Inland Christian Home

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was properly stored when: 1. For one of five sampled residents (Resident 41), barrier cream was found open and not in a sanitary manner on the night table next to the Resident 41's bed. This failure had the potential to cause contamination to the barrier cream and lead to skin infection. 2. One of one treatment cart was found to have 5 expired packets of hydrogel statured gauze (a wound dressing consisting of gauze that has been infused with a hydrogel, a gel-like substance that is primarily composed of water). This failure had the potential to cause worsening of the wound, delayed wound healing and can lead to wound infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices when: 1. Two food items (BBQ sauce and Shredded Parmesan Cheese) were found in the refrigerator unlabeled and undated. 2. One food item (A tray of tomatoes) was found in the refrigerator beyond its expiration date on the label. 3. The cooling logs for May and June 2025 indicated improper cooling practices and techniques. These failures had the potential to cause significant health risks for all 54 vulnerable residents who reside in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain essential equipment in the kitchen free of accumulation of dirt, food residue, and other debris, when on June 16, 2025, at 9 AM during the initial kitchen tour, the 4-burner stove, the flat top griddle, and the grill were found to be in unsanitary conditions. These failures had the potential to lead to the growth of harmful microorganisms, such as bacteria, viruses, and fungi, which could result in foodborne illnesses for all 54 residents who reside in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS] every 3 months or quarterly) was completed in accordance with federal submission timeframes, for two of two sampled residents (Resident 4 and 46) when: 1. Resident 4's Annual Comprehensive Assessment RAI/MDS assessment was completed on June 18, 2025. (146 days late). 2. Resident 46's quarterly RAI/MDS assessment was not completed on June 18, 2025. (122 days late) These failures had the potential to result in a delay in determining the resources necessary to competently care for the Resident 4 and 46 during the day-to-day operations and emergencies.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the quarterly (every 3 months) Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was transmitted (submitted) to CMS in accordance with federal submission timeframes, for two of two sampled residents (Resident 4 and 46) reviewed for resident assessment when: 1. Resident 4's comprehensive RAI/MDS assessment was completed on June 18, 2025 (146 days late) 2. Resident 46's quarterly MDS assessment was completed on June 18, 2025 (122 days late). These failures resulted in inadequate monitoring of Residents 4 and 46 progress or decline and the lack of Residents 4 and 46 specific information to CMS for payment and quality measure monitoring.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Physician Orders Life Sustaining Form (POLST-medical orders that communicates to healthcare facilities and providers a patient's wishes for end-of-life interventions) was appropriately completed for one of five sampled residents (Resident 37) reviewed for Advance Directives (legal document that allows you to spell out your decision about end-of-life care) when the facility had Resident 37 with a BIMS (brief interview for mental status indicating decision making capacities in which a score of 13-15 has no significant decisions making impairment, a score of 8-12 has moderate decisions making impairment, a score of 0-7 has severe decisions making impairment) of 00 sign the POLST instead of the legally recognized decisionmaker. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that proper and safe infection control policies were followed for one of 15 sampled resident (Resident 2) when in Resident 2's room, a yankauer (a rigid, hollow medical instrument used for suctioning fluids, secretions, and debris from the mouth and throat) was left uncovered and exposed. Further observation in Resident 2' room, the yankauer and suction canister was found not dated. These failures had the potential to result in cross-contamination (transfer of harmful bacteria) which can lead to infection.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 37) received the influenza (also known as the flu, which is a contagious respiratory illness caused by influenza viruses) vaccination even though the flu vaccine was requested on November 14, 2024. This failure had the potential for Resident 37 to have an increase the risk of illness, higher risk of complications, and it may contribute to spreading the virus to others.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food by methods that conserve nutritive value, flavor, and appearance when a tray of pudding and cut melon was stored in the refrigerator uncovered and undated. There was a bag of hot dogs with a mold like substance, tortillas were stored uncovered and leftover pork from May 4 was stored in the refrigerator drawer, ready for use. These failures had the potential for food to not be palatable when served to 52 of 53 vulnerable residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a sanitary kitchen when: 1. Floor behind the cooking line had a build-up of grease and food crumbs. This had the potential to attract pest and for microorganism growth. 2. Floor under the shelves in the dry storage had build-up of food crumbs. This had the potential to attract pests. 3. In the walk-in refrigerator, thawing meat was not labeled or dated. This had the potential to cause food borne illness (illnesses contracted from eating contaminated food or beverages). 4. Ice machine had a brown slime build-up underside of icemaker, in the top portion of the ice bin. This had the potential to cause food-borne illness. These failures had the potential to cause food borne illness to 52 of 53 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program when a roll up door in the paper goods storage closet had a gap where light could be seen coming through. This failure is a potentially for pest entry into the kitchen which could contaminate food and cause food borne illness to 52 of 53 residents that received food from the kitchen.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to ensure the correct amount of enteral feeding nutrition (a liquid nutrition formula for tube feeding administered directly into the stomach) was administered as ordered for two of two sample residents (Resident 45 and 13) when the nursing staff did not give the correct amount of feeding formula as prescribed and in accordance with their care plans (the individualized plan for medical care of a resident). These failures resulted in Resident 13 and 45 to not receive the daily calories as ordered and had the potential to cause sub-optimal (less than ideal) nutritional status that may negatively affect Resident's health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility did not follow the menu when residents on a Consistent Carbohydrate Order (CCHO) diet (diet involves eating the same number of carbohydrates every day to manage blood sugar levels) received ¼ cup serving of Yukon whipped potatoes instead of ½ cup serving and residents on a regular diet received 2.6 ounces of baked ham instead of 3 ounces that the menu indicated, for lunch on Monday May 6, 2024. This failure caused residents to not get the nutrients that their physician ordered diet included and affected 29 of 52 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call system (a system that triggers a visual and/or auditory queue when a resident requests assistance) was functional and accessible in 6 resident restrooms and three shower/bathing rooms, when the call system pull cords (a cord which when pulled, activates the call system) were too short and not accessible to a resident from the floor. This failure had the potential to delay staff response time when residents were experiencing an emergency or needing assistance which could jeopardize residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 13) received medications in the route (way by which a medication is taken into the body) prescribed by the physician when Licensed Vocational Nurse 2 (LVN 2) administered Tramadol (pain medication) 50 milligram (mg - a unit of measure) PO (by mouth) instead of administering the medication through the residents gastrostomy tube (G-tube - a feeding tube inserted directly into the abdomen and into the stomach to deliver nutrition) as ordered by the physician. This failure resulted in a medication error and LVN 2 to not follow the five rights of medication administration (right drug, right dosage, right patient, right route, right time). This placed Resident 13 at risk for adverse outcomes associated with medication errors.

Inspectors wroteBased on interview, and record review, the facility failed to ensure pharmacist recommendations made during monthly resident Medication Regimen Reviews (MRR - medication reviews done by a pharmacist to identify irregularities in each resident's medication regimen) were communicated to the physician for two of five residents (Residents 41 and 43) sampled for unnecessary medications when: 1) For Resident 41, there was no indication that a physician was notified regarding the pharmacist's MRR recommendations dated October 18, 2023, which included: 1a) Assessment of the risk versus benefits of therapy related to the increased risk of death associated with elderly residents with dementia who receive antipsychotics (medications which alter brain chemistry to help reduce psychotic symptoms like hallucinations, delusions, and disordered thinking). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed from one of one the facility's medication supply rooms when an expired bottle of [brand name] docusate sodium (a stool softener commonly used to treat constipation) was observed to be in the medication supply room available for use. This failure had the potential for the medication to have decreased efficacy (ability to produce a desired result) and sub-therapeutic (less than optimal) effects when administered.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the medical record for one resident (Resident 13) was complete and accurate when staff did not document a physician's telephone order (a physicians order received by a nurse over the phone) regarding a change in the route of medication (means by which a medication is taken into the body) in Resident 13's clinical record. This failure resulted in Resident 13's medical record to be incomplete regarding physician's orders which had the potential for staff to not provide Resident 13 care as specified by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, sanitary and comfortable environment when a used syringe (a small hollow tube with plunger used for injecting or withdrawing fluid) was left on the bedside table for one of five sampled residents (Resident 251). This failure had the potential to expose residents and staff to used medical equipment that may be contaminated with human blood, body fluids or other infectious material.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the walk-in refrigerator was in safe operating condition when there was ice build-up across the bottom portion of one wall. This failure had the potential to cause the refrigerator to not cool properly and put 52 of 53 vulnerable residents who receive food from the kitchen at risk of food-borne illness (illnesses that can cause upset stomach, vomiting and diarrhea within hours of eating contaminated food).

Inspectors wroteBased on interview and record review, the facility failed to provide three of three residents (Residents 8, 17, and 23) with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN: CMS-10055 - a document that provides information about skilled services provided by the facility that may no longer be covered by Medicare Part A), when residents remaining admitted to the facility were not informed of Medicare Part A benefits ending. This failure resulted in the facility not meeting the obligation to notify Residents 8, 17, and 23 of their choices regarding their claim appeal rights and financial liability for services no longer covered by Medicare Part A.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post Direct Care Service Hours Per Patient Day (DHPPD - number of hours of direct care service hours per patient day based upon the facility census [total resident count] and staff working within a 24-hour period) in a prominent place readily accessible to residents and visitors. This failure resulted in the facility's nurse staffing information to not be readily available for review by residents and visitors at any given time as required by regulations.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident ' s family member of changes in the resident ' s condition when laboratory results were received with abnormal findings for one of three sampled residents (Resident 1). This failure prevented Resident 1 and his family to express concerns, raise questions, and participate in the plan of care for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that preventative maintenance was performed by the due date as detailed on one out of five oxygen concentrators (an electrically powered medical device that uses environmental air and delivers it to a patient in the form of supplemental oxygen) being used within the facility. This failure had the potential to cause harm to residents due to inadequate oxygen levels being produced by the machine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Expired intravenous (IV) fluids (solution given through a vein) for one (1) expired resident (Resident 104) were removed from the medication refrigerator. 2. Four (4) expired over-the-counter (OTC) medication bottles and one (1) expired IV start kit were removed from the medication room. 3. Three (3) expired over-the-counter (OTC) medication bottles were removed from two (2) of two (2) medication carts. These failures had the potential for the distribution/use of expired medication(s)/ IV solutions which could cause an adverse reaction resulting in serious harm.