Apostolic Christian Home

In the surveyor’s words

From the most serious findings on record at Apostolic Christian Home, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 10, 2024

  The facility identified a census of 60 residents. The sample included three residents reviewed for accidents. Based on observation, record review, and interviews, the facility failed to provide a safe environment, free from preventable accidents for Resident (R) 1. On 05/29/24 at 12:15 PM, Transportation FF strapped R1's wheelchair into the facility's transportation van but did not place the seatbelt around R1. When Transportation FF braked before making a turn, R1 slid out of her wheelchair onto the van floor. R1 was taken to the hospital for evaluation where she was found to have left tibia (bone in the lower leg) and fibula (bone in the lower leg) fractures as a result of the accident. […]

• Actual harm, isolatedF689Jun 27, 2023

  The facility had a census of 66 residents. The sample included 18 residents, with 10 reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure staff provided Resident (R)52 with his call light when he went to bed, resulting in a fall in which R52 obtained a right trimalleolar ankle fracture (a break in the lower leg section that form your ankle joint). The facility further failed to assess residents for safe lift chair use, after falls out of a lift recliner for R52 and R36. The facility failed to follow R36 and R46's plan of care which resulted in falls and failed to implement meaningful, resident centered interventions for R14 and R57. […]

• No harm, potential for more than minimal, widespreadF801Dec 18, 2024

  The facility identified a census of 58 residents and one kitchen. Based on record review and interviews, the facility failed to provide the services of a full-time certified dietary manager for the 58 residents who resided in the facility and received their meals from the kitchen. This placed the residents at risk for inadequate nutrition. Findings included: - On 12/16/24 at 07:26 AM, during the initial tour of the kitchen, Dietary Staff BB stated she had started the certified dietary manager course three years ago. Dietary Staff BB stated she had completed three months of the course before staffing shortages at the facility required her to return full-time in dietary. […]

• No harm, potential for more than minimal, widespreadF838Dec 18, 2024

  The facility identified a census of 58 residents. The sample included 15 residents. Based on observations, interviews, and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. This failure affected all 58 residents residing in the facility. Findings Included: - On 12/18/24 an inspection of the Facility Assessment was completed. The assessment was revised on 06/28/2024. […]

• No harm, potential for more than minimal, patternF558Dec 18, 2024

  The facility had a census of 58 residents. The sample included 15 residents with five reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to ensure the residents were provided foot pedals during wheelchair transports for Resident (R) 23, R36, R46, R34, R40, and R33. This placed the residents at risk for preventable accidents and injuries due to unmet care needs. Findings Included: - On 12/16/24 at 08:16 AM, R23, a severely cognitively impaired resident, sat upright in his Broda chair (specialized wheelchair with the ability to tilt and recline). R23 had socks on both feet. Certified Nurse Aide (CNA) O pushed R23 in his Broda chair and R23's feet slid along the floor before he lifted his legs. […]