate representation of the actual experiences of the resident and enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be accurate, relevant, and complete containing sufficient details about the resident's care and or responses to care. Review of the facility policy titled, Nutrition…

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 observation, interview and record review the facility failed to ensure proper hand hygiene and infection control measures were used for equipment sanitation, during staff assistance during meals, personal care and indwelling urinary catheter care for 1 of 1 resident (Resident 32) observed for cares and dining observations. The facility failed to ensure the staff were compliant with appropriate hand hygiene practices while serving meals, and during catheter care. These failed practices placed the residents and staff at increased risk of contracting and/or spreading potential infections. Findings included . Review the facility's procedure titled, Handwashing/Hand Hygiene, revised on 06/08/2020 showed the purpose of the procedure was to provide guidelines to employees for proper and appropriate hand washing and hygiene techniques that would aid in the prevention and control of the transmission of infections and diseases. The guidelines included hand hygiene after contact with secretions and mucous…

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 interview and record review, the facility failed to provide the careplanned supervision that was necessary to avoid accidents for 1 of 5 residents (Resident 83) reviewed for accidents.Resident 83, who was left unattended on the toilet, sustained a fall where they struck their head and sustained a bump to the back of their head. This failed practice placed other residents with similar care needs at an increased risk of falls and serious injury. Findings included . Review of the facility's policy titled, Fall Management Plan-Safety Awareness Fall Elimination (SAFE) revised 11/06/2024, documented that each resident will be assessed on admission, quarterly and when safety issues occur to identify residents at risk for falls and implement strategies to prevent falls and injury from falls. All staff were to report immediately residents who are restless. Review of the Nursing Home Guidelines, The Purple Book, October 2015 edition documented a substantial injury would be in an area not vulnerable to trauma such…

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 interview and record review, the facility failed to ensure adequate monitoring was conducted for use of an anticoagulant (medication that prevent blood clot) for 1 of 5 residents (Resident 53), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medications, adverse side effects, and related complications. Findings included . Review of the facility's policy titled, Anticoagulation Therapy Guideline, revised in 2025, documented all residents receiving anticoagulation therapy will be monitored by LN for signs and symptoms of bleeding and possible food and drug interactions. The policy further documented residents on anticoagulation therapy will have addressed on care plan potential risks related to therapy. Resident 53 readmitted to the facility on [DATE] with diagnoses to include atrial fibrillation (A-Fib - an irregular and often very rapid heart rhythm). According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated…

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 interview and record review, the facility failed to ensure policies and procedures for timely reporting of fall for 1 of 4 residents (Resident 51) reviewed for abuse. The facility failed to report to the state agency when a resident fell after, during a transfer, in which their care plan was not being followed. This failure by the facility to identify, report, and investigate for an allegation of potential abuse or neglect placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect and limited the thoroughness of investigations. Findings included . Review of the facility policy titled, Reporting Abuse to Facility Management dated 10/24/2022 showed: When an alleged or suspected case of serious injuries of unknown source, or abuse is reported, the facility Administrator or designee, will immediately (within two hours of alleged incident) notify the following persons or agencies of such incident as indicated by regulation; if the alleged violation involves neglect,…

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 observation, interview, and record review the facility failed to ensure possible allegations of abuse/neglect were thoroughly investigated for 1 of 4 residents (Residents 51), reviewed for abuse/neglect investigations. This failure placed the resident at risk for unidentified abuse or neglect and a diminished quality of life. Findings included . Review of the facility policy titled, Abuse Investigations Policy dated 10/24/2022 stated an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or their designee, will appoint a member of management to investigate the alleged incident. Witness reports will be obtained and be required to sign and date written reports. The individual conducting the investigation would, as appropriate Interview the person(s) reporting the incident and staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Resident 51 admitted to the facility on…

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.