Apostolic Christian Home

Inspectors wroteThe facility identified a census of 58 residents and one kitchen. Based on record review and interviews, the facility failed to provide the services of a full-time certified dietary manager for the 58 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. This failure affected all 58 residents residing in the facility. Findings Included: - On 12/18/24 an inspection of the Facility Assessment was completed. The assessment was revised on 06/28/2024. A review of the evaluation revealed the following: The assessment identified the average daily staffing required for the facility but failed to identify the specific staffing levels needed and the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse's Aides (CNA) needed for each unit, shift, and per census. [...]

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents with five reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to ensure the residents were provided foot pedals during wheelchair transports for Resident (R) 23, R36, R46, R34, R40, and R33. This placed the residents at risk for preventable accidents and injuries due to unmet care needs. Findings Included: - On 12/16/24 at 08:16 AM, R23, a severely cognitively impaired resident, sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline). R23 had socks on both feet. Certified Nurse Aide (CNA) O pushed R23 in his Broda chair and R23's feet slid along the floor before he lifted his legs. On 12/17/24 at 07:18 AM, Staff pushed R36 in her wheelchair with no foot pedals. Staff repeatedly told R36 to keep her feet up. [...]

Inspectors wroteThe facility reported a census of 58 residents. The sample included 15 with five residents reviewed for drug regimen review. Based on interviews, observations, and record review, the facility failed to ensure the Consulting Pharmacist (CP) identified and made recommendations related to Residents (R) 55, R8, R52, and R32's indications for their antipsychotic medications (a class of medications used to treat major mental conditions that cause a break from reality). This placed the residents at risk for unnecessary psychotropic (alters mood or thoughts) medications and related complications. Findings Included: - The Diagnosis tab within R55's Electronic Medical Records (EMR) included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), fatigue, and pain. [...]

Inspectors wrote- The Diagnosis tab of R32's Electronic Medical Record (EMR) documented diagnoses of anemia (an inadequate number of healthy red blood cells to carry adequate oxygen to body tissues), dementia (a progressive mental disorder characterized by failing memory and confusion), protein-calorie malnutrition, bipolar disorder (a major mental illness that causes people to have episodes of severe high and low moods), delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), chronic pain, hypertension (high blood pressure), major depressive disorder (major mood disorder that causes persistent feelings of sadness), insomnia (inability to sleep), chronic pain, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and dysuria (painful urination), The Annual Minimum Data Set (MDS) dated [DATE] documented [...]

Inspectors wroteThe facility had a census of 58 residents. The sample included 15 residents. Based on observation, record review, and interview, the facility failed to keep Resident (R) 112's protected health information (PHI) private on a medication cart parked in the main dining room. This placed R112 at risk for impaired privacy.

Inspectors wroteThe facility reported a census of 58 residents. The sample included 15 residents with 15 reviewed for care plan revisions. Based on interviews, observations, and record reviews, the facility failed to revise Resident (R) 33's Care Plan to reflect his increased behavioral episodes. The facility additionally failed to revise R32's Care Plan to reflect her sleeping preferences. This deficient practice placed both residents at risk for impaired care due to uncommunicated care needs. Findings Included: [...]

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents with two residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, because of pressure, or pressure in combination with shear and/or friction). Based on observation, record review, and interviews, the facility failed to ensure pressure-reducing heel protectors or boots were in place for Resident (R) 34 who had a pressure-related injury on her left heel. These deficient practices placed R34 at risk for complications related to further skin breakdown and worsening of pressure ulcers.

Inspectors wroteThe facility reported a census of 58 residents. The sample included 15 residents with five reviewed for accidents. Based on interviews, observations, and record review, the facility failed to ensure a safe care environment related to the use of Resident (R)35's fall prevention interventions for his wheelchair. This deficient practice placed R35 at risk for preventable falls and injuries.

Inspectors wroteThe facility identified a census of 58 residents. The facility identified one resident on Enhanced Barrier Precautions (EBP - infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care). Based on record review, observations, and interviews, the facility failed to ensure the blood pressure cuff, pulse monitor, and oxygen saturation equipment were sanitized after each resident's use. This deficient practice placed the residents at risk for infectious diseases.

Inspectors wroteThe facility identified a census of 58 residents. The sample included 15 residents, with five reviewed for immunization status. Based on record reviews and interviews, the facility failed to offer and administer or obtain informed declinations for the Pneumococcal Conjugate Vaccine (PCV20 - vaccination for bacterial pneumonia infections) vaccination for Resident (R) 32 and R52. This placed the residents at increased risk for complications related to pneumonia.

Inspectors wroteThe facility identified a census of 60 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to provide a safe environment, free from preventable accidents for Resident (R) 1. On 05/29/24 at 12:15 PM, Transportation FF strapped R1's wheelchair into the facility's transportation van but did not place the seatbelt around R1. When Transportation FF braked before making a turn, R1 slid out of her wheelchair onto the van floor. R1 was taken to the hospital for evaluation where she was found to have left tibia (bone in the lower leg) and fibula (bone in the lower leg) fractures as a result of the accident. This failure placed R1 in immediate jeopardy.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with 10 reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure staff provided Resident (R)52 with his call light when he went to bed, resulting in a fall in which R52 obtained a right trimalleolar ankle fracture (a break in the lower leg section that form your ankle joint). The facility further failed to assess residents for safe lift chair use, after falls out of a lift recliner for R52 and R36. The facility failed to follow R36 and R46's plan of care which resulted in falls and failed to implement meaningful, resident centered interventions for R14 and R57. This placed the residents at risk for further falls and avoidable injuries.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to prepare pureed foods (a texture-modified diet in which all foods have a soft, pudding-like consistency) by methods that conserve nutritive value, flavor, and appearance for nine residents who received pureed diets placing the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to report to the state agency Resident (R)16's injuries of unknown origin and failed to report to the state agency R14's unwitnessed fall resulting in fracture. This placed the residents at risk for unidentified and ongoing abuse or neglect.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with one reviewed for post-traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for PTSD for one sampled resident, Resident (R) 36, to provide direction to staff to ensure R36 received care to eliminate or mitigate triggers that may cause re-traumatization of the resident. This placed the resident at risk for unmet needs.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents of which 18 were reviewed for care planning. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent falls for Resident (R) 14, 57, and 21. This deficient practice placed the residents at risk for injuries to uncommunicated care needs.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review and interview the facility failed to prevent medication administration errors for Resident (R) 10's when staff crushed and mixed the medications and placed them in R10's food. The services the facility provided R10 did not meet professional standards of quality. This deficient practice placed R10 at risk for adverse reactions by not receiving the appropriate amount of medications prescribed.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents with one reviewed for discharge. Based on record review and interview, the facility failed to develop a discharge summary that included a recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay for Resident (R)67. This placed the resident at risk for unmet care needs.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with two reviewed for skin conditions not pressure related. Based on observation, record review, and interview, the facility failed to implement interventions to prevent skin tears for one sampled resident, Resident (R) 16, and the facility failed to protect skin to prevent bruises during a transfer for R65. This placed the residents at risk for further injury.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents with two being reviewed for bowel/bladder incontinence, indwelling catheter (tube placed in the bladder to drain urine into a collection bag), and urinary tract infections (UTI). Based on observation, record review and interviews, the facility failed to provide Resident (R) 35 with sanitary catheter care while draining the urine drainage bag which placed R35 for risk of infection and cathter related complications.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with one reviewed for post -traumatic stress disorder (PTSD-psychiatric disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress, such as natural disaster, military combat, serious automobile accident, airplane crash or physical torture). Based on observation, record review, and interview, the facility failed to ensure Resident (R) 36 received trauma-informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident which placed the resident at risk for unmet behavioral health care needs.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with five reviewed for dementia (progressive mental disorder characterized by failing memory, confusion) care. Based on observation, record review, and interview, the facility failed to provide the necessary treatment and services to attain or maintain the highest practicable physical and psychosocial well-being for Resident (R) 21, who had dementia and related behaviors. This placed the resident at risk for decreased quality of life.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with six reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Pharmacy Consultant addressed the facility's lack of assessing and monitoring behaviors and side effects for Resident (R) 60's use of Haldol (antipsychotic medication class used to treat major mental disorder characterized by a gross impairment in reality and other mental emotional conditions). This deficient practice placed the resident at risk for unnecessary psychotropic (alters mood or thought) medication.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with six reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to assess and monitor behaviors and side effects related to Resident (R) 60's use of Haldol (antipsychotic medication class used to treat major mental disorder characterized by a gross impairment in reality and other mental emotional conditions). This deficient practice placed the resident at risk for unnecessary psychotropic (alters mood or thought) medication.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, record review and interview the facility failed to prevent medication administration errors for Resident (R) 10 when staff crushed and mixed his medications and placed them in R10's food. This deficient practice placed R10 at risk for adverse reactions by not receiving the appropriate amount of medications prescribed.

Inspectors wroteThe facility had a census of 65 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to employ a full time certified dietary manager for 43 residents who resided in the facility and received meals from the facility kitchen.

Inspectors wroteThe facility had a census of 65 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to prepare and serve food in the facility kitchen under sanitary conditions.

Inspectors wroteThe facility had a census of 65 residents. The sample included 16 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 6's, and R35's insulin (hormone which allows cells throughout the body to uptake glucose) pens with the date opened, expiration date and resident name in two of four medication carts.

Inspectors wroteThe facility had a census of 65 residents. The sample included 16 residents. Based on observation, record review, and interview, the facility failed to prevent the development and transmission of infection when staff failed to properly store Resident (R)29 and R30's oxygen tubing and nasal cannula (a device used to deliver supplemental oxygen or increased airflow to a person in need of respiratory help).