A list of the most recent deficiencies for Church of Christ Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-14 | 2023-07-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-14 | 2023-07-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-14 | 2023-07-15 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-06-14 | 2023-07-15 | N |
| Provide or obtain dental services for each resident. | Health | 2023-06-14 | 2023-07-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-06-14 | 2023-07-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-14 | 2023-07-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-14 | 2023-07-15 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-13 | 2023-07-15 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-06-30 | 2022-07-29 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-06-30 | 2022-07-29 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-30 | 2022-07-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-30 | 2022-07-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-04 | 2022-06-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-04 | 2022-06-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-04 | 2022-06-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-05-04 | 2022-06-06 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-05-04 | 2022-06-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-05-04 | 2022-06-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-05-04 | 2022-06-06 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-05-04 | 2022-06-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-05-04 | 2022-06-06 | N |
| Report COVID19 data to residents and families. | Health | 2022-05-04 | 2022-06-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-05-04 | 2022-06-06 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-05-03 | 2022-06-06 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-02-24 | 2022-03-26 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2022-02-24 | 2022-03-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-02-24 | 2022-03-26 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-09-21 | 2021-09-22 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-07-08 | 2021-07-31 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2021-07-08 | 2021-07-31 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-07 | 2019-12-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-11-07 | 2019-12-31 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-07 | 2019-12-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-11-07 | 2019-12-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-07 | 2019-12-31 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-18 | 2019-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-18 | 2019-12-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-18 | 2019-12-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-11-18 | 2019-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-18 | 2019-12-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-11-18 | 2019-12-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-18 | 2019-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-18 | 2019-12-13 | N |
