Apostolic Christian Restmor

In the surveyor’s words

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

• Actual harm, isolatedF689Sep 3, 2025

  Based on interview and record review the facility failed to ensure a previously implemented fall intervention was in place to reduce the risk of a fall for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 being transferred to the local area emergency room with a left forehead laceration, a left frontal scalp soft tissue hematoma, multiple skin tears and experiencing severe pain.Findings include: The facility's Fall Prevention Policy, dated 2/2025, documents Purpose: To provide as safe an environment as possible by taking measures to prevent falls to the extent possible. Policies: C. Every resident shall have safety measures included in the Care Plan from the time of admission. D. […]

• Actual harm, isolatedF689Aug 27, 2024

  Based on observation, interview, and record review the facility failed to provide safe transfer for one (R1) of three residents reviewed for transfers in a sample of three. This failure resulted in R1 being sent out to the hospital and suffering from bruising, left elbow hematoma and a head laceration. Findings include: The facility's Fall Prevention policy, dated April 2024, documents Purpose: To provide as safe an environment as possible by taking measures to prevent falls to the extent possible. The facility's Lift Policy, dated January 2022, documents I. Purpose - To prevent injury to residents and staff during transfers and to reduce physical strain on staff .J. The Instruction manual for the lift shall be available at each care base for reference. […]

• Actual harm, isolatedF689Apr 19, 2024

  Based on observation, interview, and record review the facility failed to ensure resident fall interventions were in place and functioning for one of five (R34) residents reviewed for falls in a sample of 26. This failure resulted in R34 having falls and suffering from nasal bone fractures. Findings include: The facility's Fall Prevention policy, dated January 2024, documents Purpose: To provide as safe an environment as possible by taking measures to prevent falls to the extent possible. Policies: C. Every resident shall have safety measures included in the Care Plan from the time of admission. D. The Care Plan safety measures shall be revised as appropriate after a fall occurs and when deemed necessary by nursing. E. […]

• Actual harm, isolatedF600Mar 23, 2023

  Based on observation, interview, and record review the facility failed to prevent employee to resident abuse for one of two residents (R26) reviewed for abuse in the sample of 26. This failure resulted in V3 (CNA/Certified Nursing Assistant) rough handling R26 during cares, resulting in R26 crying and sustaining bruises, a hematoma, and pain to the left arm. Findings include: The facility's Abuse Prevention and Abuse Reporting policy dated 12/2017 documents, Purpose: To assure the prevention of mistreatment, neglect, or abuse of residents or misappropriation of residents' property to the extent it is in the control of the facility. Policy: Residents of this facility will be free from abuse, neglect, or misappropriation of resident property. […]

• Actual harm, isolatedF689Aug 11, 2021

  Based on record review and interview, the facility failed to ensure foot pedals were applied to a wheelchair prior to transporting a resident, for one of three residents (R5) reviewed for falls in a sample of five. This failure resulted in R5 abruptly dropping his feet during wheelchair transport, causing R5 to fall forward, hitting his nose and sustaining a fracture of the nasal bone. Findings include: The facility policy titled Wheelchair Safety Policy (August 2016), documents Wheelchair Pedals: 1. Pedals will be applied to the wheelchair as needed for resident mobility, as designated in the care plan. 2. To prevent injuries, staff, volunteers, and visitors are discouraged from pushing a resident in a wheelchair unless they have front pedals. […]