Christian Community Home of Osceola, Inc

Inspectors wroteBased on interview and record review, the facility did not report an allegation of neglect to the State Survey Agency or local law enforcement within 24 hours after being made aware of the allegation for 1 of 1 resident (R1) reviewed. On 05/10/26 at 10:56 PM, Director of Nursing (DON) B was notified via email by Certified Nursing Assistant (CNA) D of a neglect concern regarding R1. DON B did not submit a Misconduct Incident Report to the State Survey Agency after being made aware of concern. This is evidenced by:On 05/26/26 at 8:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding quality of care of residents and reporting grievances. CNA D stated on 05/10/26, CNA D sent an email to DON B (Director of Nursing) regarding concerns of neglect. [...]

Inspectors wroteBased on interview and record review, the facility did not complete a thorough investigation after being made aware of a concern of neglect for 1 of 1 resident (R1) reviewed. On 05/10/26 at 10:56 PM, Director of Nursing (DON) B was notified via email by Certified Nursing Assistant (CNA) D of a neglect concern regarding R1. The facility did not immediately begin a thorough investigation of reported neglect, collect information that corroborates or disproves the incident, and document the findings. This is evidenced by: On 05/26/26 at 8:39 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D regarding quality of care of residents and reporting grievances. CNA D stated on 05/10/26, CNA D sent an email to DON B regarding concerns of neglect. [...]

Inspectors wroteBased on interview, observation and record review, facility did not implement professional standards of practice to ensure a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 1 of 3 residents (R1) reviewed. R1 was assessed as high risk for PI development. The facility failed to implement interventions to prevent PI development, ensure treatment orders were completed as ordered, and failed to complete a comprehensive assessment upon discovery of a new avoidable PI on R1's buttocks. This is evidenced by:Facility policy titled, Skin Alteration Policy and Procedure, with no date, states: Purpose: To establish a comprehensive facility program to maintain optimal skin condition for the residents. Policy: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that falls were thoroughly investigated to determine root cause, new safety interventions implemented, staff education, and monitoring of effectiveness of interventions for 1 of 3 residents (R4) reviewed.-On 12/03/25, R4 sustained a fall. Facility determined root cause of fall was that staff did not follow R4's care plan interventions of:Pressure alarms in place on bed and chair (10/02/25). Pressure and laser alarm (10/02/25). Tab alarm (10/02/25).-After fall on 12/03/25, new intervention of checking R4 every 2 hours at bedtime for alarm placement was implement. No documentation on staff education following fall and new intervention.-On 12/23/25, R4 had a fall. No new interventions were implemented. No documentation on staff education. Interventions implemented after -On 02/02/26, R4 had a fall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness to 33 out of 33 residents reviewed. The kitchen cooler contained a variety of foods not labeled with open or use-by dates. Cook Q had personal beverages on the food prep table.

Inspectors wroteBased on observation, interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of communicable diseases. The facility was not tracking infection surveillance accurately. These failures have the potential to affect 31 of the 31 residents. LPN L was observed touching medications with bare hands for 2 of 2 residents (R133 and R1) during medication pass. Improper hand hygiene observed for 2 of 4 residents (R8 and R23).

Inspectors wroteBased on record review, observation and interview, the facility did not ensure the resident environment remains free of accident hazards possible and each resident receives adequate supervision and assistance devices to prevent accidents. Facility did not assess residents for safe use of the EZ sit to stand lift for 5 out of 5 residents (R) (R23. R9, R21, R12, R17). Facility does not have a procedure in place to assess appropriate EZ Way Smart Stand mechanical lift (sit to stand) slings for accurate size and fit for each resident requiring use of the EZ stand lift for transfers. Certified Nursing Assistants (CNA) are determining what size sling to use for each resident.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 5 of 5 residents (R) reviewed (R8, R14, R232, R11, R4). -Medication storage room had 2 opened unlabeled bottles of Lorazepam for resident (R8 and R14) with unknown expiration date. -Medication storage room had 1 opened and expired bottle of Amoxicillin for R232 stored in refrigerator that expired on 04/24/25. -Medication cart had R11's Morphine Sulfate liquid bottle opened unlabeled with unknown expiration date. -Observation of prescribed Nystatin powder left unattended in R4's room during 1 observation.

Inspectors wroteBased on observation, interview and record review, the facility did not notify the physician on call of R4's refusal of insulin for 1 of 1 resident (R) reviewed for insulin administration (R4).

Inspectors wroteBased on record review and interview, the facility did not implement policy and procedures related to screening employees for a prior history of abuse, neglect, exploitation of residents, or misappropriation of resident property for 1 of 8 employees reviewed. The facility did not ensure their abuse policy was implemented when one employee's background information disclosure (BID) was not obtained before employee started working at facility. (RN O).

Inspectors wroteBased on observation, interview and record review, the facility did not ensure prescription medications were administered by qualified staff for 1 of 8 residents (R) observedduring medication administration (R4). -Surveyor observed prescribed Nystatin powder at R4's bedside table. During medication administration, Registered Nurse (RN) O stated Certified Nursing Assistant (CNA) I applied prescribed Nystatin powder to resident (R4)'s skin earlier in the AM.

Inspectors wroteBased on record review, observation and interview, the facility did not ensure a resident who required substantial assistance for repositioning and toileting received timely assistance for 1 of 12 residents (R) reviewed for Activities of Daily Living (ADLs) (R23). R23 requested to use the bathroom and waited 36 minutes before being assisted into restroom, resulting in clothing change, feeling embarrassed and like she is a burden.

Inspectors wroteBased on record review and interview, the facility did not ensure that 1 of 1 resident (R) reviewed received appropriate respiratory care during administration of respiratory therapy (R6). Registered Nurse (RN) O did not perform pre-respiratory assessments for R6 when administering nebulizer treatments.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Long-Term Care Ombudsman of hospital transfer and discharge for 2 residents (R11 and R31) of 2 residents reviewed in the sample of 12. The facility failed to have a system in place to ensure notifying the State Long-Term Care Ombudsman of hospital transfers and discharges. This had the potential to affect all 33 residents that reside in the facility. R11 was hospitalized from [DATE] through 04/05/25 and the Ombudsman was not notified of that transfer to the hospital. R31 was discharged from the facility on 03/06/25 and the Ombudsman was not notified of discharge. This is evidenced by: Example 1 R11 was admitted to the facility on [DATE] with diagnoses, in part, of aortic stenosis, constipation, type 2 diabetes mellitus and irritable bowel syndrome with constipation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not prepare, distribute, and serve food in a manner that prevents foodborne illness to 33 out of 33 residents reviewed. Cook touched ready-to-eat foods with contaminated gloves when serving meals. The facility did not ensure the foods were served at safe temperatures in accordance with professional standards for food safety. Staff identified the temperature of the pork tenderloin on the hot steam table at 132.6 degrees Fahrenheit when serving the lunch meal. The facility did not ensure dishes had proper sanitization completed by observations of low-temperature wash cycles and incomplete chemical solution testing. The kitchen cooler contained a variety of foods in cups not labeled with open or use-by dates. Dietary Aide (DA) laid personal belongings on the food prep table.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not establish a water management program with measures to monitor the control measures in place. The facility did not ensure the standard of practice for infection surveillance and treatment and McGeer's criteria were being utilized in the facility's infection control program. This has the potential to affect all 33 of 33 residents (R) residing in the facility.

Inspectors wroteExample 2 R17 was admitted to the facility on [DATE] with diagnoses that included in part cognitive communication deficit, vascular dementia, abdominal pain, colitis and gastroenteritis, diverticulosis, GERD (gastroesophageal reflux disease), zoster (shingles), long term (current) use of anticoagulant, and atrial fibrillation. R17's MDS assessment, dated 2/13/24, indicated that R17 had frequent pain that was moderate and use of anticoagulant. R17's pain assessments were done quarterly with noted nonpharmacological interventions, pain scale, location, and use of PRN (as needed) Tylenol that helped with R17's pain. R17's pain interviews were completed quarterly with detailed information on R17's pain. Current pain control works for R17. R17's provider orders: *Warm foot soak PRN for foot/joint discomfort as needed. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable for one of one resident reviewed for pressure injuries. Resident (R)12 developed an unavoidable stage 2 pressure injury while at the facility. Observations of poor infection control occurred during wound care. This has the potential to effect 1 of 1 resident observed for pressure injuries.

Inspectors wroteBased on interviews and record reviews, the facility did not ensure that the resident's environment remained as free of accident hazards as possible for 2 of 4 residents (R4, R5). This is evidenced by: Example 1 The facility policy, entitled Fall/Injury Reporting, states in part: 5. Provide immediate safety interventions and document interventions. Utilize fall template for documentation in progress note. 6. Complete Falls Report forms 7. Initiate Fall Investigation 10. A Resident Fall Tracking log will be completed at the Interdisciplinary Team (IDT) meeting to assess trends for each resident and continue with implementation for a plan of prevention. 11. The IDT will audit the medical record for appropriate documentation and conduct a post fall review. 12. The IDT will then evaluate the fall and recommend intervention. [...]

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure pain management orders were followed for 1 of 2 residents (R) reviewed for pain (R183). R183 was prescribed a pain medication with dosage to be given based on the pain scale. The facility did not provide the appropriate amount of pain medication based on R183's pain scale, giving less medication than prescribed.

Inspectors wroteBased on observation, interview and policy review, the facility did not ensure that a resident was provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 resident (R9) reviewed. The facility did not ensure R9 was administered insulin appropriately based on the observation of the Licensed Practical Nurse (LPN) not priming the insulin pen before administration. This is evidenced by: The facility policy, entitled Insulin pens, dated 08/23, states: .-#8. Turn the dial to 2, push the plunger, and waste 2 units. -#9. Turn the dial to an appropriate number of units . On 04/03/24 at 7:25 AM, Surveyor observed LPN E draw 7 units of insulin glargine from R9's insulin glargine pen. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. The facility did not ensure PRN (as needed) orders for psychotropic drugs are limited to 14 days. The facility did not ensure adverse consequence such as unwanted, uncomfortable, or dangerous effects that a drug may have, such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status. This occurred for 1 of 5 residents (R) reviewed for unnecessary medications. (R4). This is evidenced by: The facility's policy entitled Psychotropic Use developed 01/21/14 and last revised August 2023 states: Purpose: [...]

Inspectors wroteBased on observation, interview and policy review, the facility did not ensure all drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, did not ensure only authorized personnel had access to medication carts and did not ensure expired medications were removed from stock supply. This occurred for 2 of the 3 medication carts/storage rooms observed. During the three-day survey, 3 of 4 observations were made of medication carts left unlocked when unattended and out of view of staff. One observation was made of a lorazepam liquid bottle opened and not labeled with an open or expiration date stored in the E-hall medication storage room. One observation was made of an opened bottle of liquid Humalog vial not labeled with resident identification, nor with an open or expiration date label.

Inspectors wroteBased on the interview and record review, the facility did not establish an Infection Prevention and Control Program (IPCP) that must include, at a minimum, the following elements: An Antibiotic Stewardship Program that includes antibiotic use protocols and a system to monitor antibiotic use. This has the potential to affect all 33 residents in the building who may utilize antibiotics. The facility did not ensure the standard of practice for infection surveillance and treatment, and McGeer's criteria were being utilized in the facility's antibiotic stewardship program. The facility did not follow Standards of Practice (SOP) for Antibiotic Stewardship for antibiotic use for residents on the line list logs from [DATE] through [DATE] line lists. This is evidenced by: The Facility Policy entitled Nosocomial Infection Surveillance/Antibiotic Stewardship Program, dated 10/22, states in part: [...]

Inspectors wroteBased on observations and interviews, the facility did not serve food in accordance with professional standards for food service safety. This has the potential to affect all 27 residents in the facility. Exhaust fans over food prep area dirty No hand hygiene between glove changes This is evidenced by: On 02/27/23 at about 9:20 AM, Surveyor performed an initial tour of the kitchen with Director of Dietary (DD) C. Observations of the cooktop hoods were dirty and fuzzy. Surveyor asked DD C if they had a cleaning schedule. DD C indicated they did but due to staff shortages it doesn't always get done. Surveyor asked DD C who was in charge of cleaning the hoods. DD C indicated the lead cook used to do them, but she left. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Housekeeping staff was observed entering a resident room on Transmission Based Precautions (TBP) without wearing proper Personal Protective Equipment (PPE.) Contracted housekeeping staff did not receive training on facility infection control policies and procedures prior to working in the facility. This had the potential to affect all 27 residents in the building. TBP room was not labeled with correct signs to inform staff and visitors what PPE to wear when entering the room. This had the potential to affect all 27 residents in the building. No hand hygiene was offered to residents (R) prior to eating. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not have a rationale documented in the resident's medical record for extending PRN (as needed) psychotropic medications beyond 14 days. This occurred for 3 of 3 residents (R) reviewed for PRN psychotropic medications. (R17, R26, and R19) The facility did not ensure residents who use psychotropic medications receive a gradual dose reduction (GDR). This occurred for 1 of 4 residents reviewed for psychotropic medications. (R11) R17 and R26 had orders for PRN Lorazepam (anti-anxiety medication) which was in place for greater than 14 days without a clinical rationale and no end date. R19 had a physician's order for as needed Haldol with a stop date of indefinite. This allowed R19 to receive the as needed psychotropic medication for longer than 14 days without an indication of use by the ordering physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure each resident's right to be free from physical restraints for 1 of 5 residents (R6) reviewed for falls The facility initiated bed and wheelchair alarms for fall prevention against R6's wishes. R6 was admitted to the facility on [DATE], and has diagnoses that include osteoarthritis, major depressive disorder, and dementia. R6's Minimum Data Set (MDS) assessment, dated 02/07/23, indicated that R6 has a Brief Interview for Mental Status (BIMS) of 14 which indicates R6 is cognitively intact and is his own decision maker. On 02/27/23 at 2:17 PM, on initial tour, Surveyor was interviewing R6 and asking R6 how things were going for them at the facility. R6 indicated they don't like the alarms on their bed and wheelchair. Surveyor asked R6 if they had any falls. R6 indicated they did not. [...]