Christian City Rehabilitation Center

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Elopement Prevention, the facility failed to implement adequate supervision and elopement prevention measures to safeguard one of three sampled residents (R) (R1). This failure allowed the resident to leave the facility without staff knowledge, resulting in an elopement. On July 23, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Health Services (DHS), and Corporate Nurse Consultant were informed of the Immediate Jeopardy (IJ) on July 23, 2026, at 6:05 PM. The noncompliance related to the IJ was identified to have existed on July 16, 2026. [...]

Inspectors wroteBased on observations, staff interviews, and reviews of the Administrator and Director of Nursing (DON) Job Descriptions, the facility administration failed to manage the facility in a manner that protects residents and safeguards them from elopement. Specifically, the administration was aware that the front entry door did not have an operational Wander Guard system to ensure residents at risk for elopement were protected. Despite this known hazard, corrective measures were not implemented. Resident (R) (R1) was placed in imminent danger due to the facility's failure to implement interventions for R1 upon admission. As a result, R1 was able to exit the facility unsupervised, exposing the resident to serious injury, harm, or death. [...]

Inspectors wroteBased on observations, family and staff interviews, record reviews, and review of the facility's policy titled Care Plans, the facility failed to follow the care plan for one of three sampled residents (R) R1 related to a two-person assist with transfers. This failure caused R1 to suffer a fall while being assisted by one staff member and placed the resident at risk of injury.

Inspectors wroteBased on family and staff interviews, record review, and review of the facility's policy titled, Occurrences, the facility failed to provide assistance to prevent a fall for one of three sampled residents (R) (R1) assessed for falls. This deficient practice had the potential to cause injury to the resident.

Inspectors wroteBased on observations, staff interviews, record reviews, and a review of the facility's policy, the facility failed to ensure medication was refilled before the medication ran out and over-the-counter medication was available for one of six residents (Residents (R) 129) observed during the medication administration and two residents (R436 and R98) out of a total of 51 sampled residents. This failure had the potential for adverse effects if medications were not administered due to a lack of timely refills or short supply.

Inspectors wroteBased on observations, resident and staff interviews, and policy review, the facility failed to ensure the call devices used were tailored to meet the individual physical needs of the residents and failed to respond promptly to the call system for two residents, (Resident (R) 25 and R238), out of a sample of 51 residents. This failure placed R25 and R238 at risk of experiencing unmet care needs.

Inspectors wroteBased on observations, resident and staff interviews, and document review, the facility failed to create a homelike environment by ensuring resident rooms were clean or in good repair for four residents (Resident (R) 125, R106, R98, and R56) in the sample of 51 residents.

Inspectors wrote2. Review of R197's undated Face Sheet located under the Resident tab of EMR revealed R197 was admitted to the facility on [DATE] with diagnoses including acute respiratory failure and encounter for orthopedic aftercare, cognitive communication deficit. R197 was discharged to an assisted living facility on 04/09/24. Review of R197's Grievance/ Complaint Form: Health Center, dated 10/23/24, provided by the Administrator, documented there was a late grievance received by the facility Administrator on 10/23/24 after R197 was discharged on 04/09/24. The Grievance form documented the following: wound RP [responsible party] not informed. fall-p't [patient] trapped by male nurse. showers. feeding. weight lost. Resident RP reported issues to [R197's Insurance company name] .forward concerns to facility. Review of R197's Grievance/ Complaint Form: [...]

Inspectors wroteBased on staff interviews, record review, and review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI), the facility failed to complete a significant change Minimum Data Set (MDS) assessment following a decline in a resident's status for one of eight residents reviewed for a change in condition (Resident (R) 120) out of a total sample of 51 residents. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on staff interviews, record review, and review of Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, the facility failed to complete a discharge Minimum Data Set (MDS) assessment within 14 days of a resident's discharge and submit it to the Centers for Medicare and Medicaid Services (CMS) system for two out of 51 sampled Residents (R) (R 131 and R154) reviewed for MDS completion. This failure prevented the transmission and compilation of resident-specific information for payment and quality measure purposes.

Inspectors wroteBased on staff interviews, record review, review of the Centers for Medicare & Medicaid Services' Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual and review of the facility's policy titled, MDS Assessment Accuracy, the facility failed to code pressure ulcers on a Minimum Data Set (MDS) assessment for two of 11 Resident (R) (R194 and R98) reviewed for pressure ulcers. This had the potential to cause the residents to have unmet care needs.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled, Care Plans, the facility failed to ensure a baseline care plan was created within 48 hours of admission for one of 51 sampled Residents (R) (R192) reviewed for baseline care plan. This failure had the potential for the residents to have unmet care needs.

Inspectors wroteBased on staff interview, record review, and review of the facility's policy titled Care Plans, the facility failed to develop a comprehensive care plan for one of 11 Residents (R194) reviewed for pressure ulcers. This had the potential to cause the residents to have unmet care needs.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policy titled, Nursing: Patient/Resident Rights, Accommodation of Needs, the facility did not ensure that two of the 51 sampled Residents (R) (R98 and R151) received nail care. This failure had potential to increase the risk of infectious disease and nail damage for R98 and R151.

Inspectors wroteBased on record reviews, staff interviews, and a review of the facility's policy, the facility failed to administer long-acting insulin in accordance with physician orders for two residents (Resident (R) 436 and R98) out of 51 sampled residents. This failure had the potential to have adverse effects on residents if their insulin was not given or their dose was reduced without a physician's order.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to identify pressure ulcers and initiate treatment orders in a timely manner for one of 11 residents reviewed for pressure ulcers (Resident (R) 194) out of 51 total sampled residents. This had the potential for residents' pressure ulcers to decline.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide restorative nursing services for one of two residents (Resident (R) 98) reviewed for position and mobility out of a total sample of 51 residents. This failure had the potential to negatively affect Resident 98's ability to perform activities of daily living (ADL) and place R98 at risk of ADL decline.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have physician orders and an indication for an indwelling catheter for one (Resident (R) 85) of three residents reviewed for urinary catheters out of a total sample of 51 residents. This failure increased the risk of urinary catheters being implemented without an acceptable indication.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to obtain and document weight for one of nine residents (Resident (R) 197) reviewed for nutrition out of a total of 51 sampled residents. This failure had the potential to place R197 at risk of weight loss if the weight was not obtained and monitored in a timely manner to provide accurate information for nutrition need calculation.

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to ensure documentation of assessment prior to, and upon return from, dialysis and failed to ensure communication forms used between the facility and the dialysis center were completed for one of two residents reviewed for dialysis (Resident (R) 106) out of 51 sampled residents. This had the potential to affect the health of residents receiving dialysis.

Inspectors wroteBased on observations, interviews, record reviews, and a review of the facility's policy, the facility failed to adequately label insulin pens and failed to properly dispose of expired medication in the designated disposal container for one of the four medication carts (MC) that were observed during medication administration on [DATE]. This failure had the potential to increase the risk of medication administration errors and posed a potential biohazard.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Procedure: Blood Glucose Monitoring, the facility failed to ensure infection control practices were followed during a blood glucose (BG) check for one of two residents (Resident (R) 151) observed during medication administration observation. These failures placed all the residents who received a BG check and insulin from the medication cart at risk of contracting infectious diseases.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Foodborne Illness, Patients/Residents' Personal Food', and Labeling, Dating, and Storage, the facility failed to properly thaw frozen foods by not allowing running water to overflow to prevent potential harmful particles/bacteria to run freely. The facility also failed to ensure resident nourishment refrigerators and freezers were clean, resident foods were labeled and dated, as well as food items discarded past the use by date. The deficient practice had the potential to affect 170 residents receiving an oral diet. The facility census was 174.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure an application for Preadmission Screening and Resident Review (PASRR) Level I that included a diagnosis of schizophrenia was submitted prior to or on admission to the facility for evaluation and determination of specialized services for one of 43 sampled Residents (R) (R32). This failure had the potential for residents with mental disorders not to receive identified specialized services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the kitchen was maintained in clean and sanitary condition. This deficient practice had the potential to affect all residents receiving an oral diet. As indicated on the facility's Form Centers for Medicaid and Medicare Services (CMS)-672, Resident Census and Conditions of Residents Form, the facility's census on 6/21/22, was 170 residents.

Inspectors wroteBased on interviews and record review the facility failed to ensure that one of 16 sampled residents (R) (R#35) was provided Activities of Daily Living (ADL) care related to incontinence care.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to obtain a Physician's Order for oxygen use, including the frequency of use and flow rate for one of 57 sampled residents (R) (R#281).