Christian Community Home

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that 1 of 4 residents (R16) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent potential skin breakdown and promote healing of existing PIs. R16 was at risk for PI on admission having no PIs, weekly PI assessments were not completed consistently, physician was not notified with changes in the PI, alternate support surfaces were not provided when skin issues were noted. The PI care plan was not developed until 2 months after the identification of the stage 3 PI. Offloading of the PI was not observed by Surveyor. This is cited at actual harm.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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): [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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, .). [...]