Christian Care Nursing Center

F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

told about that.During an interview on 9/26/25 at 12:13 PM, CNA I revealed, Resident R200 was in a mood that day. I did not see a gait belt around the wheelchair; I was told about it but did not see it. He was having major behaviors that morning. He was not sitting in his wheelchair at all because he kept getting up. CNA I revealed she had been interviewed and had received education by administration because a Gait belt wrapped around the wheelchair (and resident) is considered a restraint and needs to be reported because it's a type of abuse. Review of Nursing Home Guide: Restraints education provided to facility staff from 8/22/25 - 9/16/25 revealed the following is considered a physical restraint, Lap belts, bed rails, locked chairs, wrist/ankle ties.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Christian Care Nursing Center

2053 South Sheridan Drive Muskegon, MI 49442

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

made or suspicion is formed. d. Any reasonable suspicion of a crime against a resident will also be reported to the local Law Enforcement Agency in addition to the State Agency. Further review of the facility's Reporting of Incidents policy and procedure, revised 2/2024, reflected, 5. The Administrator will complete

the 24-hour report via the online reporting system established by [Name of State Survey Agency]. The following statement was reviewed on the bottom of the first page NOTE: WHEN IN DOUBT AS TO WHETHER THE INCIDENT/OCCURRENCE IS REPORTABLE TO THE STATE AGENCY/LAW ENFORCEMENT AGENCY THE FACILITY SHOULD REPORT THE EVENT.

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Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Christian Care Nursing Center

2053 South Sheridan Drive Muskegon, MI 49442

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

better to help prevent a fall. RN D stated it wasn't even 10 minutes later when CNA E asked if I had saw the gait belt on Resident R200. I thought she meant around his waist. I had not seen it around the wheelchair until she brought it to my attention. The gait belt was around Resident R200 and his wheelchair. I told the aides to take it off him immediately because it was being used as a restraint. Resident R200 seemed fine, he was just at the table eating breakfast. I then called and left messages for the DON and the Unit Manager (UM) J and reported what happened. I talked to the Nursing Home Administrator (NHA). RN D stated a skin assessment was completed on Resident R200 with no concerns. She stated she had not talked to Resident R200's family or physician about

the incident. RN D clarified she had three aides in the dining room besides CNA E and none of them admitted to restraining Resident R200 with a gait belt. RN D revealed she reported the incident because she considered it to be abuse.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Christian Care Nursing Center

2053 South Sheridan Drive Muskegon, MI 49442

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 2628080Based on interview and record review, the facility failed to ensure the medical records for 1 of 3 residents (Resident R200) was complete and accurate.Findings include:R200A review of Resident R200's admission Record, dated 9/25/25, revealed Resident R200 was an [AGE] year-old resident initially admitted to the facility on [DATE REDACTED] with multiple diagnoses that included Alzheimer's Disease and Dementia.A review of Resident R200's Minimum Data Set (MDS) (a tool used for assessing a resident's care needs), dated 7/19/25, revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 3 which revealed Resident R200 was severely cognitively impaired.A review of the Facility Reported Incident (FRI) revealed the incident occurred on 8/10/25 at approximately 8:30 AM. [Name of Resident R200] was observed in

the dining room by staff with a gait belt around his waist and his wheelchair.A review of Resident R200's Electronic Medical Record (EMR), dated 8/07/25 to 9/22/25, failed to reflect documentation (e.g., a progress note, a physician note, assessment) that indicated on 8/10/25 Resident R200 was observed being restrained by a gait belt to his wheelchair while he was in the dining room eating breakfast.During an interview on 9/26/25 at 3:23 PM,

the NHA (Nursing Home Administrator) revealed he did not see any documentation in Resident R200's EMR that he had been being restrained by a gait belt to his wheelchair while he was in the dining room eating breakfast

on 8/10/25. The NHA further revealed they had completed an incident report. A copy of the incident report was requested from the NHA.A review of Resident R200's incident report, dated 8/10/25 at 9:39 AM, revealed, It was reported to me [Unit Manager (UM) J] via Phone by nurse [Name of RN D] that resident had been progressively combative over the weekend peaking on Sunday, hitting, kicking, walking in the hallways and urinating, staff assisted him to a wheelchair and he was attempting to get out of w/c and hit staff. He was assisted to the dining room to eat and that is when it was observed by [Name of CNA E] that there was a gait belt around the resident's chair. In addition, the following statement on bottom of page one of the incident report revealed, Privileged and Confidential - Not part of the Medical Record - Do not Copy.

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