Every finding on record at Christ's Home Retirement Community

Based on a review of facility policy, review of employee files, and staff interview, it was determined that the facility failed to initiate an employee criminal background check and complete required abuse training prior to the start of employment for two of five newly hired employees. (Employees E1 and E2)Findings include:Review of the facility policy entitled, Abuse Prevention Policy, last reviewed December 16, 2025, revealed that the facility was to screen potential employees for a history of abuse, neglect, or mistreating residents prior to employment. This included criminal background checks, checking references for previous and/or current employers and collaboration with appropriate licensing boards and registries.Review of employee files revealed the following:Employee 1 (E1) had been working at the facility as a cook since February 10, 2026. The facility failed to conduct a criminal background check, collect references, and document that abuse training had been completed prior to employment. Employee 2 (E2) had been working at the facility as an Assistant Dining Director since January 20, 2026. The facility failed to conduct a criminal background check and document that abuse training had been completed prior to employment.In an interview on February 19, 2026, at 11: 00 a.m., the Administrator confirmed that the required background checks and training had not been completed in a timely manner as per facility policy for E1 and E2. 28 Pa. Code 201.19(7)(8) Personnel policies and procedures.

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement Enhanced Barrier Precautions (EBP) to prevent the spread of infection for one of 12 sampled residents. (Resident 54) Findings include:Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed December,15, 2025, revealed that when EBP was ordered, staff was to wear a gown and gloves during high contact care activities with residents, such as during incontinence care and hygiene. Clinical record review revealed that Resident 54 had diagnoses that included pressure ulcer of the sacrum (lower back region). On January 10, 2026, the physician ordered that staff use EBP during care for Resident 54 due to the pressure ulcer. On February 17, 2026, at 10:15 a.m., nurse aide (NA) 1 and NA 2 were observed changing Resident 54's brief without wearing gowns in accordance with the facility policy regarding EBP.In an interview on February 18, 2026, at 1:00 p.m., the Director of Nursing confirmed that gowns should have been used during Resident 54's care.28 Pa. Code. 211.10(d) Resident care policies.28 Pa. Code. 211.12(d)(1)(5) Nursing services.

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to attempt non-pharmacological interventions to alleviate pain prior to the administration of pain medication prescribed on an as needed basis for one of 12 sampled residents. (Resident 18) Findings include: Review of the facility policy entitled, Pain Management, last reviewed January 2025, revealed that non-pharmacological interventions should be attempted prior to administration of pain medication that was prescribed on an as needed basis. Clinical record review revealed that Resident 18 had diagnoses that included muscle weakness, cellulitis, and chronic ulcers to the left foot. A physician's order dated December 12, 2024, directed staff to administer tramadol (a pain medication) every 12 hours, as needed, for severe pain. Review of the medication administration records (MAR) for December 2024, and January 2025, revealed no evidence that staff attempted non-pharmacological interventions to alleviate pain prior to the administration of tramadol on 13 occasions in December and six occasions in January. There were no documented refusals of non-pharmacological interventions. In interviews on January 8 and 9, 2025, at 2:03 p.m., and 9:12 a.m., the Director of Nursing confirmed that non- pharmacological interventions should be documented in the MAR and that there was no evidence that staff attempted non-pharmacological interventions prior to the administration of the as needed pain medication. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation, policy review, and staff interview, it was determined that the facility failed to dispose of controlled medications in accordance with facility policy and in a manner to prevent potential diversion for one of five residents observed during the medication pass. (Resident 41) Findings include: Review of the facility policy entitled, Destruction of Unused Medications, last reviewed January 2025, revealed that drugs will be destroyed in a manner that renders the drugs unfit for human consumption. Medications were to be destroyed using a Drug Buster (a device that renders medications inert prior to disposal) and witnessed by a second licensed nurse. Clinical record review revealed that Resident 41 had diagnoses that included nerve pain. On January 5, 2025, the physician ordered that staff apply fentanyl patch (a narcotic pain medication) 75 micrograms/hour every three days. On January 8, 2025, at 8:13 a.m., RN 1 administered a fentanyl patch to Resident 41. At that time, she was observed removing the old patch and disposed of it in a syringe disposal container without a witness. In an interview on January 8, 2025, at 12:30 p.m., the Director of Nursing confirmed that RN 1 should have discarded the fentanyl patch in a Drug Buster with a second licensed nurse as a witness. 28 Pa. Code 211.9(j.1)(5) Pharmacy services. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on review of facility policy and observation, it was determined that the facility failed to store food under sanitary conditions on the nursing unit. Findings include: Review of facility policy entitled, Outside Food, last reviewed [DATE], revealed that all items would be labeled and dated with the resident's name and room number and that expired items would be discarded. Observation of the unit refrigerator in the common, activity area of the nursing unit on [DATE], at 1:30 p.m., revealed a box of butter with an expiration date of [DATE], and a bag of grapes, a bottle of water, and two bags of various food items that were not labeled. There were four pre-mixed pouches of smoothies with expiration dates of [DATE], and [DATE] and [DATE]. 28 Pa. Code 201.18(b)(3) Management.

Based on policy review, clinical record review, resident interview, family interview, and staff interview, it was determined that the facility failed to ensure that each resident's wishes regarding the provision of cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest be considered and consistent with the physician's order for two of 12 sampled residents. (Resident 26, 87) Findings include: Review of the facility policy entitled, Advance Directives - Skilled Nursing, reviewed by the facility on [DATE], indicated that it was the policy of the facility to support the rights of all residents to participate in their own health care decisions, including the right to decide whether they wished to accept or refuse life-prolonging measures or other treatments. At admission, the facility must determine if the resident had an advance directive, that a copy would become a part of the medical record, and the resident's wishes would be communicated to the resident's direct care staff and physician. Clinical record review revealed that Resident 26 had diagnoses that included paroxysmal atrial fibrillation (intermittent irregular heart rhythm), hypertension (high blood pressure), and diabetes mellitus. The physician's order dated [DATE], directed staff to provide full code. (Meaning if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures would be provided to keep them alive. This process could include chest compressions, intubation, and defibrillation, which is referred to as CPR.) A social services assessment dated [DATE], identified that Resident 26 had an advance directive (no specifics documented) with no evidence that it was communicated to the direct care staff and physician. During an interview on [DATE], at 11:13 a.m., the resident and the resident's family member stated that Resident 26 had an advance directive of DNR (do not resuscitate). Clinical record review revealed that Resident 87 was admitted to the facility on [DATE], and had diagnoses that included dementia and paroxysmal atrial fibrillation. A physician's order dated [DATE], through [DATE], directed staff to provide full code. The social services assessment dated [DATE], identified that the resident had an advance directive (no specifics documented) with no evidence that it was communicated to the direct care staff and physician. On [DATE], nursing documentation indicated that the family member called and stated that Resident 87 had an advance directive of DNR. During an interview on [DATE], at 11:27 a.m., the nurse (RN 1) confirmed that the resident's physician's order for code status in the electronic record was consulted to identify current advance directive information. 28 Pa. Code 201.29(a)(j) Resident rights. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to maintain accurate clinical records for one of 12 sampled residents. (Resident 7) Findings include: Clinical record review revealed that Resident 7 had diagnoses that included heart failure, anxiety, stage four chronic kidney disease, and atrial fibrillation. A physician's order dated March 17, 2023, directed staff to restrict the resident's fluid intake to 1920 cubic centimeters (cc) per day. A physician's order dated March 25, 2023, directed staff to restrict the resident's fluid intake to 1500 cc per day. Review of physician progress notes dated March 20, 22, 27, 29, 2023, and April 3, and 5, 2023, revealed that the physician documented that the resident's fluid intake was to be limited to 1200 cc per day. There was no evidence that a physician ordered staff to restrict the resident's fluid intake to 1200 cc per day. In an interview on March 6, 2023, at 11:55 a.m., the Director of Nursing confirmed that the physician incorrectly documented that the resident's fluid intake was to be restricted to 1200 cc per day. 28 Pa. Code 211.5(f) Clinical records.

Based on clinical record review and staff interview, it was determined that the facility failed to review and revise the care plan for one of 12 sampled residents. (Resident 6) Findings include: Clinical record review revealed that Resident 6 had diagnoses that included hypertension, insomnia, and dysphagia. A physician's order dated June 12, 2021, directed staff to administer mirtazapine (an antidepressant medication), 15 milligrams at bedtime for depression. Review of the Minimum Data Set assessment dated [DATE], revealed that the resident received an antidepressant medication seven days during the review period. Review of the Care Area assessment dated [DATE], revealed that the use of an antidepressant would be addressed on the resident's care plan. Resident 6's care plan was not updated to reflect the use of an antidepressant medication. In an interview on March 6, 2023, at 12:30 p.m., the Director of Nursing confirmed that Resident 6's care plan was not updated to reflect the use of an antidepressant medication. 28 Pa. Code 211.11(d) Resident care plan.

Based on clinical record review and staff interview, it was determined that the facility failed to notify the resident's representative of a change in condition and treatment for one of 12 sampled residents. (Resident 14) Findings include: Clinical record review revealed that Resident 14 had diagnoses that included hypertension, muscle weakness, and heart failure. On March 13, 2023, staff documented that the resident experienced a syncopal episode (a temporary loss of consciousness) while getting out of bed and the resident's blood pressure dropped to 70/40 millimeters of mercury (mmHg) from an average usual blood pressure of 141/65 mmHg. The physician ordered increased monitoring of vital signs for three days. There was no evidence that the facility notified the resident's representative of the syncopal episode or the change to the resident's treatment plan. In an interview on March 6, 2023, at 12:30 p.m., the Director of Nursing stated that there was no evidence that staff notified the resident's representative and that staff were to notify a resident's representative of changes to the treatment plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review, observation and staff interview it was determined that the facility failed to provide assistance with dining in a manner that promoted and maintained dignity for one resident on one of three nursing units. (Resident 15) Findings include: Clinical record review revealed that Resident 15 was admitted to the facility with [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set assessment, dated December 28, 2020, the resident was cognitively impaired and required extensive assistance from staff with eating. Review of Resident 15's current and ongoing care plan revealed that she was at risk for altered nutrition related to her altered mental status. An intervention was for staff to assist her with feeding. On February 16, 2021, from 12:30 p.m. through 12:52 p.m., LPN1 was observed standing while feeding the resident her lunch. In an interview on February 17, 2021, at 11:00 a.m., the Director of Nursing stated that staff should be seated to feed residents. 28 Pa. 211.12 (d)(1)(5) Nursing services.

Based on observation, it was determined that the facility failed to ensure the kitchen was clean and maintained in a sanitary manner to prevent the potential for contamination of food in the dietary department. Findings include: Observation during the environmental tour of the dietary department on February 2, 2020, at 9:26 a.m., revealed a hood/exhaust system located above kitchen equipment used to cook food to have a heavy accumulation of dust/dirt. In an interview on February 21, at 10:30 a.m., the Director of Maintenance provided documentation indicating that the hood/exhaust system was last cleaned on September 17, 2019.

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that non-pharmacological interventions were attempted prior to the administration of as needed pain medication for three of four sampled residents who were on a pain management program. (Residents 9, 17, 20) Findings include: Review of the facility policy entitled Pain Management dated December 12, 2019, revealed that all residents were to be provided a comprehensive method of assessment and evaluation of pain with the goal of adequate pain management. Part of the procedure was for non-pharmacological interventions to be atttempted prior to the as needed (PRN) pain medication administration. Clinical record review revealed that Resident 9 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and had experienced occasional, moderate pain in the last five days. On December 18, 2019, a physician ordered for staff to administer an as needed pain medication ([MEDICATION NAME]) every four hours PRN for pain. Review of the Medication Administration Record [REDACTED]. There was no documented evidence that staff had attempted non-pharmacological interventions prior to the PRN pain medication. Clinical record review revealed that Resident 17 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated that the resident had no memory impairment and had experienced occasional, moderate pain in the last five days. On January 11, 2020, a physician ordered for staff to administer an as needed pain medication ([MEDICATION NAME]) every four hours PRN for pain. Review of the MAR for January 2020, revealed that staff had administered the [MEDICATION NAME] 18 times and two times in February 2020. There was no documented evidence that staff had attempted non-pharmacological interventions prior to the PRN pain medication. Clinical record review revealed that Resident 20 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated that the resident had memory impairment and had experienced occasional, moderate pain in the last five days. On January 16, 2020, a physician ordered for staff to administer an as needed pain medication ([MEDICATION NAME]) every six hours PRN for pain. Review of the MAR for January 2020, revealed that staff had administered the [MEDICATION NAME] 13 times and three times in February 2020. There was no documented evidence that staff had attempted non-pharmacological interventions prior to the PRN pain medication. In an interview on February 21, 2020, at 9:58 a.m., the Director of Nursing confirmed that there was no consistent documented evidence that staff had attempted non-pharmacological interventions prior to the administration of the PRN pain medication as per facility policy for the three aforementioned residents. CFR 483.25 Pain Management Previously cited 2/28/19 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that assessed safety interventions (protective skin sleeves) were in place to prevent skin tears for one of 15 sampled residents. (Resident 9) Findings include: Clinical record review revealed that Resident 9 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE], indicated that the resident had memory impairment, required extensive assistance from staff for dressing and transfers, had unsteady balance and utilized a wheelchair. Review of the care plan identified that the resident's skin was fragile related to age and skin changes. Review of a nursing note dated December 30, 2019, revealed that the resident sustained [REDACTED]. At this time, an intervention was added for staff to apply protective sleeves (Derma savers) at night in order to help prevent skin tears. Review of a nursing note dated January 21, 2020, at 9:30 a.m., revealed that the resident had an area on her right leg that was bleeding. Review of the incident report revealed that the nurse aide had not been aware of the need for the resident to have the Derma savers in place and the resident sustained [REDACTED]. In an interview on February 21, 2020, at 9:25 a.m., the Director of Nursing stated that the assessed safety intervention (Derma savers) had not been in place in order to prevent skin tears. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to implement and develop comprehensive care plans to meet the current needs of four of 15 sampled residents. (Residents 9, 11, 23, 37) Findings include: Clinical record review revealed that Resident 9 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had memory impairment and a history of falls. Review of facility generated incident reports revealed that the resident experienced a fall on December 11, 2019, in her room. An intervention was added for staff to keep her out of her room when awake. Review of a second incident report dated December 13, 2019, revealed that the resident experienced another fall. An intervention was added for staff to provide close supervision while the resident was awake. Review of the current care plan identified that the resident was at risk for falls related to a history of falls. The interventions from December 11, or 13, 2019, had not been added to the care plan. In addition, Resident 9 was identified with fragile skin related to age and skin changes. Review of an incident report dated December 30, 2019, revealed that the resident had sustained a skin tear on her right lower extremity. An intervention added at this time was for staff to apply protective sleeves (Derma savers) at night and do not transfer resident without her legs covered. This intervention had not been added to the care plan to reflect the current needs of the resident. Clinical record review revealed that Resident 11 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated that the resident had memory impairment and utilized an anti-psychotic medication in the last seven days. On October 20, 2019, a physician ordered for staff to administer and anti-psychotic medication ([MEDICATION NAME]) at bedtime for [MEDICAL CONDITION]. Review of the Medication Administration Records for October, November, and December 2019, and January and February 2020, revealed that the resident had been administered the anti-psychotic medication as ordered by the physician. There was no care plan developed to reflect the use of the anti-psychotic medication with specific interventions to address the use of the medication. Clinical record review revealed that Resident 23 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On December 11, 2019, a physician ordered for staff to apply a palm protector for hours of sleep, as tolerated. A review of the Treatment Administration Records for December 2019, January 2020, and February 2020, revealed that a splinting device had been applied as ordered by the physician. There was no care plan developed to reflect the use of the splinting device with specific interventions to address the use of the palm protector. Clinical record review revealed that Resident 37 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE], indicated that the resident had a risk for blood clots and utilized an anti-coagulant medication in the last seven days. On February 4, 2020, a physician ordered for staff to administer an anti-coagulant medication ([MEDICATION NAME]) every eight hours. Review of Medication Administration Records for February 2020, revealed that the resident had received the anti-coagulant medication as ordered by the physician. There was no care plan developed to reflect the use of the anti-coagulant medication with interventions to address the use of the medication. In an interview on February 21, 2020, at 9:30 a.m., the Director of Nursing stated that the specific care plan interventions had not been developed or added to reflect the current needs of the aforementioned residents. 28 Pa. Code 211.10(d) Resident care plans

Based on clinical record review, observation and staff interview, it was determined that the facility failed to implement a care planned intervention for one of 13 residents sampled. (Resident 11) Findings include: Clinical record review revealed that Resident 11 had [DIAGNOSES REDACTED]. On (MONTH) 14, 2019, a physician ordered and the care plan identified that a Dycem placemat (a non slip placemat) was to be utilized under his plate for all meals to improve his ability to feed himself. Observations on (MONTH) 26, 2019, at 12:50 p.m., (MONTH) 27, 2019, at 9:20 a.m., and at 12:40 p.m., and again on (MONTH) 28, 2019, at 12:47 p.m., revealed the resident's meal plate was directly on the table without the Dycem placemat. In an interview on (MONTH) 28, 2019, at 1:25 p.m., the Nursing Home Administrator confirmed that the Dycem was not in place. 28 Pa. Code 211.10(c)(d) Resident care plan. 28 Pa. code 211.12(d)(5) Nursing services

Based on clinical record review and staff interview, it was determined that the facility failed to notify the residents and residents' representative(s) of the transfers and the reasons for the moves in writing upon transfer from the facility for two of three residents sampled. (Residents 4, 11) Findings include: Clinical record review revealed that Resident 4 was transferred and admitted to the hospital on (MONTH) 14, 2019, after a change in condition. There was no documented evidence that the resident and resident's responsible party was provided written information regarding the resident's transfer to the hospital. Clinical record review revealed that Resident 11 was transferred and admitted to the hospital on (MONTH) 28, (YEAR), after a change in condition. There was no documented evidence that the resident and resident's responsible party was provided written information regarding the resident's transfer to the hospital. In an interview on (MONTH) 28, 2019, at 10:00 a.m., the Nursing Home Administrator confirmed that the resident and residents' representatives were not notified in writing of the transfer or the reason for the transfer to the hospital.

Based on observation and interview, it was determined that the facility failed to ensure that food was stored and served in a sanitary manner. Findings include: During the tour of the kitchens on January 2, 2018, from 10:14 a.m. through 10:58 a.m., bearded Dietary Employee 1 was preparing food without a beard restraint in place. Review of the sanitizer concentration log for the three compartment sink from December 1, 2017, to January 2, 2018, revealed numerous omissions where staff had failed to document that the chemical solution was at the correct concentration to sanitize the dishware. On eleven occasions staff documented that the concentration was zero parts per million (ppm). The manufacturer recommendations require that the concentration be between 150-400 ppm. to adequately sanitize dishware. There was no evidence to support that corrective action was taken at the times when the sanitizing solution was not meeting the manufacturer's requirement. The dietary manager stated that it was not until the morning of the observation that an outside company was contacted to correct the chemical sanitizing dispensing unit that was malfunctioning. Review of steam table temperature logs from December 17, 2017 through January 2, 2018, revealed that staff had failed to consistently document the holding temperatures of hot foods that were served to residents to ensure that food was held at appropriate temperatures.

Based on observation, a review of facility documentation and staff interview it was determined that the facility failed to monitor temperatures of hot beverages to minimize the resident risk of scalding [MEDICAL CONDITION] one of one satellite kitchens that served hot beverages directly to residents. (main dining room) Findings include: On January 2, 2018, between 10:14 a.m., and 10:58 a.m., temperature logs for food and hot beverages that were served directly to residents were reviewed. The logs lacked documentation to support that the temperatures of coffee and hot water that were served to residents that morning at the breakfast meal were checked. Further review of temperature logs from December 17, 2017, to January 2, 2018, revealed that staff had failed to document the temperature of hot beverages served to residents at each meal. In an interview during the observations the Dietary Manager stated that he had no evidence to support that staff had taken and documented the temperatures of hot beverages on the days in question. Without temperatures being monitored there was no way to determine if beverages served to residents were at a safe temperature. 201.18(b)(1) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed-hold policy to the resident, family member or legal representative at the time of transfer for one of three residents transferred out of the facility. (Resident 48) Findings include: Clinical record review revealed that Resident 48 was transferred and admitted to the hospital on October 18, 2017, after a change in condition. There was no documented evidence that the resident, responsible party or legal representative were provided written information about the facility's bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization ) at the time of transfer.

Based on observation it was determined that the facility failed to ensure that a dignified dining experience was provided for one of two residens that required to be fed in the main dining room on the second floor. (Resident 26) Findings include: Observations during the noon meal in the main dining room on the second floor of the facility, on January 2, 2018, from 12:29 p.m., until 12:44 p.m, revealed that Resident 26 observed her table mate Resident 18 being fed the noon meal. Both residents required staff to feed them their meals. In an interview on January 4, 2018, at 1:00 p.m., the Director of Nursing stated that both residents should have been fed their meal at the same time. 28 Pa. 211.12(d)(1)(5) Nursing services.