Church of Christ Care Center

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the state agency for one resident (R901) of three reviewed for verbal abuse.

Inspectors wroteThis citation pertains to Intake: 3030980 Based on interview and record review, the facility failed to prevent misappropriation of property for one resident (R901) of three residents reviewed for misappropriation.

Inspectors wroteThis citation pertains to Incident 2984504. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff, affecting one resident (R701) of three reviewed for abuse.

Inspectors wroteThis citation pertains to intake 1238200. Based on interview and record review the facility failed to utilize the required two staff to complete incontinence care for one sampled resident (R4) of four residents reviewed for accidents, resulting in a fall from the bed and a fracture of the right arm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have available and don/doff (put on and take off) personal protective equipment (PPE-gowns, gloves, masks, etc.) for one resident on Enhanced Barrier Precautions (EBP) (R117) out of six reviewed for infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice machine near the main kitchen was backflow protected. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop/implement comprehensive care plans for three residents (R13, R88, and R99) out of four reviewed for Care Plans. Findings Include:R13 On 8/18/25 at 9:00 AM, R13 was observed sitting on the side of the bed. R13 appeared anxious with nervous speech and finger movements. A review of the medical record for R13 occurred and revealed the following: R13 was initially admitted to the facility on [DATE] and after a brief hospitalization was readmitted [DATE] with following diagnoses including: Dementia, Schizophrenia, Depression and Chronic Obstruction Pulmonary Disease. A review of R13's Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental status (BIMS) assessment score of 14/15 indicating intact cognition. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete an accurate resident assessment for one sampled resident (R36) of 23 reviewed for assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide built up utensils for one resident (R99) out of one reviewed for Adaptive Equipment.

Inspectors wroteThis citation pertains to intake 1238202. Based on observation, interview, and record review, the facility failed to provide 1:1 feeding assistance for one resident (R16) and grooming assistance for one resident (R20) out of three reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on observation, interview, and record review the facility failed to reposition one resident (R113) in a timely manner out of two reviewed for interventions for pressure ulcers.

Inspectors wroteBased on observation, interview and record review the facility failed to apply oxygen per physician order for one resident (17) out of 2 reviewed for respiratory care.

Inspectors wroteThis citation pertains to Intake MI00146997. Based on observation, interview, and record review, the facility failed to protect one resident's (R700) right to be free from physical abuse by staff of one resident reviewed for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, identify, provide treatment and prevent pressure ulcers for two residents (R78 and R21) of seven reviewed for pressure ulcers, resulting in the development and worsening of pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to review and report monthly pharmacist medication recommendations for four residents, (R19, R31, R35 and R70) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive wound care plan for two (R78 and R91) of two residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow an OBRA II Evaluation (Omnibus Budget Reconciliation Act, federal law aimed at improving the quality of care and life for resident's of long term care facilities) recommendation timely, inform the resident of their rights regarding their trust, and address guardianship for one resident, (R22) of one resident reviewed for life satisfaction.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide showers for one sampled resident (R19) of six reviewed for activities of daily living.

Inspectors wroteDeficient practice #2. Based on interview and record review the facility failed to assess and address a change in condition and control pain for one (R107) out of one resident reviewed.

Inspectors wroteThis citation pertains to intake M100144181. Based on observation, interview and record review, the facility failed to implement measures to prevent multiple falls for one (R701) of eight residents reviewed for falls, resulting in a right femur fracture that required a surgical repair, additional assistance with transfers and pain management.

Inspectors wroteThis citation pertains to Intake M100143631. Based on interview and record review, the facility failed to honor the advance directive/code status wishes for one (R707) of four resident's reviewed for advance directives.

Inspectors wroteThis citation pertains to MI00141118. Based on observation, interview, and record review the facility failed to ensure timely repair, maintenance and cleanliness in five of five rooms (103, 213, 413, 414, 415).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for three residents (R3, 93, and R15) and six confidential group residents of eleven residents reviewed for palatable food, resulting in resident dissatisfaction during meals.

Inspectors wroteBased upon observation, interview and record review, the facility failed to provide therapist recommended bed mobility assist bars in a timely manner for one (R83) of five residents reviewed for adaptive equipment, resulting in resident dissatisfaction and reduced resident independence with bed mobility and repositioning.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that showers were provided on scheduled shower days for one resident (R65) of two residents reviewed for activities of daily living care (ADLs), resulting in a resident having a disheveled appearance and feelings of being Dirty.

Inspectors wroteBased upon observation, interview and record review, the facility failed to complete or facilitate bed repositioning per care plan and professional standards for two (R61, R65) of four residents reviewed for repositioning resulting in resident dissatisfaction with care and the potential for onset or worsening of skin breakdown.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the resident's name, date, time, and order information for enteral feeding (Liquid nutrient solution fed through a PEG-Percutaneous Endoscopic Gastostomy tube inserted in through the stomach) was completed, and failed to maintain a clean pole, for one (R39) of one resident, reviewed for tube feedings, resulting in the potential for tube feeding not administered according to the physicians orders.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident's fluid restriction amount was monitored and actual intake documented for one (R78) of one dialysis resident reviewed resulting in the potential for fluid intake greater than the ordered amount and fluid overload.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dental services for one resident (R4) of one reviewed for dental services, resulting in downgrade of diet and unmet dental needs or desires.

Inspectors wroteBased on interview and record review the facility failed to ensure restorative services were documented and documentation maintained in the medical record for four (R13, R17, R25, R78) residents of five who were reviewed for implementation of restorative services resulting in missing documentation for any visits completed and the potential for services not rendered.