Christian Extended Care & Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure employee two-step tuberculin skin tests were completed in accordance with guidelines from the Centers for Disease Control and Prevention (CDC) and State health department, as per the facility policy, for four out of nine employees reviewed. The census was 47. Review of the facility's Employee Health policy, last reviewed July 2022, showed: -Purpose: To provide specific directions for consistent processing of all employee health-related concerns within the corporation's residences; -Policy: -Employment History and Physical Examinations: --All newly hired employees must be medically certified to be free from communicable disease before there is contact with any resident; -Tuberculosis Control Program: [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide the required assistance with activities of daily living (ADLs, bathing, dressing, hygiene, grooming, and toileting) for three residents to maintain adequate personal hygiene (Resident #270, Resident #169, and Resident #19). The sample was 12. The census was 47. Review of the facility's Skin Integrity policy, revised, September, 2022, showed: -Policy: All residents will be assessed for the risk of skin breakdown; Risk factors identified will be evaluated; Interventions will be developed and implemented to minimize or stabilize the risk; Interventions will be care planned; -Prevention: Excessively dry skin should be treated with a moisturizing lotion. Review of the facility's A.M. and P.M. Care policy, revised October, 2022, showed: -Purpose: [...]

Inspectors wroteBased on observation and interview, the facility failed to label and cover opened food packages, keep the kitchen floor and ceiling clean, and failed to ensure staff followed the facility hairnet/beard net policy. This had the potential to affect all residents who consumed food prepared by the facility. The census was 48. 1. Observation on 10/10/23 at 9:35 A.M. of the bulk storage room, showed the following: -An opened, undated jug of syrup on the shelf with dry pasta; -An undated, opened package of sandwich cookie pieces, with no covering on the far back storage rack. Observation on 10/11/23 at 7:56 A.M. of the dry storage room, showed the following: -An opened, undated jug of syrup on the shelf with dry pasta; -An undated, an opened package of sandwich cookie pieces, with no covering on the far back storage rack; [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit resident Minimum Data Sets (MDS), a federally mandated assessment instrument completed by facility staff, in a timely manner for four of four months reviewed. The census was 48. Review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) manual, version 1.18.11 dated October 2023, showed: -All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System; -Transmitting Data: Providers must transmit all sections of the MDS 3.0 required for their State-specific instrument and all tracking or correction information; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications kept in the facility medication room were within the date of expiration and to ensure a medication in the medication cart was labeled when it was opened and with the expiration date from opening. These practices affected one out of one medication room and one out two medication/treatment carts reviewed. The census was 48. Review of the facility's Storage and Expiration Dating of Medications, Biologicals policy, last revision on 8/7/23, showed: -Facility should ensure that medications and biologicals that have an expired date on the label, have been retained longer than recommended by the manufacturer or supplier guidelines, are stored separate from other medications until destroyed or returned to the pharmacy or supplier; [...]

Inspectors wroteBased on observation and interview, the facility failed to post, in a form and manner accessible and understandable to residents and resident representatives, the name, address, and telephone number for the State Survey Agency, and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, and misappropriation of resident property. The census was 48. Observations throughout the survey from 10/10/23 through 10/13/23, showed no contact information for the State Survey Agency posted. During a group interview on 10/11/23 at 11:00 A.M., six out of six residents, whom the facility identified as alert and oriented, said they did not know where contact information for the State Survey Agency was posted in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the State Long-Term Care (LTC) Ombudsman of resident transfers and discharges. The census was 48. Review of the facility's Discharge/Transfer of a Resident, Including Against Medical Advice policy, revised December 2022, showed: -Purpose: To provide guidelines when discharging or transferring a resident to another health care residence, another bed within the residence, or when leaving against medical advice (AMA); -Non-emergency transfers of discharges - initiated by the community, return not anticipated; --A copy of the discharge notice shall be provided to a representative of the Office of the State LTC Ombudsman. This copy must be sent at the same time notice is provided to the resident and resident representative; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used acceptable infection control procedures by wearing the appropriate Personal Protective Equipment (PPE) while providing personal care on the COVID-19 quarantine unit for one resident (Resident #183) and not ensuring staff washed their hands and changed gloves appropriately during wound care for one resident (Resident #232). In addition, staff failed to follow infection control practices regarding mask usage while preparing food and failed to ensure an ice scoop remained covered to prevent contamination. The census was 45. Review of the facility's policy on Infection Control Novel Coronavirus Prevention and Response, updated 7/30/20, showed: -Purpose: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one resident sampled with a hand brace received assistance to wear the left hand brace per skilled therapy instructions (Resident #5). The total sample was 12. The census was 45. Review of Resident #5's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 5/25/20, showed: -admission date of 2/14/15; -Diagnoses of dementia and depression. Review of a restorative care program form, dated 6/30/20 with an effective date of 7/1/20, showed: -Patient will tolerate application of left hand splint following meals; -Place splint on after meals, leaving thumb out. Allow resident to wear as tolerated. He/she may remove the splint or ask staff to remove the splint; -Notify therapy of any redness or skin breakdown if it occurs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have systems in place to ensure one resident received proper care and staff assistance while turning and positioning during incontinence care. The resident rolled from the bed, landed on the floor and sustained a left arm fracture (Resident #182). The sample was 12. The census was 45. Review of Resident #182's admission face sheet, showed an admission date of 9/1/20. Review of a document titled CORP-One-Click (MDS 3.0, (Minimum Data Set, a federally mandated assessment instrument completed by facility staff)) Report (a seven day look back assessment completed by direct care staff showing the level of care a resident required during the assessment period and used by the facility MDS Coordinator to complete the residents MDS assessment. The assessment period for this report was 9/2/20 through 9/8/20. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure insulin pens were dated when opened for one of four medication carts. The census was 45. Review of the facility's Insulin Administration and Storage policy, updated 10/2018, showed: -Purpose: To provide guidelines for proper administration of insulin and establish safe practices for storage of insulin agents; -Policy: Insulin will be stored and administered according to pharmacy and manufacturer's guidelines; -Practice: Safety Storage Guidelines for insulin: A) All parenteral insulin agents should be stored in the refrigerator until opened and are good until the expiration date if the temperature is maintained at 36-46 Fahrenheit. B) After opening, insulin vials should be stored on the medication cart as long as the temperature does not exceed the recommended temperatures for the particular insulin. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue written emergency transfer/discharge notices to residents and/or residents' representatives when the residents were transferred to a hospital for various medical reasons, and failed to send a copy of the notice to a representative of the State Long-Term Care (LTC) Ombudsman, for three residents (Residents #7, #60, and #58). The sample was 12. The census was 45. 1. Review of Resident #7's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, admission and discharge assessments, showed: -admission date of 1/1/15; -discharged to the hospital 4/25/20; -readmission to the facility 6/2/20. Review of the resident's medical record, showed no documentation the resident and/or their representative were provided a written notice of the resident's transfer to the hospital. 2. [...]