Christian Care Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders and nursing professional standards of practice for 4 residents (Resident #2, #34, #23, and #53) out of 15 residents reviewed for medication administration.

Inspectors wroteThis citation pertains to intake 2727057. Based on interview and record review, the facility failed implement dietary orders and care plan interventions to ensure safety with evening snacks for 5 residents (R52, 33, 34, 44, 45), of 5 residents reviewed for eating safety.

Inspectors wroteThis citation pertains to 2628080. Based on observation, interview and record review, the facility failed to prevent the physical restraint of 1 Resident (R200) out of 3 reviewed for restraints.

Inspectors wroteThis citation pertains to intake 2628080. Based on observations, interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act regarding reportable incidents for 1 Resident (Resident#200) of 4 residents reviewed for reporting.

Inspectors wroteThis citation pertains to intake 2628080Based on interview and record review, the facility failed to complete and report a thorough investigation for an allegation of abuse for 1 Resident (R200) of 3 residents reviewed.

Inspectors wroteThis citation pertains to intake 2628080Based on interview and record review, the facility failed to ensure the medical records for 1 of 3 residents (R200) was complete and accurate.

Inspectors wroteThis citation pertains to intake 2572210. Based on interview and record review, the facility failed to report verbal abuse and intimidation from a staff member to the State Agency for 1 Resident (Resident #2) of 3 residents reviewed for reporting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteThis citation has two Deficient Practice Statements DPS A Based on observations, interviews and record review, the facility failed to meet standards of care for infection control related to tracking and trending employee/resident illnesses, maintaining up to date infection control policies and procedures, practicing appropriate hand hygiene for 3 residents (R1, R4 and R25) of 3 residents reviewed for care, and medication storage in 1 of 2 medication storage rooms.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide care in a dignified manner for four Residents (R5, R30, R35 and R40) of 15 Residents reviewed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow policies and procedures to accurately assess, monitor and treat/improve pressure ulcers for 2 Residents (R1, and R350) of 4 Residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1) post daily nurse staffing data in a prominent place readily accessible to residents and visitors and 2) list the facility census and actual hours worked by category of licensed and unlicensed nursing staff (i.e., Registered Nurse, Licensed Practical Nurse, Nursing Assistant) directly responsible for resident care per shift on the historic daily nurse staffing data sheets.

Inspectors wroteBased on interview and record review, the facility failed to inform 1 of 5 residents (R350) reviewed for unnecessary medications of the risks versus benefits and indications for use of a psychotropic medication prior to administering it.

Inspectors wroteBased on observations, interviews and record review, the facility failed to respond timely to resident grievances for 2 Residents (R10 and R40) of 15 residents sampled.

Inspectors wroteBased on interview and record review, the facility failed to record the reason for a transfer to the hospital emergency department in the resident's medical record for 1 of 1 resident (R47) reviewed for hospital transfers.

Inspectors wroteBased on interview and record review, the facility failed to provide to the resident and/or the resident representative written notice which specified the duration of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility for 1 of 1 resident (R47) reviewed for hospital transfers.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor and provide care for one (R30) of one resident reviewed for dental care.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide the care of contractures for one (R3) of one resident reviewed for contractures.

Inspectors wroteBased on observations, interviews and record review, the facility failed to prevent a fall for 1 Resident (R17), of 1 Resident reviewed for falls.

Inspectors wroteBased on interview and record review, the facility failed to follow policies and procedures to maintain a sensical system of accountability for controlled substances for 1 Resident (R4), of one resident reviewed for narcotic administration.

Inspectors wroteBased on observation and interview, the facility failed to appropriately maintain medication storage for one medication room of two medication rooms.

Inspectors wroteBased on interview and record review, the facility failed to ensure admission orders were thoroughly reviewed and transcribed accurately, and pertinent physical assessment findings recognized and promptly addressed for 1 resident (Resident #49) out of 3 closed records reviewed, resulting in two hospitalizations due to missed orders and failure to address a change in condition in a timely manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Properly date mark and discard food product; 2. Properly store food product; 3. Ensure cleaning of food and non-food contact surfaces; 4. Air dry pots and pans; and 5. Minimize bare hand contact with ready to eat food. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 49 residents who consume food from the kitchen. Findings Include: 1. During an interview with Certified Dietary Manager (CDM) M, at 9:25 AM on 4/15/24, it was found that potentially hazardous foods made in house are held for three days and commercially prepared products are generally held for seven days. Observation of the walk in cooler at this time found the following: [...]

Inspectors wroteased on observation, interview, and record review, the facility failed to implement and maintain an effective Infection Control Program to include comprehensive surveillance of facility infections and education and implementation of infection control measures for one facility Resident (R9).

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain a process to ensure pharmacy monthly medication reviews and recommendations were reviewed and acted upon by the attending physician for five facility Residents (R2, R24, R30, R42, and R9) resulting in pharmacy recommendations not being reviewed and the potential for unnecessary medication to be administered. Resident #2 (R2) Review of the medical record reflected R2 was admitted to the facility 12/4/23 with diagnosis that included Fractures with Multiple Other Trauma and Depression. Review of the EMR for R2 reflected Pharmacy Notes (Pharmacy Review) entered 12/20/23 and 1/24/24. Both entries reflected Consultant Pharmacist Monthly Review . Recommendation(s): Non-Significant Recommendation to Physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure certified nursing assistants completed the required 12 hours a year of in-service training, resulting in the potential for inadequate and substandard quality of care for residents living at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure Advanced Directives were documented and communicated sufficiently to reflect the code status of 1 resident (Resident #19), out of 13 residents reviewed for Advanced Directives, resulting in the potential failure to carry out a resident's medical treatment decisions.

Inspectors wroteBased on interview and record review, the facility failed to provide notification of planned discontinuation of coverage for Medicare Part A services for 2 residents (Resident #1 and #40) of 3 residents reviewed for this requirement, resulting in the loss of the right to appeal the determination and the potential for unforeseen obligation and hardship.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the Plan of Care for one Resident (R10) with displays of behaviors affecting others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of quality were followed for 1 resident (Resident #38) of 13 residents reviewed for professional standards of quality, resulting in the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident did not experience bowel incontinence and/or complications from constipation for 1 resident (Resident #34), out of 13 residents reviewed, resulting in diarrhea and subsequent constipation when the facility did not implement appropriate bowel monitoring and protocols.

Inspectors wroteBased on interview and record review, the facility failed to attempt gradual dose reductions of psychotropic medications and ensure PRN (as needed) psychotropic medications were limited to 14 days for 2 residents (Resident #30 and #42) of 5 residents reviewed for unnecessary medications, resulting in the administration of unnecessary medications and the potential for residents to not meet their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement antibiotic use protocols and a system to monitor antibiotic use for 1 resident (Resident #34) out of 5 residents reviewed for high-risk medications, resulting in the potential for antibiotic resistance, adverse reactions and/or complications from inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate neurological assessments were completed for 1 resident (Resident #1) out of 4 residents reviewed for falls, resulting in the potential for a delay in treatment after an unrecognized acute change in condition.

Inspectors wroteBased on interview and record review, the facility failed to treat 2 of 4 residents with dignity (R1 and R4), resulting in R1 soiling herself and R4 spilling his urinals on himself because of a staff member's refusal to provide assistance when requested.

Inspectors wroteThis citation pertains to Intake M100140268 Based on interview and record review, the facility failed to implement policies and procedures to ensure pre employment screenings were complete, employee trainings done, ensure 2 Certified Nursing Assistants (CNAs) were evaluated for skills competencies, and 2 CNAs in Training (CNAT) were evaluated for skills competencies and licensed within the allotted time frame after the completion of formal nurse aide training, in a total sample of 5 staff reviewed, resulting in the potential for unqualified personnel with incomplete background checks providing care to a vulnerable population that could be a potential for abuse and/or neglect.