Christian Park Health Care Center

Inspectors wroteThis citation pertains to complaint #3053535Based on interview and record review, the facility failed to ensure the safe wheelchair transportation of one resident (R4) of three residents reviewed for accidents and environmental hazards. This deficient practice resulted in actual harm when the resident's leg slipped from the wheelchair footrest during transport, causing hyperextension of the knee, an inoperable femur fracture due weight and respiratory status, chronic pain, and confinement to bed.

Inspectors wroteThis citation pertains to complaint intake #3010662. Based on interview and record review, the facility failed to notify the state agency of a resident-to-resident altercation to the State Agency (SA) for two Residents (#1 and #5) of five residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a complete infection control program as evidenced by failure to:Effectively mitigate outbreaks of COVID-19 and Influenza A resulting in widespread dissemination of infection disease throughout the facility. Properly disinfect and store multiple-resident use glucometers and individual insulin pens following use. Maintain clean and sanitary medication carts, andProperly clean and sanitize resident bed pans for 5 of the 5 residents in the facility that use bed pans. This deficient practice resulted in the harm when COVID-19 and Influenza A outbreaks in January and February 2026, respectively, spread throughout all Halls of the facility, infecting 25 Residents with one death for COVID-19, infecting 10 Residents with one death for Influenza A, and a decreased quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to protect the residents' right to be free from willful neglect in answering a call light for one Resident (8) of 4 residents reviewed, resulting in Resident #8 waiting for over 20 minutes to be addressed while moaning, crying out and thrashing. Based on the reasonable person concept Resident #8 exhibited signs and symptoms of extreme pain and overwhelming anxiety caused by this extended time of unmet needs.

Inspectors wroteThis citation pertains to Complaint # 2972928. Based on interview, and record review, the facility failed to timely readmit one Resident (#1) of three residents reviewed for admission, transfer, and discharge rights, resulting in Resident #1 feeling of unnecessary separation from family and friends and uncertainty related to continued medical care and financial stress, as well as psychological stress and anxiety.

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

Inspectors wroteBased on observation and interview, the facility failed to maintain general repair of patient equipment and the premises resulting in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents of the facility. Findings Include:On 4/7/2026 at 8:25 AM in room [ROOM NUMBER] Bed A, observed that the headboard was broken away from the bed and sitting askew with the left corner of the headboard sitting on the floor. During this observation, resident 1 stated that they had requested this be repaired three to four months ago and nothing had been done yet. On 4/7/2026 at 09:29 AM observed duct tape on the handle of the hopper water hose that is used to rinse out soiled linens. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Medication Regimen Reviews (MRRs) were addressed by the physician in a timely manner and maintained in the clinical record for three Residents (#5, #45, and #52) of five residents reviewed for MRRs.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate advanced directive information was in place for one Resident (7) of two residents reviewed for accuracy of advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time).

Inspectors wroteBased on interview and record review, the facility failed to ensure unnecessary psychotropic medications were not administered for an extended duration and without appropriate indications for use for 2 Residents (R45 & R59) of 5 residents reviewed for unnecessary medications/chemical restraints. This deficient practice resulted in administration of antipsychotic medications for an extended duration, administration of antipsychotic medication without appropriate diagnoses for use, and lack of timely gradual dose reductions (GDRs).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement its Abuse Program Policy and Procedure and immediately protect other this and other residents from neglect, for 1 Resident (#8) from 4 residents reviewed for abuse/neglect. This deficient practice resulted in the potential for continued resident abuse/neglect.

Inspectors wroteBased on observation, interviews and record review the facility failed to investigate a report of neglect for 1 Resident (#8) of 4 residents reviewed for abuse/neglect, resulting in the potential for continued abuse and/or neglect of residents residing in the facility to go unrecognized.

Inspectors wroteThis citation pertains to Intake Complaint # 2972928. Based on interview and record review, the facility failed to fully implement their policy and procedure and provide applicable bed hold policy information, written transfer notifications, and required hospital documents for 1 (Resident #1) of four residents reviewed for hospitalizations resulting in worry, fear and frustration for R1 and the delay in his re-admission from a lengthy out of state hospitalization.

Inspectors wroteBased on interview and record review the facility failed to obtain a PASARR (Preadmission Screening/Annual Resident Review) prior to admission for one Resident (#3) of two residents reviewed for PASARR screening.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen services per standards of practice for two Residents (#65 & #83) of four residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident medications were securely stored in locked compartments for all Residents residing on the 200 Hall. This deficient practice resulted in the potential for tampering and/or diversion of resident medication.

Inspectors wroteThis citation pertains to intake: 2674136Based on interview and record review, the facility failed to implement preventative measures, promptly assess and treat constipation for 1 resident (Resident #1) of 3 residents reviewed for quality of care and prevent further medical complications from constipation. This failure resulted in actual harm when R1was hospitalized for a small bowel obstruction, leading to acute kidney injury and sepsis.

Inspectors wroteThis citation pertains to intake #2674136Based on interviews and record review the facility failed to implement, review and revise care plans and interventions for 1 of 3 residents (Residents #1) reviewed for quality of care resulting in delay in treatment for constipation, development of a small bowel obstruction, and hospitalization.

Inspectors wroteThis citation pertains to intake #MI00150692 Based on observation, interview, and record review, the facility failed to treat a resident with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life and individuality for 1 Resident (#1) of 4 residents reviewed for dignity and resident rights, resulting in R1 having increased anxiety, and feelings of frustration.

Inspectors wroteThis citation pertains to Intakes: MI00147097 and MI00147132. Based on observation, interview, and record review, the facility failed to assure residents received food as prescribed by a physician and in accordance with preferences for three residents (R12, R13, and R15) of four residents reviewed for therapeutic diets. This deficient practice resulted in a potential for choking and the potential for health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary treatment and services to promote healing and prevent wound infection for two Residents (R57 & R71), out of four residents reviewed for pressure injuries. This deficient practice resulted in harm with delay and/or removal of recommended pressure relieving mattresses, delayed healing, and worsening of condition with the development of osteomyelitis for R71.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient numbers of staff to provide adequate care to the resident population in accordance with the facility assessment. This deficient practice resulted in the potential for unmet care needs and the provision of inadequate care for all 70 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, and serve food in accordance with professional standards for food service safety as evidenced by failing to properly clean areas with a potential to contaminate food during preparation. This deficient practice had the potential to result in food borne illness among any or all 70 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a correct therapeutic diet was served as prescribed for four residents (R59, R29, R275, and R66) of 20 residents reviewed for therapeutic diets. This deficient practice resulted in the potential for health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate positioning during meals for two Residents (R17 & R57) of eight residents reviewed for activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to recognize, address, and provide the fluid requirements as ordered by the physician for one dialysis resident reviewed for fluid needs (Resident #43). This deficient practice resulted in the potential for fluid overload and medical complications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe resident self-administration of medication for one Resident (R41), of five residents reviewed for unnecessary medications This deficient practice resulted in the potential for improper medication administration for R41.

Inspectors wroteThis citation is linked to intake #MI00139805 Based on observation, interview, and record review the facility failed to care for multiple pressure wounds according to physician orders for three Residents (R4, R5, & R6) out of three residents reviewed for pressure ulcer care. This deficient practice resulted in R6 developing infection, deterioration of pressure wound, hospitalization, wound debridement, and sepsis.