Christian Community Home

Based on observation, record review and interview, the facility failed to ensure the chemical sanitation used in the 3-compartment sink for dishwashing was the correct concentration per manufacturer's guidelines. This had the potential to affect all 36 residents who are served food from the facility's kitchen. This is evidenced by: Facility policy titled, Resource: Sanitation of Dishes/Manual Washing, dated 2021, states in part: Manual washing using chemical to sanitize: - An exposure time of at least 10 seconds for a chlorine solution of 50mg/L that has a pH of 10 or less and a temperature of at least 100 degrees Fahrenheit; -Or a pH of 8 or less and a temperature of at least 75 degrees Fahrenheit; - An exposure time of at least 30 seconds for other chemical sanitizing solutions per manufacturer. Quaternary Ammonium Compound Solutions - Minimum 75 degrees Fahrenheit - Concentration as indicated by manufacturer - Used only in water with 500 mg (milligrams)/L (Liter) hardness or less, or in water with a hardness no greater than specified by the manufacturer. The facility did not have…

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 did not provide pharmaceutical services, including procedures that ensured the accurate acquiring, dispensing, administering and disposal of all drugs and biologicals. The facility did not ensure controlled medications were disposed of timely for 11 out of 11 residents (R) observed during medication storage observation. (R1, R2, R289, R290, R291, R292, R293, R294, R295, R296, R298). The facility did not ensure proper dose of topical medication was administered for 1 out of 1 resident (R9). Findings include: Example 1 The facility policy titled Controlled Substance Accountability, dated June 2023, states in part: .Disposing of Narcotics 1. All narcotics will be destroyed according to Pharmacy and Regulatory timelines . The Statute DHS 132.65 Pharmaceutical Services refers to the handling of medication in Wisconsin facilities, including hospitals and nursing homes. It states in part: .(c) Destruction of medications. 1. 'Time limit.' Unless otherwise…

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 did not provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This occurred for 1 of 1 sampled resident being reviewed for heart failure with increased edema, Resident (R) R17. R17 had no edema in lower extremities on admission. R17 was observed to have 3+ pitting edema in left lower extremity on 02/12/25. The facility did not assess or add interventions to decrease increasing edema for R17. Facility did not complete weekly assessments for heart failure inlcuding missed weights weekly. This is evidenced by: According to the National Institutes of Health (NIH) Congestive Heart Failure (CHF): Nursing Diagnosis, 2023, indicates nurse assessment of CHF is to assess current symptoms such as dyspnea, fatigue, orthopnea, peripheral edema, vital signs, cardiovascular examination such as (abnormal heart sounds, jugular venous distention), respiratory examination such as (auscultate lung sounds for…

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 did not ensure a resident with limited mobility receives appropriate restorative services, and assistance to maintain or improve mobility with the maximum practicable independence for 1 out of 2 sampled residents (R7). R7 was not ambulated per recommendation of Physical Therapy (PT) or receive restorative exercises per recommendation of PT. This is evidenced by: R7 was admitted to the facility on [DATE]. R7's diagnoses included cerebral infarction unspecified, type 2 diabetes mellitus, history of falling, essential hypertension, and unspecified diastolic congestive heart failure. R7's Minimum Data Set (MDS), dated [DATE], confirmed R7 scored 12 out of 15 during Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. R7 understands and is understood by others, and he can make his needs known. R7 needs partial to moderate assistance with toileting, sit to stand, and ambulation. Surveyor reviewed R7's PT recommendations…

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 did not ensure that 1 of the 4 residents reviewed for falls (R7), received adequate supervision and assistance to prevent accidents. The facility did not follow R7's care plan: -CNA did not apply gait belt to R7 during transfer to toilet as care planned. -CNA did not lock R7's wheelchair brakes during transfer from wheelchair to bed. -Staff did not apply pressure alarm in recliner as care planned. -R7 was observed self-transferring to toilet without staff assistance for 2 different events. This is evidenced by: R7 was admitted to the facility on [DATE]. R7's diagnoses included cerebral infarction unspecified, type 2 diabetes mellitus, history of falling, essential hypertension, and unspecified diastolic congestive heart failure. R7's Minimum Data Set (MDS), dated [DATE], confirmed R7 scored 12 out of 15 during Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. R7 understands and is understood by others, and he can make…

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 interview and record review, the facility did not ensure each residents' drug regimen was free from unnecessary medications for 1 of 13 sampled residents (R4). R4 was prescribed a prophylactic antibiotic without adequate indications for use. R4 at times was prescribed excessive dose (duplicate drug therapy) when two antibiotics were given at the same time. This is evidenced by: R4 was admitted to the facility in 2022 with diagnoses including chronic kidney disease, urinary retention, multiple sclerosis, prostate cancer, neurogenic bladder, and reoccurring urinary tract infections (UTIs). R4's physician orders dated 06/18/24, state in part: Macrodantin 100 mg daily for reoccurring UTIs. R4's physician had changed his orders from Doxycycline prophylactically for recurrent UTIs to Macrodantin. R4 had been on Doxycycline since admission. R4 was last seen by urology in 2022. The urology note from 2022 makes no mention of the use of prophylactic antibiotics, at that time, even though R4 was receiving daily Doxycycline prophylactically. R4 was diagnosed with a UTI on 12/06/24 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.

Based on observation, interview and record review, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety by not wearing hairnets appropriately, and did not ensure proper hand hygiene with food handling. This has the potential to affect all 26 of 26 residents residing in the facility. Findings include: The facility policy, entitled Company Dress Code, dated December 2023, states in part: All those in the kitchen must wear hair restraint (i.e., Hairnet, CCHS ball cap, chef's hat, bonnet). On 01/02/24 at 9:08 AM, Surveyor observed Dietary Aide (DA) K wearing a hat that had their ponytail protruding from the cap. The ponytail was not restrained with a hair net and was exposed to the kitchen area. On 01/02/24 at 11:48 AM, Surveyor observed DA J not wearing a hair net while dishing up food from serving area. Surveyor noted hair was noticeable on DA J's head and could be seen from across the dining room; no hair net was observed. On 01/02/24 at 11:55 AM, Surveyor interviewed DA J regarding the lack of a hair net. DA…

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 did not establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections; the facility did not have a clear water management process or plan in effect to prevent transmission of Legionella infection. This has the potential to affect 26 of the 26 residents reviewed. Improper hand hygiene occurred for 5 of 26 residents. (R21, R15, R23, R8, and R12.) Improper use of PPE for 2 of 2 resident observations (R181, R183). Findings: Example 1 The facility policy entitled, Water Management for Legionnaires' Disease, states in part: Facility will identify and manage the risks arising from exposure to Legionella bacteria in water systems, and complete flow diagrams for proper control measures to avoid infections. The facility's Water Management Plan (WMP) was not based on current standards of practice and did not: - Describe the building's water system in the policy and in a flow diagram of the system to include an assessment of the facility's…

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 interviews and record review, the facility did not ensure the right of a resident to receive visitors at the time of their choosing for 1 (R181) of 1 resident reviewed for visitation rights. The facility restricted R181's family's immediate access to R181 during a decline in health conditions related to COVID-19 infection. Findings include: R181 was admitted on [DATE] with diagnoses of fall with T8-T9 spinal fractures, atrial fibrillation, heart failure, neurogenic bladder, diabetes mellitus, and arthritis. Surveyor reviewed R181's admission Minimum Data Set (MDS) dated [DATE] which documents R181's Brief Interview for Mental Status (BIMS) score to be a 13, indicating R181 was cognitively intact for daily decision-making. The facility provided Surveyor with a copy of a progress note regarding R181. The progress notes document in part, on 12/28/23 at 3:04 pm, R181's daughter called and asked about coming to visit R181. R181's daughter was informed by the Director of Nursing (DON) B that R181 should not…

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 interview, medical record review and facility document review, the facility did not have a comprehensive system for ensuring residents received influenza immunizations, for 1 of 5 sampled residents, (R181). This is evidenced by: The CDC Influenza Vaccine Timing for Adults reads, in part: One dose of Influenza vaccine is recommended for adults each flu season . Surveyor requested a list of current residents and their influenza, pneumococcal, and COVID-19 immunization dates. R181's immunization record stated influenza immunization last received was on 11/02/22. On 12/13/23, influenza vaccination was listed as being: Historical. No actual dates of these immunizations had been obtained to verify R181 was up to date with his influenza immunization. Surveyor reviewed a consent form signed on 12/12/23 titled, Consent to administer Influenza vaccine, signed by R181 which indicated the desire to receive the influenza vaccination from the facility. Surveyor reviewed the physician's order dated 12/12/23 which stated in part, Administer influenza vaccine upon admission on e time at…

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 policy review, the facility failed to distribute food under sanitary conditions. This has the potential to affect 30 of the 30 residents that reside at the facility. Staff was observed to be working with food without a hair restraint in place to cover all hair. During dishwashing, Staff was observed to touch a item that fell on the floor and then remove dirty gloves and replace gloves without hand washing. During meal service, Staff was observed to touch a resident's foot and slipper and then return to serving food without hand washing. The [NAME] was observed to serve food at tray line with his facial mask below his nose or chin. This is evidenced by The facility policy entitled Hair Restraints dated October 2011 states in part; Hair .must be secured and pulled up, must wear hair restraint (i.e. Hairnet, .). The facility policy entitled Handwashing dated October 2011 states in part; When to wash hands . After handling soiled equipment or utensils after engaging in other activities that contaminate the hands. The facility policy entitled Bare Hand…

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.