Church of Christ Care Center

In the surveyor’s words

From the most serious findings on record at Church of Christ Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Jul 8, 2021

  This citation pertains to Intakes: MI 044 and MI 045. Based on observation, interview and record review, the facility failed to prevent Certified Nurse Aide (CNA) staff to resident physical, verbal and psycho-social abuse during a shower for two sampled Residents (R800 & R801), resulting in Immediate Jeopardy with both residents being exposed to what was described as unbearable/scalding hot water, physical penetration and covering the residents mouth (R800), fear of taking showers, and the need for an psychiatric consult and anti-anxiety medication for (R801). This deficient practice placed the residents at risk for serious injury, serious harm and/or death. […]

• Actual harm, isolatedF689Aug 20, 2025

  This 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. Findings include:During a closed record review of R4's medical record it was noted that R4 was transferred to the hospital after a fall during care. A review of R4's medical record progress notes revealed, 8/17/25 -Writer called to room by nurse assistance. Res (resident) observed on floor, lying on right side. Lying next to bed closest to the window. Nightstand and bed side table next to [R4], close to [R4's] head. Res is alert and verbal. Verbal complaints of pain to right side. […]

• Actual harm, isolatedF686Aug 1, 2024

  Based 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. Findings include: R78 On 07/31/24 at 11:12 AM, Registered Nurse (RN) H was observed assessing R78's wound in their room. A strong foul odor was noted coming from the wound when RN H pulled R78's covers back. A review of R78's record revealed they were initially admitted to the facility on [DATE], and readmitted on [DATE] with the following diagnoses: Muscle weakness generalized, wounds and unspecified encephalopathy. The Brief Interview for Mental Status (BIMS) revealed a score of 6/15 indicating a cognitive impairment. […]

• Actual harm, isolatedF689May 2, 2024

  This 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. Findings include: Review of the facility record for R701 revealed an admitted [DATE] with diagnoses that included Alzheimer's Disease, Diabetes Mellitus, and Difficulty in Walking. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Mental Status (BIMS) score of 03/15 indicating Severe Cognitive Impairment. […]

• Actual harm, isolatedF578Jun 30, 2022

  This citation pertains to Intake: MI 039 Based on observation, interview and record review, the facility failed institute and operationalize policies and procedures and honor the rights of one sampled Resident (R702) of one resident reviewed for resident rights resulting in, Cardiopulmonary Resuscitation (CPR) being provided against the resident/resident representative's wishes, and pain. Findings include: A review of intake MI 039 revealed the following, Incident Summary Dining Room Nursing Attendant observed resident's eyes rolling upward and skin discoloration. CODE BLUE (cardiac or respiratory arrest) was called and resident was rushed to [their]room. Since the resident was unresponsive and had no pulse or respiration, one of the nurses responding to the CODE BLUE started CPR. […]